If you have had surgery in the last few months, you may notice more hair shedding than usual.
While alopecia can be an indication of underlying issues, this type of hair loss, called telogen effluvium, may not be directly related to the surgery – rather, it is the stress associated with the surgery that spurs the body to act on your scalp.
The large clumps of hair gathered menacingly on the brush or shower drain will initially come as a big shock, but it is a relatively common side effect that many doctors neglect to mention to their patients.
According to the American Hair Loss Association, telogen effluvium is the second most common form of hair loss. As of current standing, very little research has been done on this type of alopecia, making it shrouded with a degree of mystery.
Here is what we do know about it, of the mechanisms and what you can do to minimize the damage.
Background on Telogen Effluvium
Telogen effluvium is a form of alopecia characterized by diffuse non scarring and non inflammatory hair shedding.
The hair shedding is most noticeable approximately 2 months after the surgery during washing or combing of the hair. You will also notice a generalized thinning, but for the most part, the scalp and remaining hair should look healthy.
It is often expressed in an acute onset and lasts for a short duration, but a chronic form (longer than 6 months) also exists.
You can distinguish hair afflicted with telogen effluvium mainly by the white, club-shaped bulb at the end of a strand.
Pathophysiological of Hair Cycles
In order to understand the pathophysiology of hair loss from surgery, it is important to first familiarize oneself about hair growth cycle.
Unlike most mammals, the human hair follicle is rather special. Each follicle has its own inherent rhythm and thus the cycles do not synchronize with the others. They can act independent of certain external factors that would normally affect other animals, such as light and temperature.
All mature hair follicles undergo four major life cycle: anagen, catagen, telogen, and exogen.
Anagen phase is best defined as the growth stage. During this point, cells are rapidly dividing in order to regenerate the composition of the lower cyclic portion of follicle, or the bulb. The hair grows approximately 1 cm for every month, or 6 inches per year and will likely stay in this phase for two to six years.
Catagen phase is the transition stage, where the hair undergoes the cessation of cell growth and pigmentation and begins pushing the completed hair follicle out of the papilla. This cycle generally lasts from a few days to up to two weeks.
Telogen phase is the resting/inactive stage, where there are no growth and the cell activities remains minimal. The stationary hair club remains firmly attached to the follicle. Meanwhile, a new anagen hair deep under the telogen hair is slowly forming.
The anagen hair will continue growing until it has the capacity to push the telogen hair out. This telogen hair cycle can last from three to six months.
Exogen phase is the final stage, where hair is officially shed off to make way for the newly forming anagen hair underneath. Normally, around 50 – 100 hair strands are lost every day from daily activities, which are pennies when we consider that there are 100,000 – 150,000 strands on an average scalp.
In most people, 70 to 85 percent of the total hair follicles on the scalp are in anagen phase. Anywhere from 5 to 15 percent are in the telogen phase.
While the emerging hairs may help force the resting hairs out of the follicle, evidence from several research have suggested that the shedding of telogen hair may occur rather independently from the emerging anagen hair.
Telogen Effluvium and Surgery
Around the time of the surgery or other significant event, the person undergoes an acute peak of stress, expressed physiologically, psycho-emotionally, and/or hormonally.
In order to best prepare the body to handle the stressful event, more attention and resources are diverted to the vital organs such as heart, lungs, muscles, and liver.
Because scalp hair is not considered an essential structure, the body makes a conscious effort to reduce unnecessary functions such as hair growth and maintenance. Hair follicle matrix cells are among the most rapidly dividing cells in the body and therefore may be exquisitely sensitive to changes.
As a result, a sizeable percentage of anagen hair prematurely enters into the telogen phase. Specifically, up to 70 percent of the anagen hairs can be expedited, thus creating an unusually greater ratio of telogen hair.
Moreover, existing telogen hair attachment to the follicle will be weakened and will likely fall out with even the gentlest manipulation.
As mentioned before, telogen phase takes approximately three to six months before entering the exogen phase. Therefore, the hair shed may not become evident until months after the surgery.
Though the exact mechanisms are not clear, there are some plausible explanations for why this happens from several researches.
Telogen Effluvium and Nervous System
It is suggested that the action of nerves, as well as various nervous system products called neuropeptides, could be related to the sudden premature shift in hair growth.
There are many sensory nerves in and around the hair follicles. These nerves transmit information about the effect caused by stressors to the brain, which in turn develops a systemic response.
Around the time of the surgery, the sensory nerves release a distress signal, prompting the release of a neuropeptide called substance P.
While generally involved in pain transmission, substance P has also been identified as a key mediator of stressed-induced hair growth inhibition.
One study by Arck et al took two groups of mice and induced a highly synchronized anagen development. After 14 days, when the mice’s hairs enter into a late anagen phase, the experimental group was exposed to sound stress for the duration of 24 hours. The control mice were left in peace.
The results showed that the hair follicles in a majority of stressed mice underwent a premature conversion to catagen phase, whereas the majority of non-stressed control mice remained in late anagen phase.
