Loss of hair 3 months after labor and delivery. Ferritin, TSH, Vitamin D and zinc all normal.

The patient with telogen effluvium may bring in a bag of hair to show you ("bag of hair sign").

TELOGEN EFFLUVIUM

Telogen Effluvium (TE) is the loss of hair on the scalp starting about 2-3 months after a stressful event--either emotionally or physically. Common triggers include significant weight loss, labor and delivery, surgery, COVID-19, or severe psychological stress.

• Normally, 90% of hairs are growing, 10% resting. but in telogen effluvium, 70% growing, 30% resting.
• Normal to loose 100 hairs per day, In telogen effluvium, lose 300 hairs per day.
• SEND hairs to telogen = Stress, endocrine (pregnancy, thyroid), nutritional, drug.
• Vitamin D deficiency was much more common compared to patients with alopecia areata with an odds ratio of 3.6.
• Don't make this diagnosis without making sure the iron level is adequate and the thyroid is normal.
• Or maybe it is telogen effluvium triggered by SEND in the settig of low iron.
• Consider drug induced TE, e.g. from retinoids, azole antifungals, mood stabilizers, anticoagulants (e.g heparin, coumadin) and antihyptensives.

Clinical

The patient, usually a woman, complains of loss of hair diffusely, but mainly across the top and along the frontal hair line. She may bring in a bag of hair to show you ("bag of hair sign"). The hair pull test is positive in the acute phase. Microscopic examination of the hair shows an excess of club hairs.

One proposed variant is chronic telogen effluvium which is defined as chronic diffuse scalp hair shedding for more than 6 months. In this case, the severity may wax and wane. Some have defined chronic telogen effluvium as diffuse hair loss that includes the occipital area (to exclude androgenetic alopecia).

Workup

Workup should include thyroid function, ferritin, vitamin D and zinc levels. Ferritin should be above 40 ng/ml. If the ferritin is below 40, see iron deficiency alopecia. Carefully analyze the drug list, paying particular attention to medications started 1-6 months prior to onset of the alopecia. See also workup of hair loss in a woman.

Potential Drugs inducing Alopecia

• Heparin
• Coumadin
• Isotretinoin
• Anticonvulsants. Anticonvulsants can cause low biotin, resulting in hair loss.

Differential Diagnosis

See hair loss in a woman.

RegionalDerm

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