ACUTE TELOGEN EFLUVIUM IS ASSSOCIATED WITH THE PRESENCE OF FEMALE ANDROGENETIC ALOPECIA

Potential Therapeutic Implications - A retrospective study of 503 female patients

RESULTS

The results of the univariate analysis of ATE – FAA association are shown in Table 2. The results of the univariate analysis of

different therapies on the progression to CTE are shown in Table 3. Both univariate approaches entered binary logistic re-

gression analysis to identify and select independent predictive factors as related to ATE - FAA association and to CTE pro-

gression.

DISCUSSION

Other authors have proposed five different types of telogen effluvium based on changes in different phases of the follicular

cycle. But they did not mention any correlation or association of such classification with a different clinical pattern (6): cured

ATE, association with FAA, or progress to CTE.

Previous studies have distinguished CTE, from classic acute telogen effluvium by its long fluctuating course, and from FAA by

its clinical and histological findings (1, 2, 3) and there is also some evidence that Telogen Effluvium may progress rapidly to

FAA (4).

The conclusions of our study may be summarized as follows:

ATE – FAA Association Our logistic regression analysis confirmed that Triggering Cause is a significant independent factor

that predicts association of Acute Telogen Effluvium with Female Androgenetic Alopecia. The triggering causes with higher

risk of FAA association were: severe diet (10.6 odds ratio), iron deficiency (10.6 odds ratio) and thyroid dysfunction (16.4

odds ratio) when compared with seasonal hair loss as reference.

As a consequence, patients suffering ATE may benefit from different therapeutic approaches (depending on the triggering

cause) to prevent or treat the association with FAA.

ATE and Progression to CTE Overall 70.2% of patients treated, were cured or experienced significant improvement in less

than 6 months. Minoxidil use appears to improve the patient outcome with a lower percentage of progression to CTE. Apart

from treating the precipitating cause, the different additional oral treatments used have not shown any correlation with pro-

gression to CTE. Patient age seems to be an independent predictive factor of ATE outcome: women with positive outcome

showed a mean age of 5.1 years less than those with CTE (P<.01).

Variables Triggering Causes b

Age at the time of diagnosis Triggering cause Year when ATE diagnosis was made Area of Spain where Svenson center was lo-

cated Oral treatment modality Minoxidil topical therapy

a

(1) Seasonal hair loss (2) Severe Diet (3) Postpartum (4) Iron deficiency (5) Psychoemotional stress (6) Thyroid dysfunction (7) Medication intake or withdrawal (8) Antineoplastic therapies and/or major surgery (9) More than one of the above mentioned.

Year of Diagnosis Area of Spain - Svenson center

(1) Before 2010 (2) 2010 (3) 2011

(1) Balearic Islands (2) Canary Islands (3) Madrid Centers (7 centers) (4) Mediterranean regions (5) Northern Spain (6) Southern Spain

Oral Treatment Modalities c

(1) Pyridoxine, (2) Pyridoxine plus L-Cystine (3) Pyridoxine plus L-Cystine plus L-Arginine (4) Multivitamin compound (5) Finasteride 1 mg per day (6) Other different treatment

(7) No oral treatment given Notes (a) Topical Minoxidil was used at 5% concentration 1-2 times per day and indicated according to the patient physician’s clinical criteria. (b) Psychoemotional stress category was only considered when all other triggering causes were excluded. Iron deficiency category was only considered if not associated to severe diet or postpartum condition. (c) Svenson Medical standard oral treatments for diffuse hair loss in female patients:

Diagnosis and appropriate treatment of potential triggering causes such as: anemia, iron deficiency, thyroid dysfunction, severe diet, etc.

Pyridoxine (300mg) 1 tab per day during four months. Add L-Cystine (500mg) 1 tab per day, with or without L-Arginine (500mg) 1 tab per day, during two months.

Variables Triggering Causes b

Age at the time of diagnosis Triggering cause Year when ATE diagnosis was made Area of Spain where Svenson center was located Oral treatment modality Minoxidil topical therapy

a

(1) Seasonal hair loss (2) Severe Diet (3) Postpartum (4) Iron deficiency (5) Psychoemotional stress (6) Thyroid dysfunction (7) Medication intake or withdrawal (8) Antineoplastic therapies and/or major surgery (9) More than one of the above mentioned.

Year of Diagnosis Area of Spain - Svenson center

(1) Before 2010 (2) 2010 (3) 2011

(1) Balearic Islands (2) Canary Islands (3) Madrid Centers (7 centers) (4) Mediterranean regions (5) Northern Spain (6) Southern Spain

Oral Treatment Modalities c

(1) Pyridoxine, (2) Pyridoxine plus L-Cystine (3) Pyridoxine plus L-Cystine plus L-Arginine (4) Multivitamin compound (5) Finasteride 1 mg per day (6) Other different treatment

(7) No oral treatment given Notes: (a) Topical Minoxidil was used at 5% concentration 1-2 times per day and indicated according to the patient physician’s clinical criteria. (b) Psychoemotional stress category was only considered when all other triggering causes were excluded. Iron deficiency category was only considered if not associated to severe diet or postpartum condition. (c) Svenson Medical standard oral treatments for diffuse hair loss in female patients:

Diagnosis and appropriate treatment of potential triggering causes such as: anemia, iron deficiency, thyroid dysfunction, severe diet, etc.

Pyridoxine (300mg) 1 tab per day during four months. Add L-Cystine (500mg) 1 tab per day, with or without L-Arginine (500mg) 1 tab per day, during two months.

