Identify, Eliminate Triggers To Reduce Hair Shedding

STOWE, VT. — Getting to the root of diffuse hair shedding requires uncovering and eliminating or treating the possible triggers, said Wilma F. Bergfeld, M.D.

“The key to optimal management of shedding, or telogen effluvium, is detective work,” Dr. Bergfeld said at a dermatology conference sponsored by the University of Vermont. “You can't make most diagnoses from the door. You have to get up close and really look at the scalp.”

Taking adequate time for a thorough history, determining whether the hair is coming out at the root or breaking off, acquiring hair and scalp samples for biopsy and culture in the absence of a well-defined trigger, and assessing hair density and loss patterns using hair-loss measurement scales can provide important clues, as can the results of laboratory tests, including complete blood count, comprehensive metabolic panel, mineral levels, and an androgen screen, said Dr. Bergfeld, head of the clinical research and dermatopathology sections at the Cleveland Clinic.

“Ask the patient to describe how much hair they think they shed and when they notice it most,” Dr. Bergfeld suggested. “And if a patient comes in with a bag of hair that she's lost, remember to ask her how long she's been collecting it.”

Ask patients when the hair loss began, if it has been consistent, and whether there's a family history, Dr. Bergfeld continued. Also note all medications the patient takes, routine hair care habits, and whether the patient has had recent medical problems, surgeries, or childbirth.

Sometimes, the hair-loss trigger may be something as easy to identify as a deficiency of dietary zinc or vitamin A. In such cases, “when the nutrients are replaced, the shedding disappears,” Dr. Bergfeld said. In other cases, however, multiple triggers may be responsible. The range of possibilities includes illness or infection, childbirth, drug reactions, metabolic events (such as iron-storage anemia), hormonal abnormalities, endocrine disorders, surgery, psychological stress, scalp disease, systemic disorders, or genetic conditions such as androgenic alopecia.

“Noticeable shedding usually begins within 2-4 weeks after the insult, or trigger, although it can be months in some cases,” Dr. Bergfeld said. “For example, significant shedding is common in young females post partum as a consequence of the trauma and hormonal changes associated with birthing, but breast-feeding can delay the shed by months.”

Patients should be reminded that some shedding of hair is normal. In most people, up to 20% of the scalp hair is in telogen at a given time. Telogen effluvium is triggered when a physiologic or other event causes a greater number of hairs to enter telogen at one time. Acute telogen effluvium is usually self-limiting as the trigger event doesn't recur, Dr. Bergfeld said. When this type of nonscarring hair loss is persistent, however, either the trigger has not been eliminated or there is a more pervasive underlying medical condition that warrants further evaluation, she noted.

Management should include education about the hair growth cycle, treatment of underlying nutritional deficiencies, and possibly a prescription for minoxidil to promote hair growth, she said. “Often what is most important is reassurance that the shedding will not lead to baldness and that hair is being replaced.”