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Abrupt Onset, Excessive Hair Fall (Telogen Effluvium)

Body hair has played a key role in the evolutionary success of all warm-blooded creatures that inhabit the Earth. Heat insulation is perhaps the most crucial, but other important functions of hair are the communication of social and sexual maturity – such as a lion’s mane, or the sensory antennae that is the whiskers of cats; as vital camouflage with surroundings, in displays of aggression, or to promote scent dispersal of territorial and mating animals.

Man is the least hairy of the primates but body hair still aids as a thermal regulator; odour dispersion through armpits and groin – and perhaps most significantly over the past centuries – as a fashion and cosmetic adornment of the head.

Hair grows from follicles, which together with sweat and oil glands are appendages of skin tissue. It is estimated that a sexually-mature adult male possesses approximately five million hair follicles on his body; one million on the head and (on average) 100,000 in the scalp (Dawber + Van Neste: 1995). All the hair follicles a person will possess during their lifetime are believed to be in place at the halfway point of a normal pregnancy. And whilst there has been much research into follicle ‘cloning’ – hair follicles cannot be regenerated by adult skin once they are lost.

Scalp follicle hair growth in humans is a continuous cycle which in normal hair growth comprises two main phases:

  • Anagen – the growth phase of 2-8 years; 85-90% of all hair is ‘anagen’ in normal circumstances.
  • Catagen/Telogen – the resting and shedding phase of the hair cycle are generally combined; ‘catagen’ duration is around 7 days and ‘telogen’ 2-3 months. Only 6-10% of hair is in ‘telogen’ at any given time.

Human hair follicles are NON-synchronised to prevent seasonal moulting, although different parts of the body have varying hair growth depending upon the season of the year (Van Neste + Lachapelle: 1989). Every follicle has an independent hair cycle, and repeats this cycle 10-20 times over a person’s lifetime.Telogen Effluvium/Defluvium (TE) was the diagnostic term to describe the rapid and excessive shedding of follicle scalp hair following pyrexia illness and fever. TE was also known as ‘Post-febrile Alopecia’.

TE is now held to be a non-specific reaction to a wide variety of physiological and/or emotional stressors that synchronise up to 50% of all scalp hair follicles into a premature termination of ‘anagen’ phase – which then moves into ‘telogen’ shedding phase.

Some common initiators of TE are:

  • Acute illness – particularly when accompanied high febrile states (elevated body temperature); vomiting and diarrhoea – especially from contaminated food/water.
  • Severe Allergic reactions from any source, but most commonly from colour tints, perming solutions or topical treatments such as Minoxidil (usually with added Retinoic acid). These reactions may occur spontaneously or from incorrect application/exposure time, or NOT ‘patch’ testing prior to 1st-time use – OR the user (or their hair professional) has ignored early signs of irritation such as itching, burning or breathing difficulties.

Severe reactions are potentially life-threatening as they may lead to anaphylaxis and respiratory arrest, and medical advice must always be sought. Excessive hair shed in its various forms (Telogen Effluvium, Alopecia areata/totalis/ universalis) or hair breakage may occur even before the sufferer leaves the Salon. Scalp scarring, follicle destruction and ongoing- skin hyper-sensitivity as permanent damage may also result.

Exposure to toxic chemicals due to inhaling or skin contact. These chemicals may be industrial forms (ammonia, chlorine, hydrochloric acid), or motor vehicle exhaust (i.e.: mechanics working in vehicle repair garages), or deliberately ‘sniffing’ the contents of aerosol cans; petroleum or gases.

  • Surgical or extensive dental procedures – particularly when substantial blood loss or intra-operative complications have occurred.
  • The commencement or (especially) cessation of certain medication such as oral or troche’ hormonal therapy (OCP/HRT); injected or implanted contraceptives/HRT, thyroid medication, Statins; anti-androgen medication such as Spironolactone), anti-convulsant/mood stabilising drugs (Sodium Valproate/Phenytoin Sodium), the use of certain performance enhancing or ‘body-building’ drugs (anabolic steroids).
  • The administration of intravenous or strong combination drugs such as antibiotics or chemotherapy or blood dialysis.
  • Rapid weight loss in a short period of time either by ‘crash-diet’ or illness. A dramatic change in one’s diet; any ‘fad’ diet that promotes the exclusive or excluded intake of certain major foods groups, or harsh detoxification diets.
  • Severe shock or intense protracted stress – ‘stress’ is a common reason given for hair loss problems, but it’s usually only the most severe events which will trigger a TE hair shed or onset of Alopecia areata – or other autoimmune problem.

The death or grave illness of a loved one, marriage or other relationship breakdown, employment or career termination with resultant financial anxieties are just some examples of the ‘types’ of emotional stressors likely to cause scalp hair loss.

