Telogen Effluvium · Blood Work · CityLink Mall
Hair coming out in handfuls is frightening, and it is usually not what it appears to be. Telogen effluvium is a synchronised release of hair that was pushed out of its growth phase by an event roughly three months earlier — and it is usually self-limiting, which is the opposite of how it feels.
At any moment the scalp is a mosaic: most follicles growing, a small minority resting, and the two states distributed randomly so that shedding is spread evenly across the day and goes unnoticed. Telogen effluvium destroys that randomness. A systemic stressor pushes a large cohort of growing follicles into the resting phase at the same moment, and because they entered together they leave together. The resting phase lasts around three months. Three months after the event, that cohort is released in synchrony, and the shedding is unmistakable.
The delay is the most useful diagnostic feature of the condition and the one most patients miss. The hair falling out today records something that happened in the region of two to four months ago — a fever, a surgical procedure, a general anaesthetic, a delivery, a period of severe caloric restriction or rapid weight loss, a bout of genuine psychological stress, or a new medication started or stopped. By the time the shedding begins, the person has usually recovered from the event and no longer connects the two, which is why the history has to be taken backwards rather than forwards.
What is shed is normal hair. This distinguishes effluvium from pattern loss at a glance on trichoscopy: in telogen effluvium the hairs remaining on the scalp are of uniform calibre, because the follicles are healthy and merely out of phase. In androgenetic alopecia the remaining hairs vary markedly in thickness, because miniaturisation has progressed at different rates in different follicles. Uniform calibre with heavy shedding is effluvium; mixed calibre with modest shedding is pattern loss. The two problems feel similar and look entirely different under magnification.
The prognosis follows from the mechanism. The follicles were not damaged, only reset, and once the trigger has passed they re-enter growth on their own schedule. Acute telogen effluvium is therefore usually self-limiting over three to six months, with density recovering over the following year as the regrown hair reaches length. Shedding that continues beyond six months, or that fluctuates over years, is chronic telogen effluvium — a different course, more likely to have a sustaining cause such as iron deficiency or thyroid disease, and more likely to be sitting on top of an underlying pattern loss it has unmasked.
Types
Diffuse shedding is not one entity. It differs by how long it has run, whether a single trigger can be identified, and — most consequentially — whether it is happening on a scalp that also has pattern loss underneath it. That last distinction is the reason density sometimes fails to return when the shedding stops.
Shedding and balding are different diseases. Treating a telogen effluvium as pattern loss buys a year of the wrong treatment while the thing that actually caused it goes uninvestigated.
Assessment
Bloods are not a reflex here, they are the point. Full blood count, ferritin with iron studies, and thyroid function are the core, because iron deficiency and thyroid dysfunction are both common, both sustain a telogen effluvium indefinitely, and both are correctable. Ferritin is specified deliberately: it reflects iron stores rather than circulating haemoglobin, and a normal full blood count sits comfortably alongside depleted stores. The hair follicle registers that depletion earlier than most tissues do.
The history is taken backwards. Work from today to four months ago and account for what happened in that window — illness, fever, surgery, anaesthesia, delivery, a new or discontinued medication, a period of rapid weight loss, a genuinely difficult stretch. Rapid weight loss deserves particular attention in Singapore at present, because sustained caloric restriction of the kind now commonly achieved pharmacologically is a reliable trigger, and patients rarely volunteer it as relevant to their hair. Examination adds a pull test, and trichoscopy establishes whether hair calibre is uniform or variable.
Where the scalp is uniform in calibre and a trigger is identified, the correct advice is frequently to correct any deficiency, address the sustaining cause and wait — which is an unsatisfying thing to hear and an honest thing to say. Where trichoscopy shows mixed calibre, an underlying pattern component has been unmasked, and that component is a separate, progressive condition needing its own medical plan. Supportive measures including follicle stimulation have a role while the cycle recovers, but they do not substitute for identifying what started it.
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