Telogen Effluvium: Remembering Life's Events

Telogen effluvium is a common hair loss condition.  Patients note increased hair shedding - and hair starts collecting everywhere. There is hair around the house, hair on the floor, hair in the brush, hair in the sink, hair in the shower drain, hair in the car, hair at the office.  Spouses start to notice that there is more hair around than there used to be.  Even young children start picking up their parents hair and commenting that too much of mommy or daddy's hair is coming out. This is telogen effluvium.

Hair shedding can be caused by a wide range of 'triggers.'  These include physiologic stress, endocrine problems (including thyroid problems), nutritional problems, iron deficiency, and medications.  Other scalp diseases, including alopecia areata, and scarring alopecias can also cause hair shedding but these are different from telogen effluvium.

Sometimes it takes a bit of detective work to figure out what might be the trigger of a patient's hair shedding.  In many cases we find the cause, but in some cases we don't and just wait for the shedding to stop. 

There are many things I enjoy about being a hair doctor - but one aspect in particular I enjoy is pinpointing exactly in time when someone's hair loss 'trigger' might have occurred.  This usually occurs in a couple of classic scenarios.

Let me explain.

Suppose I see a patient who is worried about their hair shedding.   They tell me that the shedding used to be really bad a few months ago but is actually starting to get back to normal. After asking dozens of questions I proceed to examine the scalp.   I look for signs of various hair diseases, and there does not appear to be any.  Then as a final step, I lift 50-100 hairs straight up and - voila - I see a remarkable number of 3 cm hairs.  Normally, I would expect to see hairs of all different lengths - some 1 cm hairs, some 2 cm hairs, some 3 cm hairs, some 4 cm hairs and so on. But the patient in our example has many many 3 cm hairs. In fact - way too many 3 cm hairs!

What does this unusual number of 3 cm hairs tell me?

Well, it tells me the patient had some major trigger of hair shedding take place about 6 months ago. 

After a trigger like a surgery, or a crash diet, the hairs of some individuals can be rapidly shifted into a resting period called the "telogen phase". These hairs spend a mandatory period of three months in the telogen phase and then all get shed from the scalp at a similar time.   Because hairs normally grow back at a rate of about 1 cm per month - if I see alot of 3 cm hairs, I know they've been growing back for about three months and I know the trigger must have occured about 3 months before that - for a total of six months.

So when I see lots of 3 cm hairs, I know there was some major trigger about 6 months ago (3+3=6).When I see lots of 5 cm hairs, I know there was some major trigger about 8 months ago (5+3=8). When I see lots of 7 cm hairs,  I know there was some major trigger of hair shedding about 10 months ago (7+3=10). It's as simple as that.

 So for me, telogen effluvium can sometimes boil down to helping patients remember life's events.  If the patient's shedding has stopped and they are growing back their hair, I can often pinpoint when the hair loss occured.  If the shedding is ongoing and has not yet stopped, a bit of detective work especially blood tests, will be necessary.

So for the patient with 3 cm hairs, there is one simply question that can clinch the diagnosis... What happened in your life 6 months ago?  It sometimes takes patients a little bit of time and sometimes a calendar even gets pulled out from a bag, but the trigger often comes from remembering life's events:

Oh, now that you mention it, I was in the hospital, sick as a dog!

or ... That's when I started this new drug

or ... That's when my dad passed away

or ... That's when I have a bad flu and was off work for weeks

or ... That's when I had my surgery

The list goes on and on. Telogen effluvium can sometimes be challenging to diagnose. Every patient needs some basic blood work to make sure that there is no thyroid abnormality and no significant iron deficiency that caused the hair shedding. But if the hair shedding has already slowed down and is starting to grow back, one can often pinpoint exactly in time when the shedding started and then narrow down the exact cause.