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Telogen Effluvium Dallas

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Telogen Effluvium Hair Loss

Telogen effluvium (TE) describes abnormal shedding of telogen hairs so that noticeable shedding and/or hair thinning occurs. Headington proposed 5 mechanisms by which TE can occur. Three mechanisms for telogen effluvium occur in the anagen phase and two occur in the telogen phase:

telogen_effluvium

  1. Immediate Anagen Release: Follicles that would normally complete a longer cycle of anagen prematurely enter telogen. Typically immediate anagen release has a short time to onset of 3 to 5 weeks from the inciting factor. Drug-induced telogen effluvium may account for this type of TE. See list of drugs that may induce TE at the end of this section.
  2. Delayed Anagen Release: Hairs are maintained in anagen for longer than usual and then are released into telogen phase at the same time. Postpartum TE is the most common type of this TE in which hairs are kept in anagen during pregnancy then released into telogen after childbirth when there is a rapid TE after delivery.
  3. Shortened Anagen: If anagen is shortened by 50%, there is a corresponding doubling of telogen hairs. Etitrinate may cause a shortened anagen phase.
  4. Immediate Telogen Release: Hairs that would normally remain in telogen for the typical 4 to 12 weeks are cycled into anagen within a few days. Minoxidil is an example of a medication that can cause TE by moving the hairs prematurely into anagen phase.
  5. Delayed Telogen Release: Telogen is prolonged and there is slightly more synchronicity in cycling so that scalp hair falls out at the same time.

Acute Telogen Effluvium

Causes of acute TE include the following: drugs, fever, postpartum, crash dieting, thyroid deficiency, iron deficiency, prolonged anesthesia, malignant disease, renal failure, liver disease, malaborpstion, and psychological conditions.

Drugs
Drugs can cause acute TE, as listed in the tables at the end of this section. Certain classes of medications are known to cause TE like anti-coagulants (heparin and coumadin) with more than 10% of patients experiencing TE in a dose-dependent fashion. Anti-thyroid drugs that induce a state of hypothyroidism may also cause acute TE, like iodine, propylthiouracil, and carbimazole. Psychopharmacologic medications like lithium, valproate, carbamazepine, and tricyclic antidepressants have been implicated in acute TE. Oral contraceptives can cause TE 2 to 3 months after discontinuing treatment, which may be similar to what happens with delayed anagen release in the postpartum setting.

Fever
Fever can cause a severe TE 8 to 10 weeks afterwards. A fever may demand a high metabolic level from the body so that hair growth is impaired. Alternatively or in addition, interferons alpha and gamma that are released during a fever have also been shown to decrease epithelial proliferation that would impair the matrix cells within the follicles.

Postpartum
The state of pregnancy with an increased level of estrogen causes a sustained state of anagen, which is released synchronously into telogen following delivery. During pregnancy, anagen hairs increase from 84% in the first trimester to 94% by the third trimester. Increased hair loss may occur 1 to 4 months following childbirth and may continue for several months. Full recovery is expected in 4 to 12 months. Loss can primarily affect the frontal and temporal hairs and be less severe on subsequent pregnancies.

Crash Dieting
Young women in particular who starve themselves with a low protein diet can induce acute TE. Addition of a small amount of protein to the diet can prevent this problem. Diffuse hair shedding can occur within 1 to 6 months after the onset of a stringent diet. 0 to 1000 kCal per day has been associated with hair loss. Some related problems that may compound or be responsible for TE during a diet are relative decrease in thyroid function and associated increase in the hormone dehydroepiandrosterone during fasting.

Thyroid Influences
Hypothyroidism is a known cause of TE, and diffuse hair loss may be the first and only skin sign of hypothyroidism. A history suggestive of hypothyroidism includes weight gain, cold intolerance, and a low energy level. Thyroxine replacement usually corrects the TE unless the follicles have atrophied from longstanding hypothyroidism. The reverse is also true: very high levels of thyroid hormones can also engender TE.

Iron Deficiency
Iron deficiency with or without anemia has been found in 72% of women with diffuse hair loss. Iron deficiency even in the absence of anemia can cause acute TE. Iron deficiency can also unmask underlying androgenetic alopecia (AGA) in a woman predisposed toward AGA.

Prolonged Anesthesia
Prolonged anesthesia with possible influencing factors of blood loss and surgery can also lead to acute TE with regrowth of hair coming about 4 months afterwards.

Malignant Disease, Kidney Failure, Liver Disease, and Malabsorption
TE may be the first sign of Hodkin’s disease, which is known as “toxic telogen effluvium”. Chronic renal disease may lead to sparse, dry, and brittle hair with even thinning of body hair, including pubic and axillary hair. Liver disease can also cause diffuse hair loss whether the condition is hepatitis, cirrhosis, or fatty liver. Inflammatory bowl disease, particularly Crohn’s disease, has been associated with sparse hair and growth retardation.

Psychological Causes
Although acute anxiety and depression may cause TE, the paucity of literature to support this claim makes this cause relatively uncommon.

Chronic Telogen Effluvium

Diffuse cyclic hair loss in women was first described in 1959 by Guy et al. in otherwise healthy women. A modern term coined by Whiting is chronic telogen effluvium, which is not an uncommon condition. Typically chronic TE affects women between the ages of 30 to 60 years and occurs without a recognizable inciting factor. The degree of shedding can be severe in the early stages with hairs coming out in clumps. Unlike acute TE, chronic TE continues for years in a fluctuating pattern.

