How should I evaluate and treat chronic telogen effluvium in a 30‑ to 50‑year‑old woman with diffuse, non‑scarring hair shedding lasting more than six months?

Chronic Telogen Effluvium: Evaluation and Treatment

Initial Clinical Assessment

For a 30- to 50-year-old woman with diffuse hair shedding lasting more than six months, chronic telogen effluvium (CTE) should be distinguished from female pattern hair loss (FPHL) through scalp biopsy, which shows normal histology in CTE versus miniaturization with terminal-to-vellus hair ratio <4:1 in FPHL. 1

Key Diagnostic Features

• Excessive, alarming diffuse shedding from a normal-looking scalp with plenty of hair and no obvious cause is the hallmark of CTE, distinguishing it from acute telogen effluvium and FPHL 1
• The onset is typically abrupt, with or without a recognizable trigger, and hair may come out in handfuls initially 2
• Unlike FPHL, there is no visible mid-frontal scalp thinning (Sinclair stage 1) and no widening of the central part 3, 1
• CTE affects women aged 30–60 years who generally had a full head of hair before onset 2
• The condition fluctuates over years but does not lead to complete baldness 2

Laboratory Evaluation

Check serum ferritin, TSH, free T4, vitamin D, and zinc levels in all cases without a discernible cause, as iron deficiency and thyroid disorders are commonly associated with diffuse hair loss even without obvious clinical features. 1, 4

Specific Testing Thresholds

• Serum ferritin: Iron deficiency is the most common nutritional deficiency worldwide and a sign of chronic diffuse telogen hair loss; optimal ferritin ≥60 ng/mL is needed for hair growth 4, 5
• Vitamin D: 70% of women with hair loss have levels <20 ng/mL; lower levels correlate inversely with disease severity 4
• Zinc: Serum zinc levels tend to be lower in patients with chronic hair loss 4
• TSH and free T4: Check to exclude thyroid dysfunction, which commonly causes hair loss 4, 5
• Complete blood count and routine urinalysis should be performed 1

When to Perform Scalp Biopsy

• Scalp biopsy is essential to reliably differentiate CTE from FPHL: CTE shows normal histology with no hair follicle miniaturization, while FPHL demonstrates miniaturization with T:V ratio <4:1 3, 1
• Biopsy is indicated when the diagnosis remains uncertain after clinical examination 4, 5

Treatment Approach

First-Line Management: Reassurance and Trigger Removal

• Repeated reassurance that CTE represents excessive shedding rather than actual hair loss and does not cause complete baldness is the cornerstone of management 2, 1
• Identify and remove any causative factors (medications, nutritional deficiencies, thyroid dysfunction) 6
• CTE is self-limiting in the long run but may take 3–10 years for spontaneous resolution, contrasting with acute telogen effluvium which resolves in 3–6 months 1

Pharmacologic Intervention: Oral Minoxidil

Once-daily oral minoxidil (0.25–2.5 mg) significantly reduces hair shedding in CTE, with mean hair shedding scores decreasing by 1.7 points at 6 months (p<0.001) and 2.58 points at 12 months (p<0.001). 3

Dosing and Monitoring

• Start with low doses (0.25–2.5 mg daily) 3
• Monitor blood pressure: mean changes were minimal (−0.5 mmHg systolic, +2.1 mmHg diastolic) 3
• Trichodynia (scalp pain), if present at baseline, typically improves or resolves within 3 months 3

Expected Adverse Effects

• Facial hypertrichosis occurs in approximately 36% of patients (13 of 36 women in the study): 6 had mild hypertrichosis not requiring treatment, 4 managed with waxing, and 3 required laser hair removal 3
• Transient postural dizziness may occur but resolves with continued treatment 3
• Ankle edema is uncommon 3
• No hematological abnormalities were observed 3

Alternative Considerations

• Topical minoxidil 2% is an option, though oral formulation shows superior efficacy for CTE 3, 1
• Corticosteroids may be considered in select cases 6

Common Pitfalls to Avoid

• Do not confuse CTE with FPHL: FPHL shows gradual thinning with central scalp involvement and frontotemporal recession, while CTE presents with diffuse shedding from a full-looking scalp 1
• Do not order extensive autoimmune panels for straightforward cases, as this adds little diagnostic value 4, 5
• Do not dismiss the psychological impact: patients fear total baldness and require ongoing support and explanation 2
• Recognize that CTE may be triggered by hormonal fluctuations during menopausal transition, particularly in middle-aged women 7

Prognosis and Follow-Up

• CTE persists and fluctuates for years but is ultimately self-limiting 2
• The degree of shedding is usually most severe in early stages 2
• Patients should be counseled that improvement is gradual and treatment effects take months to manifest 3
• All 36 women in the oral minoxidil study completed 12 months of treatment, indicating good tolerability 3