Moreover, the researcher found that stressed mice triggered a significant increase of substance P positive nerve fibers in the skin, thus establishing a correlation between stress and substance P.
Arck et al further examined the relation of this neuropeptides by taking non-stressed mice that likewise had hair predominately in the late anagen phase and administered a controlled dose of substance P.
The results showed a significant hair cycle progression towards catagen, even in the absence of sound stressor, thus mimicking the effect of stress.
Once the researchers counteract the substance P with a chemical that has the opposite effects (NK1), the harmful characteristics of stress-induced telogen effluvium (such as premature onset of catagen and cell death) on the mice were severely reduced.
Telogen Effluvium and Hormonal Imbalance
Stress also induces hormonal imbalance that directly affects thinning and balding on the scalp. Once the body senses anxiety or tension, a series of glands (such as the adrenal gland) activates to release cortisol.
Cortisol is a “fight or flight” steroid hormone that is responsible for putting the person into a state with heightened sense of awareness, quicker reflexes, and increase in fat and carbohydrate metabolism.
While these functions were essential for our ancestors when they encountered a hungry predator in the wild, the “threats” in our modern era are often more benign. However, they are equally taxing to our body – and our scalp.
One certain downside of cortisol in relation to telogen effluvium includes vasoconstriction, or the narrowing of the blood vessels.
Blood provides most of the hair with essential nutrition, oxygen, and waste removal. Limiting blood flow to the scalp exacerbates the undernourishment of anagen hair and slows the healing process.
Furthermore, the relatively recent finding of an additional adrenal site located in the human hair follicle means that the scalp may be able to independently synthesize and secrete cortisol. Therefore, they are capable of directly responding to the stress and self-activating telogen effluvium.
Studies have also shown that cortisol hormone’s effect on hair follicular growth is strongly dependent on hair cycle stage.
Adrenocortical thyroid hormone (ACTH) is the precursor to the release of cortisol. In resting hair follicles, ACTH seems to help activate hair growth. However, one particular study found that ACTH treatment on anagen hair induces premature hair follicle transition to catagen.
A similar study also found that another cortisol hormone called glucocorticoids stimulate cell death in the follicle tissues, likewise leading to premature hair cycle conversion.
In addition, scalp hair is dependent on many different hormones in order to grow and function properly. However, as the adrenal glands are busy producing cortisol, they release other hormones in underwhelming numbers, thereby contributing to the onslaught of telogen effluvium.
While the profuse shedding and overall thinning of the hair may be very alarming in the beginning, telogen effluvium is not permanent and won’t likely lead to baldness.
As long as the body is not in a chronic state of stress, the hair fall will eventually lessen and gradually taper back within 6 to 9 months to normal hair growth cycle. The scalp will likewise return back to equilibrium.
Although time will be a natural ally, there are some cases where damages are irreversible and recovery will remain incomplete.
Fortunately, there are ways to increase the chance of complete recovery.
Many essential vitamins and minerals, such as vitamin D, vitamin B12, riboflavin, folic acid, vitamin A, zinc, calcium, and copper, have shown promises on treating telogen effluvium.
There are evidences that show the combined use of a shampoo and hair lotion/tonic, formulated with vitamins and zinc, shortens the course of acute telogen effluvium.
A fair number of studies have also suggested balancing iron to promote regrowth.
Iron is an essential element for blood production, and also helps the red blood cells transport oxygen to all parts of the body.
After reviewing 40 years worth of research, dermatologists from the Cleveland Clinic found that when patients are treated for iron deficiency, even in the absence of anemia, it can maximize their ability to grow hair back for patients with both acute and chronic telogen effluvium.
Other study, such as by Rushton et al, also confirmed possible link of telogen effluvium and iron deficiency. The researchers followed 22 female subjects with chronic telogen effluvium after giving them supplementation with 72 mg of iron and 1.5 g of L-lysine (amino acid responsible for hair shape and volume) daily for 6 months.
The results showed that while the mean serum ferritin concentration significantly increased from 33 to 89 ng/mL, the mean percentage of hair in the telogen phase significantly decreased from 19.5% to 11.3%.
Unless you have iron deficiency that has been diagnosed by a medical professional, taking iron supplements can cause bigger problems, such as iron overload.
You can also ask your dermatologist for minoxidil if the telogen effluvium continues to persist. It has shown to work well with many individuals, but if the root complication has not been addressed, it must be continually used.
Telogen effluvium is not to be confused with alopecia areata, which is a different type of hair loss that can manifest after surgery. Alopecia areata is an autoimmune disease that is more serious and will likely leave you with smooth, bald patches on your scalp.
The Key Takeaway
Although there are limited researches around the subject of telogen effluvium, evidences suggest that neurotransmitters and hormones produced during stress plays a large role.
Because it is not inherently permanent, hair should start to reappear in a few months. However, chronic telogen effluvium is not uncommon and should be addressed by a medical professional.
You can take measurable actions to lessen the damage of hair loss after surgery, mainly by enriching your diet with vitamin and minerals and adopting a conscious effort to address the underlying cause.
*This article was reviewed by Dr. Debra Rose Wilson