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Chronic TE: Incidence, Clinical and Biochemical Features, and Treatment (Telogen Effluvium)
Chronic Telogen Effluvium: Incidence, Clinical and Biochemical Features, and Treatment
Little has been written about telogen effluvium since the first description by Kligman1 in 1961, especially about the idiopathic and acute forms as a consequence of certain drug treatments, delivery, and other chronic or acute febrile diseases. In 1996, Whiting2 published an excellent article about chronic telogen effluvium. The term refers to a diffuse hair loss that includes the occipital area and persists for more than 8 months without any change. It appears that some dermatologists have not read this article in depth; in our trichological unit we still receive patients with this diagnosis who have been told by their physicians that there is no effective treatment for chronic telogen effluvium.
Patients and Methods
From January 1997 through February 1998, 123 patients with chronic telogen effluvium were examined in our trichological unit. A clinical history was obtained, and biochemical analysis, including the assessment of hormone levels, and a trichogram were performed. For men (n=27), we prescribed 5% minoxidil solution. For premenopausal women (n=14), we prescribed 5% minoxidil solution plus cyproterone acetate (not available in the United States), 50 mg, from day 5 to day 15 of their menstrual cycle, always taken together with ethinyl estradiol, 0.035 mg/d. For postmenopausal women (n=82), we prescribed 5% minoxidil solution plus cyproterone acetate, 50 mg/d. Alternatives to cyproterone acetate, 50 mg/d, could be spironolactone, 50 to 100 mg/d, or flutamide, 125 to 250 mg/d.
Results
As reported by Rebora,3 chronic telogen effluvium does not occur exclusively in older women; however, in our study, it clearly occurred more frequently in postmenopausal women (67%). Trichodynia4-5 was found in only 1 man (4%), in 9 premenopausal women (64%), and in 28 postmenopausal women (34%). These percentages are similar to those reported by Rebora for postmenopausal women, but much higher than those reported for premenopausal women.
Biochemical analysis revealed no significant abnormalities. In 11% of men (n=3), we observed a slightly increased level of progesterone (mean, 10 nmol/L [318 ng/dL]; normal range, 0.6-8 nmol/L [20-250 ng/dL]). In 21% of premenopausal women (n=3), slightly elevated levels of dehydroepiandrosterone sulfate (mean, 1.13 nmol/L [4.20 µg/mL]; normal range, 0.3-9.0 nmol/L [0.10-3.33 µg/mL]) and androstanediol glucuronide (mean, 2.01 nmol/L [4.3 ng/mL]; normal range, 0.14-1.59 nmol [0.3-3.4 ng/mL]) were observed. The androstenedione and free testosterone levels were always within the normal ranges. In postmenopausal women, the mean level of estradiol was 44 pmol/L (12 pg/mL) (normal range, 0-2129 pmol/L [0-58 pg/mL]); progesterone, 0.7 nmol/L (21 ng/dL) (normal range, 0.3-2.3 nmol/L [11-73 ng/dL]); and free testosterone, 0.3 nmol/L (9 ng/dL) (normal range, 0.2-0.8 nmol/L [6-23 ng/dL]), all on the low end of the normal ranges. The most important findings from the trichograms were the presence of 20% to 30% telogenic hairs and 15% to 35% dystrophic hairs when the evolution time was longer than 2 years.
Comment
Before the onset of alopecia, the hair density of our patients was normal or high; the bitemporal recession was more evident in premenopausal women than in postmenopausal women, but loss of occipital hair was demonstrated by all patients, men and women. This result allows us to make a differential diagnosis of androgenetic alopecia, and a biopsy is therefore unnecessary. The relationship between the most advanced case of chronic telogen effluvium and the observation of more dystrophic hairs in the trichogram is also important. The normal evolution period for chronic telogen effluvium is from 6 months to 7 years; in our study, this evolution period was longer for postmenopausal women (5 years, 3 months) than for men (2 years, 6 months) and premenopausal women (3 years, 2 months). This long, fluctuating course allows us to differentiate chronic from acute telogen effluvium, and the presence of 20% to 30% telogenic hairs and 15% to 35% dystrophic hairs on the trichogram confirmed the diagnosis.
Chronic telogen effluvium can improve with treatment. As outlined above, 55.2% of our patients (n=68) had a good response to treatment; 56 of these patients (84%) were postmenopausal women. Among 31 patients (25.2%) who experienced a moderate response to treatment and achieved cosmetically acceptable results, 23 (74%) were postmenopausal women. Only 24 patients (19.5%) (11 men, 10 premenopausal women, and 3 postmenopausal women) had no response. With a success rate of over 70%, we consider the response to this treatment satisfactory.
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- Chronic TE: Incidence, Clinical and Biochemical Features, and Treatment - HairSite Admin, 29.06.2008, 01:18