  • Following childbirth (post partum) or (sadly) miscarriage. Post partum alopecia in this TE form is considered the one true moult in humans, and results from the intense hormonal changes within a pregnant woman before and after childbirth. Post-partum TE usually commences 8-10 weeks childbirth but when it commences and how severe the TE depends (from my clinical experience) on the following factors:

Whether or not the woman is breastfeeding
Her nutritional status after childbirth
How ‘sleep-deprived’ she is with her newborn infant
Any metabolic disturbance arising from her pregnancy (i.e.: thyroid disturbance or diabetes)

Commonly one-four months (average 2-3 months) after any of these experiences, the hair will begin to shed abruptly and be lost in excessive amounts for about 2-3 months before settling.Whenever a telogen effluvium episode is triggered the shed is diffuse i.e.: hair fall from the entire scalp rather than focal or patchy loss. The rapidly dividing matrix cells of growing hair are very sensitive to nutritional, metabolic/hormonal or environmental disturbances – and often one of the first areas of the body to reflect disturbances in physiological functioning.

Ordinarily TE is considered a ‘temporary & self-correcting’ form of diffuse hair loss unless the scalp suffers ‘cicatricial (scarring) damage due to chemical reaction from applied topical products.

In certain circumstances an initiating incident may temporarily disrupt ‘anagen’ phasing rather than terminate it. The hair shaft continues to grow, but is fragile where the interruption occurred. As the hair grows beyond its supporting follicle it fractures and breaks off at this weakened point (termed Trichorrhexis nodosa) approximately 4-6 weeks after the initiating incident (Olsen, EA: 1994). Over-processing of hair in perming or bleaching of hair is a common cause of this.

Management:
Whilst TE is generally a self limiting and ultimately self-correcting form of alopecia, hair is shed in massive amounts and the scalp quickly exposed as hair density falls to 50% of what it previously was. The threat of total hair loss is emotionally devastating to women of any age – particularly a post-partum mother; often sleep deprived and coping with a new baby.

A careful and detailed history should be reviewed by an experienced, qualified Practitioner to establish the nature of the alopecia; that it’s initiating trigger/s and time frame of shedding fall within the parameters of a TE diagnosis.

Reassuring the client that (in time) a full recovery of lost hair density is the expected outcome cannot be over-emphasised. A blood pathology test should be ordered to assess iron studies, (red cell) zinc, Vitamin D, Iodine, B12 etc. All levels need to be in the 50-75th percentile of respective reference ranges to facilitate a more rapid‘re-adjusting’ of follicle anagen phasing.

Activance Rhodanide* is a natural ‘leave-in’ treatment (the vitaminoid Rhodanide is the active nutrient) which I have found very effective in accelerating TE resolution. Unlike Minoxidil it is completely safe for pregnant or lactating/breast-feeding women to use (Minoxidil can be excreted in breast milk). www.activance.com.au .

Photo-biotherapy such as ‘soft/cold’ low level laser light (LLLT) is in my experience most effective in TE shedding due to its anti-inflammatory and vaso-dilating (increased blood flow) properties. To be therapeutically effective these laser appliances should be classified ‘3A’; be in the red light spectrum + wavelength vicinity of 660-780nm. Bio-available power output should be 60-100mW. Note: some commercially-sold hand held lasers have a power output of barely 1.5-5mW! Despite the seller’s claims I believe they offer little more than placebo effect.

I would also be cautious of laser ‘caps’ which can be continually worn UNDER a hat or cap. Trelles et al (1984) found too-frequent LLLT had a retrograde effect on Alopecia areata trial subjects. I would caution readers to be mindful that LLLT stimulates rapid-growing tissue such as skin and hair – but malignancies (tumours and cancers) are rapidly growing also.

I would consider anyone seeking treatment for hair loss following melanoma, brain tumour, malignancy anywhere on the head or upper body; breast cancer, lymphoma NOT to be a safe candidate for LLLT due to stimulation or recurrence of metastases (Pontinen: 1992). Clients with pacemakers or labile (unstable) epilepsy is also a contraindication for LLLT.

Suitable Clients with early TE shedding would require TWO 15-20 minute sessions per week for a maximum of six weeks (12 treatments). Twelve treatments should cost no more than a couple of hundred dollars and be undertaken in conjunction with baseline blood testing and any subsequent supplementation required. LLLT is a non-UV light source and considered an adjunct (2nd line additional) treatment.

Continual hair shed over many months is often given the label ‘Chronic Telogen Effluvium’. In my opinion this is a more a ‘label’ than a diagnosis – such as ‘stress’ or ‘irritable bowel’ – and ‘Chronic hair loss for investigation’ may be a more proactive provisional diagnosis.

The reason/s for hair loss in females is multi-factorial and linked to their nutritional-metabolic and/or hormonal ability to support hair growth. Thinning scalp hair density is frequently an early warning sign of internal disturbance such as iron deficiency, thyroid dysfunction or developing autoimmune condition (such as Lupus or autoimmune thyroiditis).

The amount of hair shed daily or over a week varies in all of us, and is determined by a number of factors. Therefore the practical definition of excessive hair loss is ‘more than the individual would normally lose.’

Copyright Anthony Pearce 2009 (revised February 2015)

* ‘Professional Series’ strength is 50% stronger, anti-inflammatory + more effective in the treatment of TE than commercially-available forms. Activance ‘Blue’ ultra-hypoallergenic formula should be used on children or babies.