Stress-induced Alopecia (Telogen Effluvium)

Diffuse hair loss can be caused by physical or psychological stress such as: childbirth (most common cause), high fever, chronic illness, emotional stress, physical stress, nutritional deficiency, and various drugs. The hair loss occurs several months after the stressor. The cause of the hair loss is termed telogen effluvium, the early entry of follicles into the telogen (resting) phase. Normally, 10-20% of follicles are in telogen. In stress-induced alopecia, greater than 25% of hairs are in telogen. More than 500 hairs can be lost daily, as compared with a normal value of under 100. The scalp is normal, without inflammation, erythema, or scarring.

With what can stress-induced alopecia be confused?

The differential diagnosis for diffuse non-scarring alopecia includes: nutritional deficiencies and toxic drugs, such as chemotherapy agents. Other causes of alopecia are either focal, have a specific pattern, or are scarring. However, occasionally androgenetic alopecia can be confused with stress-induced alopecia, especially in women. A diffuse pattern of alopecia areata is also a possibility. Other conditions that can cause non-scarring alopecia include: secondary syphilis, hyperthyroidism, hypothyroidism, anemia, loose anagen syndrome, and trichotillomania. Seborrheic dermatitis and tinea infection of the scalp can also cause hair loss. Systemic lupus erythematosus may also be a consideration.

How is stress-induced alopecia diagnosed?

A history of recent childbirth clinches the diagnoses in many cases. The hair may appear diffusely thin, or may not be recognized as such by the physician; sometimes the patient's complaint of losing hair is the only guide. The "pull test" is positive if, while pulling on about two dozen hairs, more than five come free. This is characteristic of stress-induced alopecia.

It is important to determine if the condition is due to emotional stress, physiologic stress, or metabolic abnormalities. A thyroid stimulating hormone level should be drawn to screen for hypothyroidism, which can manifest with dry, brittle, thinning hair, and loss of the lateral third of the eyebrow. Iron studies to rule out anemic, ANA to rule out autoimmuine disease, and RPR to rule out syphylis may all be useful. Biopsy is not usually required.

Nails should also be examined for Beau's lines, which are transverse lines or ridges on the nail plate reflecting period of physiologic stress.

How is stress-induced alopecia treated?

If the stressor is in the past, as it usually is, only reassurance is required. The condition will reverse itself over several months.

What is the prognosis for stress-induced alopecia?

Stress-induced alopecia usually resolves over several months, once the stressor has been eliminated. With an ongoing stressor, metabolic disturbance, or nutritional deficiency, the course may be prolonged. In some cases, the course may be protracted without an identifiable stressor.

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