Effluvium (Telogen and Anagen)

Background

Effluvium are divided into two types based upon the histopatholgic and clinical findings. Telogen effluvium is a diffuse hair loss during stress with premature development of catagen and telogen follicles and premature termination of anagen follicles. It presents with diffuse thinning of scalp hair which may not be clinically obvious. A biopsy shows a relatively greater number of telogen follicles with minimal inflammation in the dermis. A hair pluck will reveal telogen hairs in excess of 25% (normal is 10-15%).

Anagen effluvium (or defluvium) occurs much faster than telogen effluvium, usually one month or less after the stressing event. There is loss of anagen hairs which usually break or become easily detached.

Similar events may cause both conditions including illness, malnutrition, chronic infections, cancers and occasionally drugs (heparin, clofibrate, gentamycin, nicotinic acid, nitrofurantoin, salicylates, oral contraceptives, anticonvulsants, excess vitamin A, and minoxidil. Anagen effluvium may develop following antimitotic agents used in cancer chemotherapy, thallium, arsenic, radiation therapy, and vitamin A inotoxication.

Outline

Disease Associations
Clinical Variants
Histopathological Features and Variants
Special Stains/Immunohistochemistry/Electron Microscopy
Differential Diagnosis
Commonly Used Terms
Internet Links

DISEASE ASSOCIATIONS CHARACTERIZATION

HIV-1

Clinical and histopathologic features of hair loss in patients with HIV-1 infection.

Smith KJ, Skelton HG, DeRusso D, Sperling L, Yeager J, Wagner KF, Angritt P.

United States Army Medical Research Institute for Chemical Defense, Aberdeen, Maryland, USA.

J Am Acad Dermatol 1996 Jan;34(1):63-8 Abstract quote

BACKGROUND: Hair loss is common in patients with HIV-1 infection, and in black patients this loss may be associated with straightening. Possible causes are frequently present in patients with HIV-1. These causes include chronic HIV-1 infection itself and recurrent secondary infections, nutritional deficiencies, immunologic and endocrine dysregulation, and exposure to multiple drugs. However, histopathologic features have rarely been reported in these patients.

OBJECTIVE: The objective was to evaluate the changes in the hairs of a group of these patients and to identify the light microscopic and ultrastructural changes in the hairs and the histologic changes in the scalp.

METHODS: Hair plucks and pulls with scanning electron microscopy of the hairs were done on 10 patients with late-stage HIV-1 infection. In addition, scalp biopsy specimens were examined in both vertical and transverse sections.

RESULTS: All patients had telogen effluvium. Numerous apoptotic or necrotic keratinocytes were seen in the upper external root sheath follicular epithelium in addition to a mild to moderate perifollicular mononuclear cell infiltrate often containing eosinophils. Variable dystrophy of the hair shafts was also a consistent feature.

CONCLUSION: Although telogen effluvium is a common response to a wide spectrum of biologic stresses, the presence of apoptotic or necrotic keratinocytes within the upper end of the external root sheath epithelium and dystrophy of hairs may be markers of hair loss in patients with HIV-1 infection.

CLINICAL VARIANTS CHARACTERIZATION

MALE

Chronic telogen effluvium in a man.

Thai KE, Sinclair RD.

Department of Medicine (Dermatology), The University of Melbourne, St Vincent's Hospital, Victoria, Australia.
J Am Acad Dermatol 2002 Oct;47(4):605-7 Abstract quote
Chronic telogen effluvium is a recently described condition, in which there is persistent excessive hair shedding. Hairs are replaced as quickly as they shed, so patients never become bald. This condition is found primarily in women.

We describe chronic telogen effluvium in a man; the diagnosis may have only become obvious because of his long hair.

HISTOLOGICAL TYPES CHARACTERIZATION

GENERAL

VARIANTS

CHRONIC TELOGEN EFFLUVIUM

Chronic telogen effluvium.

Whiting DA.

Department of Dermatology and Pediatrics, University of Texas, Southwestern Medical Center at Dallas, USA.

