Management of Telogen Effluvium in Women
Screen for vitamin D, ferritin, and zinc deficiencies in all women presenting with telogen effluvium, as these are the most commonly deficient micronutrients with non-trivial prevalence rates that justify routine laboratory evaluation. 1, 2
Laboratory Evaluation Priority
The following tests should be ordered based on evidence of deficiency prevalence:
- Serum ferritin: Deficiency found in 46.5% of female TE patients, making this the most common abnormality 3
- Serum zinc: Patients with TE have significantly lower zinc levels compared to controls, with increased odds of levels below 70 μg/dL (OR 4.65,95% CI 1.12-17.68) 1
- 25(OH) Vitamin D: Mean levels significantly lower in TE patients (13.31 ± 5.8 ng/ml) versus controls (33.61 ± 8.16 ng/ml) 4
- Hemoglobin and iron studies: Iron deficiency detected in 29.5% of TE patients 3
- Vitamin B12: Deficiency found in only 5.8% of patients 3
- Thyroid function tests (TSH, T3): Important particularly in adolescent and post-menopausal women 3
Treatment Approach Based on Laboratory Results
For Vitamin D Deficiency
Oral vitamin D supplementation shows significant improvement in TE patients. After 3 months of oral vitamin D therapy, mean serum levels increased from 13.31 ng/ml to 38.4 ng/ml with clinical improvement in both acute and chronic TE 4. Vitamin D may also have preventive value when used during acute illness 5.
For Zinc Deficiency
Zinc supplementation (100 mg zinc aspartate + 20 mg biotin daily) may achieve complete regrowth in 33.3% of treatment-resistant cases 6. However, zinc doses above 15 mg daily require copper monitoring to prevent copper deficiency-induced hair loss 7. The zinc:copper ratio should be maintained at 8-15:1, with monitoring every 6-12 months 7.
For Iron/Ferritin Deficiency
Iron supplementation is indicated when ferritin levels are low, though the association between iron deficiency and TE remains inconsistent across studies 1, 6. The evidence shows ferritin deficiency is common (46.5% of patients) but its causal role is debated 3. Iron supplementation should be separated from calcium supplements for optimal absorption 1.
Adjunctive Topical Therapy
Topical minoxidil applied twice daily is the primary evidence-based treatment for telogen effluvium 6. Individual response varies based on genetic factors and scalp sulfotransferase enzyme activity 6. Hypertrichosis occurs in approximately 15% of patients, which may limit acceptability 6.
Preventive Nutritional Strategies
Dietary supplements including vitamin C, vitamin D, lactoferrin, and zinc used during acute illness may have preventive value against post-illness telogen effluvium 5. Conversely, azithromycin and ivermectin may have negative long-term effects on hair shedding 5.
Scalp Care Recommendations
- Use pH-neutral (pH 5) gentle shampoos 6
- Apply hypoallergenic moisturizing creams once daily 6
- Wash hair with tepid water only, avoiding hot water 6
- Apply broad-spectrum sunscreen (SPF 30+) with zinc oxide or titanium dioxide to exposed scalp 6
- Avoid greasy creams, occlusive products, topical acne medications, and hot blow-drying 6
Important Caveats
Ferritin interpretation in post-COVID TE requires caution. While ferritin levels are lower in TE patients compared to controls, they often remain above the cutoff for diagnosing non-anemic iron deficiency, making ferritin a poor biomarker in post-infectious TE cases 5. This is because ferritin also serves as an inflammatory marker during acute illness.
Not all TE cases have nutritional deficiencies. Recent evidence shows nutritional deficiencies are not as common as previously thought, with vitamin B12 deficiency found in only 5.8% and folic acid deficiency in only 0.6% of patients 3, 8. A detailed history focusing on physiological stress, surgical trauma, medications, and inflammatory/infectious triggers is essential before attributing TE solely to nutritional causes 8.