Patients are oftentimes concerned that they will progress toward total baldness, but reassurance that they will not progress toward complete baldness is important. Scalp and hair pain can be a related symptom that correlates better with emotional distress than with actual hair loss. In certain cases of chronic TE, women may have low levels of ferritin when using a male reference range even though they may be in the normal female range. Van Neste and Rushton feel that topping ferritin levels off into the male range (over 30 micrograms per liter) may be helpful. Nutritional supplementation is unwarranted, and excessive dietary supplements may actually induce TE.

After ruling out other sources of TE, treatment of chronic TE is focused on two principal methods: topping off ferritin levels and maintaining topical minoxidil 5% twice daily. Patients should of course be warned that minoxidil might cause TE early on when hairs are cycled prematurely from telogen into anagen phase but that this is a temporary phenomenon.

Drug-Induced Telogen Efflluvium (Less than 1% Incidence)
Albendazole
Fluoxetine
Nisoldipine
Aldesleukin
Flurbiprofen
Nortriptyline
Altretamine
Fluroxamine
Octreotide
Amiloride
Foscarnet
Olanzapine
Amiodarone
Ganciclovir
Omeprazole
Amitriptyline
Grepafloxacin
Paroxetine
Amlodipine
Haloperidol
Prazosin
Amoxapine
Ibuprofen
Propanefenone
Azathioprine
Imapramine
Propylthiouracil
Bromfenac
Indomethacin
Protriptyline
Buproprion
Ipratropium
Risperidone
Carvedilol
Ketoprofen
Ropinirole
Clofibrate
Lansoprazole
Sertraline
Clomiphene
Levothyroxine
Sparfloxacin
Clomipramine
Liothyronine
Sulindac
Desipramine
Lisinopril
Tacrine
Diethylstilbestrol
Losartan
Testosterone
Diflunisal
Meclofenamate
Tiagabine
Dopamine
Mefloquine
Tizanidine
Epinephrine
Mesalamine
Tocainide
Esmolol
Methimazole
Trimipramine
Estramustine
Mexiletine
Venlafaxine
Ethionamide
Nabumetone
Verapamil
Fenfluramine
Naproxen
Zaleplon
Fenoprofen
Naratriptan
Flecainide
Nefazodone

 

Drug-Induced Telogen Effluvium (1-5% Incidence)
Acyclovir
Cyclosporin
Lamotrigine
Allopurinol
Cytarabine
Letrozole
Amantadine
Dacarbazine
Leuprolide
Atorvastatin
Dactinomycin
Loratadine
Betaxolol
Delavirdine
Lovastatin
Bicalutamide
Dexfenfluramine
Nifedipine
Buspirone
Diclofenac
Pentosan
Captopril
Efavirenz
Riluzole
Carbamazepine
Fludarabine
Rofecoxib
Celecoxib
Gold
Tolcapone
Ceterizine
Granisetron
Topiramate

 

Drug-Induced Telogen Effluvium (>5% Incidence)
Acitretin
Alpha-Interferon
Ramipril
Cidofivir
Isotretinoin
Terbinafine
Danazol
Leflunomide
Timolol
Granulocyte colony
stimulating factor
Levobunolol
Valproic Acid
Lithium
Warfarin
Heparin
Moexipril

 

Drug-Induced Telogen Effluvium (exact incidence unreported)
Acebutolol
Fluconazole
Oral Contraceptives
Acetominophen
Fluoxymesterone
Oxaprozin
Acetohexamide
Fluvastatin
Paramethadione
Aminophylline
Gabapentin
Penbutolol
Aminosalicylate sodium
Gemfibrozil
Penicillamine
Amphotericin B
Gentamicin
Penicillins
Asparaginase
Guanethidine
Pergolide
Astemizole
Halothane
Pindolol
Atenolol
Hydromorphone
Pirbuterol
Bendroflumethiazide
Hydroxychloroquine
Piroxicam
Bisoprolol
Indinavir
Pravastatin
Bromocriptine
Isoniazid
Prazepam
Carteolol
Itraconazole
Probenecid
Carivastatin
Ketoconazole
Progestins
Chlorambucil
Labetolol
Propanolol
Chloramphenicol
Lamivudine
Pyrimethamine
Chlordiazepoxide
Levodopa
Quazepam
Chloroquine
Loperamide
Quinidine
Chlorothiazide
Lorazepam
Ranitidine
Chlorotrianisene
Loxapine
Ropinirole
Chloropropamide
Maprotiline
Saquinavir
Chlorothalidone
Mebendazole
Selegiline
Cimetidine
Mephenytoin
Simvastatin
Clonazepam
Mesoridazine
Sotalol
Diazoxide
Methusuximide
Stanozolol
Dicumarol
Methyldopa
Sulfasalazine
Didanosine
Methylphenidate
Sulfisoxazole
Diethylstilbestrol
Methyltestosterone
Thalidomide
Diflunidal
Methysergide
Thioguanine
Dopamine
Metoprolol
Thioridazine
Epinephrine
Minoxidil
Thiothixene
Esmolol
Misoprostol
Tiopronin
Estrogen
Mitotane
Trazodone
Ethambutol
Mycophenolate
Triazolam
Ethosuximide
Nadolol
Trimethadione
Etidronate
Nalidixic acid
Ursodiol
Etodolac
Neomycin
Vitamin A
Famotidine
Nimodipine
Zalcitabine
Felbamate
Nitrofurantoin
Zidovudine
Fenofibrate
Odansetron