Dermatol Clin 1996 Oct;14(4):723-31 Abstract quote

Chronic telogen effluvium is not uncommon. It is a form of diffuse hair loss affecting the entire scalp for which no obvious cause can be found. It usually affects women of 30 to 60 years of age who generally have a full head of hair prior to the onset of shedding. The onset is usually abrupt, with or without a recognizable initiating factor. The degree of shedding is usually severe in the early stages and the hair may come out in handfuls.

Chronic telogen effluvium has distinctive clinical and histologic features that are usually diagnostic. Chronic telogen effluvium contrasts with classic acute telogen effluvium by its persistence and its tendency to fluctuate for a period of years.

Patients are particularly troubled by the continuing hair loss and fear total baldness. Repeated reassurance that the condition represents shedding rather than actual hair loss and does not cause complete baldness is necessary. Chronic telogen effluvium does appear to be self-limiting in the long run.

Chronic telogen effluvium: increased scalp hair shedding in middle-aged women.

Whiting DA.

Department of Dermatology and Pediatrics, University of Texas Southwestern Medical Center, USA.

J Am Acad Dermatol 1996 Dec;35(6):899-906 Abstract quote

BACKGROUND: Diffuse loss of scalp hair is a common problem in middle-aged women. A segment of these cases represents idiopathic chronic telogen effluvium (CTE).

OBJECTIVE: The purpose was to establish distinctive clinical and pathologic criteria for the diagnosis of CTE to facilitate its differentiation from androgenetic alopecia (AGA) and systemic causes of chronic diffuse hair loss.

METHODS: A group of 355 patients (346 females, 9 males) with diffuse generalized thinning of scalp hair of unknown origin were classified as having CTE and were included in the study. Characteristically they presented with a history of hair loss with both increased shedding and thinning of abrupt onset and fluctuating course and showed diffuse thinning of hair all over the scalp, frequently accompanied by bitemporal recession. Two 4 mm punch biopsy specimens were taken mostly from the mid or posterior parietal scalp of these patients. The biopsies were performed at these same areas in 412 patients with AGA (193 male, 219 female). Similar paired biopsy specimens were also taken from 22 normal control subjects (13 males, nine females). Specimens were sectioned horizontally and vertically and were examined for terminal and velluslike (miniaturized) hairs, follicular stelae, follicular units, and perifollicular inflammation and fibrosis.

RESULTS: In horizontal sections of 4 mm punch biopsy specimens from patients with CTE the average number of hairs was 39, the terminal/velluslike hair ratio was 9:1, 89% of the terminal hairs were in anagen, and 11% were in telogen. In AGA these values were 35, 1.9:1, 83.2%, and 16.8%, respectively, and in normal control subjects 40, 7:1, 93.5%, and 6.5%, respectively. Significant degrees of inflammation and fibrosis were present in only 10% to 12% of cases of CTE and normal controls, but occurred in 37% of cases of AGA. CTE ran a prolonged and fluctuating course in many patients.

CONCLUSION: CTE, which usually affects 30- to 60-year-old women, starts abruptly with or without a recognizable initiating factor. It may be distinguished from classic acute telogen effluvium by its long fluctuating course and from AGA by its clinical and histologic findings.

SPECIAL STAINS/
IMMUNOPEROXIDASE/
OTHER CHARACTERIZATION

SPECIAL STAINS

Elastic tissue in scars and alopecia.

Elston DM, McCollough ML, Warschaw KE, Bergfeld WF.

Department of Dermatology, Wilford Hall Air Force and Brooke Army Medical Centers, Fort Sam Houston, Texas 78234-6200, USA.

J Cutan Pathol 2000 Mar;27(3):147-52 Abstract quote

A recent report suggests that elastic fibers appear in scars in a time-dependent fashion. This observation prompted our investigation, because we have found elastic tissue stains helpful in determining the pattern of scarring in cases of permanent alopecia.