ABSTRACT: Acute telogen effluvium (ATE) is often associated with Female Androgenetic Alopecia (FAA) but predictive factors of ATE - FAA associa-

tion, and clinical factors or therapies which may influence the progression of ATE to Chronic Telogen Effluvium (CTE) have not been reported. We

have identified predictive factors of ATE – FAA association, and retrospectively evaluated the impact of therapies on the progression to CTE. Conclu-

sions: 1) Triggering Cause is a significant independent factor that predicts association of Acute Telogen Effluvium with Female Androgenetic Alopecia.

2) Triggering causes with higher risk of concurrent FAA are: severe diet, iron deficiency and thyroid dysfunction. 3) Minoxidil use shows a trend to

lower the percentage of progression to CTE. 4) Apart from treating the precipitating cause, the different additional oral treatments used have not

shown any correlation with progression to CTE.

INTRODUCTION

Acute telogen effluvium (ATE) may be associated with Female Androgenetic Alopecia (FAA) (1, 2, 3, 4) but predictive factors of ATE - FAA association

have not been reported yet. ATE may progress to chronic telogen effluvium CTE if hair shedding persists longer than 6 months (5).

The objectives of our study are to identify predictive factors of ATE – FAA association and to evaluate the impact of clinical factors and therapies on the

progression to CTE.

METHODS

Patients

In the present study, we have retrospectively analyzed patients diagnosed with ATE by 25 different physicians at 33 different hair care Svenson cen-

ters in Spain. A total of 503 patients were included into the study. Demographic and Clinical Variables considered for the study are displayed in Table 1.

Assessment of Triggering Cause, Clinical Diagnosis and Clinical Outcome

The profile and outcome of patients diagnosed with ATE between 2007 and 2011 were retrospectively assessed by using patient records and clinical

information from a single corporative intranet database. This tool allows us to verify that the diagnostic protocol is similar regardless of where or by

whom the patient was seen.

The clinical diagnosis of ATE was always made by a physician. ATE diagnosis always included a positive hair pull test. Each of the 503 patients in-

cluded into the study underwent a blood panel including thyroid function to determine and treat potential triggering conditions. This is a basic clinical

approach, before going ahead with additional treatments such as Minoxidil and/or oral supplement therapy. Therefore, the association with female an-

drogenetic alopecia diagnosis (FAA) was always established by a physician taking into account such specific patient information.

Criteria to assess patient clinical outcome included: photography at the time of diagnosis, photography after six months of diagnosis or longer, and a

minimum period of 1-year follow-up comments. Chronic telogen effluvium (CTE) diagnosis was established when telogen effluvium lasted longer than

12 months on the patient recorded follow-up.

Statistical evaluation

Statistical analyses were performed by using SPSS (20.0.0) version with P < .05 being statistically significant for all results. A logistic regression model

was used to identify predictive factors and estimated risk (odds ratio) of: 1) ATE – FAA Association and 2) Progression to CTE.

Dr. Velasco is plastic surgeon and Medical Director for the

Svenson Group in Europe. Apart from this role, he runs his pri-

vate clinic in Lima exclusively devoted to hair transplantation.

Dr. Velasco has extensive experience in hair transplantation, an

activity which he practices exclusively for the past 20 years. Dr.

Velasco is member of the ISRHS since its inception in 1993 and

also member of the ESHRS since its creation in 1998.

COI: The author certifies that he has no conflict of interest re-

garding the material discussed in this poster presentation.

REFERENCES

1. Whiting DA. Chronic telogen effluvium: increased scalp hair shedding in middle-aged women. J Am Acad Dermatol 1996;

35(6):899–906.

2. Werner B, Mulinari-Brenner F. Clinical and histological challenge in the differential diagnosis of diffuse alopecia: female an-

drogenetic alopecia, telogen effluvium and alopecia areata - Part II. An Bras Dermatol. 2012; 87(6):884-890.

3. Rebora A, Guarrera M, Baldari M, Vecchio F. Distinguishing androgenetic alopecia from chronic telogen effluvium when as-

sociated in the same patient: A simple noninvasive method. Arch Dermatol. 2005; 141(10):1243-1245.

4. Sinclair R. Chronic telogen effluvium or early androgenetic alopecia? Int J Dermatol. 2004; 43:842-3. 5. Whiting DA.

Chronic telogen effluvium. Dermatol Clin 1996; 14:723-731. 6. Headington JT. Telogen effluvium: new concepts and review.

Arch Dermatol 1993; 129:356-363.

This poster is sponsored by:

TABLE 1

TABLE 2

Credits: The present study has been possible thanks to the cooperation and data

collection of a community of over 30 doctors at Svenson centers in Spain. Nicolas

Perez-Mora MD PhD, Medical & Scientific Advisor of Svenson Medical, co-

authored this study recently published in Dermatologic Therapy (Wiley Blackwell).

58,3%

52,1%

50,0%

43,2%

40,0%

34,2%

25,8%

20,8%

9,4%

0% 10% 20% 30% 40% 50% 60% 70%

Thyroid dysfunction

Iron deficiency

Severe diet

Psychoemotional

Neopl Ther / Surg*

Medications

More than one

Postpartum

Seasonal

ATE Triggering Cause and % FAA

503 female patients

72,6%

63,7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mx Applied No Mx Applied

Minoxidil - % Cured Patients

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Fis

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P

ea

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Ch

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are

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est:

no

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nific

an

t P

ea

rso

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Ch

i-S

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are

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01

(*) Antineoplastic therapies and/or major surgery