Chronic Telogen Effluvium (CTE) is a nonscarring, generalized form of hair loss triggered by an uncertain cause. This type of excessive shedding affects the whole scalp and is common in otherwise healthy middle-aged women.
Chronic Telogen Effluvium causes diffuse thinning of scalp hair, along with the temporary recession of the hairline. CTE is considered a distinct, separate, entity from acute telogen effluvium due to its fluctuating, long course that can last 5 to 7 years.
What happens during Chronic Telogen Effluvium?
Human hair follows a four stage growth cycle:
- the anagen phase (growth phase),
- the catagen phase (transition phase),
- the telogen phase (resting phase),
- and the exogen phase (shedding phase).
In Telogen effluvium, the early entry of hair follicles in the telogen phase is one of the established pathophysiologies. This entry transition increases the rate of daily hair loss to more than the regular 100 strands per day. However, as the hair loss involves the entire scalp, the suffering individual observes a thinning of the hair rather than the development of full-blown baldness.
Functional variants of CTE.
Five potential alterations in the hair cycle are reported to be present in chronic telogen effluvium. Each of these alterations favors certain predisposed conditions that are either potential risks, or stimulating factors for Telogen Effluvium development.
- Immediate anagen release is observed when hair follicles abruptly switch from anagen to telogen phase prematurely. The result of this alteration is visible within 2-3 months.
- Delayed anagen release, this type of TE is commonly associated with pregnancy. The fluctuation of elevated maternal hormones throughout the pregnancy that drop postpartum is justified as a provoking factor of CTE. The entry of hair follicles into the telogen phase is delayed during pregnancy due to these elevated hormones, resulting in lower than regular hair loss. However, postpartum these follicles regain their normal cycle, and heavy hair loss resumes to compensate for the period of minimal hair loss.
- Short anagen syndrome is the most common type of telogen effluvium with an idiopathic cause.
- Immediate telogen release generally occurs with drug-induced shortening of telogen resulting in premature hair loss. Drugs such as minoxidil can precipitate immediate telogen release.
- Delayed telogen release, this variant of TE is frequently responsible for seasonal hair loss, involving a prolonged telogen phase followed by a delayed transition to anagen.
What are some suspected causes of chronic telogen effluvium?
CTE can also be classified into primary or secondary types, with the Primary CTE remaining idiopathic, and Secondary due to any underlying conditions. Some of the common suspected secondary causes of Chronic Telogen Effluvium involving the whole scalp include:
- acute telogen effluvium,
- anagen effluvium,
- iron deficiency,
- and nutritional disturbances.
Furthermore, emotional or physiological stress are also common trigger factors. These are generally noted after stressful events such as childbirth, chronic illness, major surgery, and severe emotional disorders.
How is it diagnosed?
The diagnosis for CTE is made by excluding other conditions that cause chronic hair loss. History and complete physical examination further support the diagnosis. The routine investigation carried out includes full blood count and thyroid function tests. If the clinical indication arises, syphilis serology, antinuclear antibody (ANA) titer, serum zinc levels, and other investigations may also be performed.
How is it managed?
The first step in the management of CTE remains patient counseling as the conditions is believed to be self-limiting. Removing the triggering factor(s) is the next step to ensure rapid recovery, this can be done through:
- removal of physical and psychological stresses,
- avoidance of catagen inducing drugs (beta-blockers, retinoids, anticoagulants, or antithyroid drugs),
- and treatment of conditions that induce early telogen (thyroid dysfunction, hyperandrogenism, or hyperprolactinemia).
Currently, no FDA approved drug is highly efficient as catagen inhibitors or anagen inducers. Supplementation therapy for deficiencies that promote catagen, such as iron, zinc, estradiol, and proteins, is also recommended by multiple studies.
Minoxidil is the only recommended medication that is employed in patients with CTE and has shown to prolong the anagen phase.
Whiting DA. Chronic telogen effluvium: increased scalp hair shedding in middle-aged women. Journal of the American Academy of Dermatology. 1996 Dec 1;35(6):899-906.
Malkud S. Telogen effluvium: a review. Journal of clinical and diagnostic research: JCDR. 2015 Sep;9(9):WE01.
Grover C, Khurana A. Telogen effluvium. Indian Journal of Dermatology, Venereology, and Leprology. 2013 Sep 1;79(5):591.
Marks, James G; Miller, Jeffery (2006). Lookingbill and Marks’ Principles of Dermatology (4th ed.). Elsevier Inc.
James, William; Berger, Timothy; Elston, Dirk (2005). Andrews’ Diseases of the Skin: Clinical Dermatology.
Rebora A. Intermittent chronic telogen effluvium. Skin Appendage Disorders. 2017;3(1):36-8.
TrÃ¼eb RM. Telogen effluvium: is there a need for a new classification. Skin appendage disorders. 2016;2(1-2):39-44.
Aziz AM, Hamed SS, Gaballah MA. Possible relationship between chronic telogen effluvium and changes in lead, cadmium, zinc, and iron total blood levels in females: A case-control study. International journal of trichology. 2015 Jul;7(3):100.
Davis, M.G.; Thomas, J.H.; van de Velde, S.; Boissy, Y.; Dawson, T.L.; Iveson, R.; Sutton, K. (December 2011). “A novel cosmetic approach to treat thinning hair”. British Journal of Dermatology.
Headington JT. Telogen effluvium: new concepts and review. Archives of dermatology. 1993 Mar 1;129(3):356-63.