We carried out this investigation to determine if the Verhoeff-Van Gieson (VVG) elastic stain can reliably differentiate scarred from non-scarred dermis and to test our hypothesis that elastic stained sections are helpful in distinguishing lichen planopilaris (LPP) from lupus erythematosus (LE), central progressive alopecia in black females ("follicular degeneration syndrome" and "hot comb alopecia" are other terms used to describe this condition) and classic ivory white idiopathic pseudopelade.

We studied histological sections from surgical scars of known duration, stained with the VVG elastic stain and VVG-stained sections of scalp biopsies from patients with established lesions of permanent alopecia. In most cases, both vertical and transverse sections were examined. In every case, the VVG stain clearly differentiated scar from the normal surrounding dermis. Distinct patterns of elastic tissue allowed for correct classification in most of the well-established cases of permanent alopecia studied.

We determined that the Verhoeff-Van Gieson stain is an excellent stain to evaluate the pattern of scarring in cases of permanent alopecia and elastic tissue stains may be helpful in the histological evaluation of alopecia.

IMMUNOPEROXIDASE

DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES

ALOPECIA

ALOPECIA,
ANDROGENIC

Distinguishing androgenetic alopecia from chronic telogen effluvium when associated in the same patient: a simple noninvasive method.

Rebora A, Guarrera M, Baldari M, Vecchio F.

Department of Endocrinological and Metabolic Sciences, Section of Dermatology, University of Genoa, Genoa, Italy.

Arch Dermatol. 2005 Oct;141(10):1243-5. Abstract quote

BACKGROUND: Distinguishing chronic telogen effluvium (CTE) from androgenetic alopecia (AGA) may be difficult especially when associated in the same patient.

OBSERVATIONS: One hundred consecutive patients with hair loss who were clinically diagnosed as having CTE, AGA, AGA + CTE, or remitting CTE. Patients washed their hair in the sink in a standardized way. All shed hairs were counted and divided "blindly" into 5 cm or longer, intermediate length (>3 to <5 cm), and 3 cm or shorter. The latter were considered telogen vellus hairs, and patients having at least 10% of them were classified as having AGA. We assumed that patients shedding 200 hairs or more had CTE. The kappa statistic revealed, however, that the best concordance between clinical and numerical diagnosis (kappa = 0.527) was obtained by setting the cutoff shedding value at 100 hairs or more. Of the 100 patients, 18 with 10% or more of hairs that were 3 cm or shorter and who shed fewer than 100 hairs were diagnosed as having AGA; 34 with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having CTE; 34 with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having AGA + CTE; and 14 with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs were diagnosed as having CTE in remission.

CONCLUSION: This method is simple, noninvasive, and suitable for office evaluation.

Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.

Commonly Used Terms

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Commonly Used Terms
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Last Updated October 24, 2005

