Telogen effluvium — SAQ

Stem

A 28-year-old woman presents 3 months after a normal vaginal delivery with a 6-week history of increased hair shedding. She reports clumps of hair on the pillow, in the shower drain and on her brush. She is exclusively breastfeeding. On examination, there is diffuse thinning over the entire scalp with a positive hair pull test (>8 of 60 hairs). The scalp surface is smooth with no scarring, the part width is normal and there is no patchy loss. She is mildly anaemic (Hb 10.8 g/dL) and her ferritin is 25 microg/L.^[4]

Questions

a) What is the most likely diagnosis, and what clinical features support it? (2 marks)

b) What is the pathophysiological mechanism, and why is there a 2-3 month lag? (2 marks)

c) What investigations would you arrange to confirm the diagnosis and exclude mimics? (3 marks)

d) Outline your stepwise management plan for this patient. (3 marks)

Model answers

a) Diagnosis and supporting features (2 marks)

• Diagnosis: acute telogen effluvium (TE), most likely postpartum TE in this patient.

• Supporting features:
  • Diffuse, non-scarring hair loss over the entire scalp (not patterned, not patchy).
  • Positive hair pull test.
  • Smooth scalp surface with preserved follicular ostia (no scarring, no erythema, no scale).
  • Normal part width with bitemporal symmetry.
  • Onset 3 months postpartum, in a breastfeeding woman.
  • Concurrent iron deficiency (Hb 10.8 g/dL, ferritin 25 microg/L) acting as a co-trigger.

^[2][3]b) Pathophysiology and the 2-3 month lag (2 marks)

• During pregnancy, high oestrogen levels prolong anagen (the growth phase) and produce thick, lush hair. After delivery, oestrogen falls sharply, releasing a large cohort of anagen hairs into catagen and then telogen.
• This corresponds to Headington's "delayed anagen release" type: the very hormonal state that produced thick hair in pregnancy is also responsible for the synchronous shedding after delivery.
• Telogen has a fixed duration of about 3 months. The hair is only shed at the end of telogen during exogen. Hence the 2-3 month lag between the trigger (delivery) and visible shedding.
• Iron deficiency (ferritin 25 microg/L) is a co-trigger because iron-dependent enzymes in the hair matrix are needed to sustain anagen.

^[2]c) Investigations (3 marks)

• Trichoscopy (first-line): empty follicles, upright regrowing hairs, NO hair diameter diversity >20 percent, NO exclamation-mark hairs, NO yellow dots. The trichoscopy discriminates TE from androgenetic alopecia (diameter diversity), alopecia areata (exclamation-mark hairs, yellow dots) and cicatricial alopecia (loss of follicular ostia).
• First-line bloods: ferritin (target >70 microg/L), TSH and free T4 (exclude thyroid dysfunction), CBC (iron deficiency anaemia), vitamin D (25-OH), and zinc if deficiency is suspected. Ferritin is an acute-phase reactant; check CRP if unexpectedly high.
• Second-line if needed: hair pluck trichogram (>25 percent telogen hairs is suggestive); wash test (Rebora) if the pull test is equivocal. Biopsy is reserved for diagnostic doubt, suspected scarring or persistent undiagnosed shedding.
• Differential exclusion: patchy loss or scarring suggests alopecia areata or cicatricial alopecia (biopsy). Patterned loss with diameter diversity suggests FPHL (trichoscopy). Hair loss with systemic symptoms (weight loss, night sweats) prompts ANA, RPR/VDRL, HIV and chest imaging.

^[1]d) Management (3 marks)

• Reassure and educate that acute postpartum TE is self-limiting, with full regrowth expected within 6-12 months. The patient will not go bald. Explain the 2-3 month lag and the expected timeline of recovery.
• Correct the iron deficiency: oral iron with vitamin C, avoiding tea/coffee around the dose; re-check ferritin after treatment and continue until it normalises per local cut-offs. IV iron if oral iron is not tolerated or absorption is poor.
• Optimise nutrition: check and replace vitamin D and zinc if low, and continue an iron-rich diet. Encourage adequate protein and a balanced diet; discourage crash dieting.
• Address breastfeeding and postpartum factors: maintain adequate sleep, hydration and nutrition; manage postpartum thyroiditis (check TSH); offer psychological support if needed.
• Gentle hair care: avoid tight hairstyles, traction, chemical processing and excessive heat; use a wide-tooth comb and gentle shampoo; avoid repeated bleaching, perming or relaxing.
• Topical minoxidil can be considered if shedding persists or if FPHL overlap is suspected — discuss risks in breastfeeding with the patient first. Oral minoxidil is avoided during pregnancy and breastfeeding.

• Follow-up at 3 and 6 months; re-evaluate if no improvement by 12 months (consider biopsy, FPHL overlap, chronic TE).