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HISTOLOGICAL TYPES	CHARACTERIZATION
GENERAL
VARIANTS
CHRONIC TELOGEN EFFLUVIUM
Chronic telogen effluvium. Whiting DA. Department of Dermatology and Pediatrics, University of Texas, Southwestern Medical Center at Dallas, USA.	Dermatol Clin 1996 Oct;14(4):723-31 Abstract quote Chronic telogen effluvium is not uncommon. It is a form of diffuse hair loss affecting the entire scalp for which no obvious cause can be found. It usually affects women of 30 to 60 years of age who generally have a full head of hair prior to the onset of shedding. The onset is usually abrupt, with or without a recognizable initiating factor. The degree of shedding is usually severe in the early stages and the hair may come out in handfuls. Chronic telogen effluvium has distinctive clinical and histologic features that are usually diagnostic. Chronic telogen effluvium contrasts with classic acute telogen effluvium by its persistence and its tendency to fluctuate for a period of years. Patients are particularly troubled by the continuing hair loss and fear total baldness. Repeated reassurance that the condition represents shedding rather than actual hair loss and does not cause complete baldness is necessary. Chronic telogen effluvium does appear to be self-limiting in the long run.
Chronic telogen effluvium: increased scalp hair shedding in middle-aged women. Whiting DA. Department of Dermatology and Pediatrics, University of Texas Southwestern Medical Center, USA.	J Am Acad Dermatol 1996 Dec;35(6):899-906 Abstract quote BACKGROUND: Diffuse loss of scalp hair is a common problem in middle-aged women. A segment of these cases represents idiopathic chronic telogen effluvium (CTE). OBJECTIVE: The purpose was to establish distinctive clinical and pathologic criteria for the diagnosis of CTE to facilitate its differentiation from androgenetic alopecia (AGA) and systemic causes of chronic diffuse hair loss. METHODS: A group of 355 patients (346 females, 9 males) with diffuse generalized thinning of scalp hair of unknown origin were classified as having CTE and were included in the study. Characteristically they presented with a history of hair loss with both increased shedding and thinning of abrupt onset and fluctuating course and showed diffuse thinning of hair all over the scalp, frequently accompanied by bitemporal recession. Two 4 mm punch biopsy specimens were taken mostly from the mid or posterior parietal scalp of these patients. The biopsies were performed at these same areas in 412 patients with AGA (193 male, 219 female). Similar paired biopsy specimens were also taken from 22 normal control subjects (13 males, nine females). Specimens were sectioned horizontally and vertically and were examined for terminal and velluslike (miniaturized) hairs, follicular stelae, follicular units, and perifollicular inflammation and fibrosis. RESULTS: In horizontal sections of 4 mm punch biopsy specimens from patients with CTE the average number of hairs was 39, the terminal/velluslike hair ratio was 9:1, 89% of the terminal hairs were in anagen, and 11% were in telogen. In AGA these values were 35, 1.9:1, 83.2%, and 16.8%, respectively, and in normal control subjects 40, 7:1, 93.5%, and 6.5%, respectively. Significant degrees of inflammation and fibrosis were present in only 10% to 12% of cases of CTE and normal controls, but occurred in 37% of cases of AGA. CTE ran a prolonged and fluctuating course in many patients. CONCLUSION: CTE, which usually affects 30- to 60-year-old women, starts abruptly with or without a recognizable initiating factor. It may be distinguished from classic acute telogen effluvium by its long fluctuating course and from AGA by its clinical and histologic findings.

SPECIAL STAINS/ IMMUNOPEROXIDASE/ OTHER	CHARACTERIZATION
SPECIAL STAINS
Elastic tissue in scars and alopecia. Elston DM, McCollough ML, Warschaw KE, Bergfeld WF. Department of Dermatology, Wilford Hall Air Force and Brooke Army Medical Centers, Fort Sam Houston, Texas 78234-6200, USA.	J Cutan Pathol 2000 Mar;27(3):147-52 Abstract quote A recent report suggests that elastic fibers appear in scars in a time-dependent fashion. This observation prompted our investigation, because we have found elastic tissue stains helpful in determining the pattern of scarring in cases of permanent alopecia. We carried out this investigation to determine if the Verhoeff-Van Gieson (VVG) elastic stain can reliably differentiate scarred from non-scarred dermis and to test our hypothesis that elastic stained sections are helpful in distinguishing lichen planopilaris (LPP) from lupus erythematosus (LE), central progressive alopecia in black females ("follicular degeneration syndrome" and "hot comb alopecia" are other terms used to describe this condition) and classic ivory white idiopathic pseudopelade. We studied histological sections from surgical scars of known duration, stained with the VVG elastic stain and VVG-stained sections of scalp biopsies from patients with established lesions of permanent alopecia. In most cases, both vertical and transverse sections were examined. In every case, the VVG stain clearly differentiated scar from the normal surrounding dermis. Distinct patterns of elastic tissue allowed for correct classification in most of the well-established cases of permanent alopecia studied. We determined that the Verhoeff-Van Gieson stain is an excellent stain to evaluate the pattern of scarring in cases of permanent alopecia and elastic tissue stains may be helpful in the histological evaluation of alopecia.
IMMUNOPEROXIDASE