Treating Stress-Related Hair Loss

How do physicians treat stress-related hair loss? First, they have to get to the root of the problem.

Stress-related hair loss, or telogen effluvium, can be the physical manifestation of internal unease.

“As the pandemic has progressed, I have seen an increase in hair loss cases corresponding with onset patterns commonly seen with stress-induced hair loss,” says dermatologist Michelle Henry, M.D., New York, N.Y.

Other common causes of stress-related hair loss, she says, include pregnancy, physiological stress, surgery and illness.

Telogen effluvium, a usually temporary cause of hair loss, is often the result of a stressor to the body that causes excessive shedding of telogen hairs.

“Typically, about 85% of the hair follicles are actively growing, called anagen hair, and about 15% are resting telogen hair,” says Dr. Henry.

A Closer Look at TE

Normally, the amount of hair in the telogen phase is from 5% to 10% at any one time.1

Telogen effluvium makes the anagen phase slow down, meaning that fewer hairs enter into the next two stages and around 30% of the hair follicles move into telogen phase where shedding occurs.1

A German study published in 2017 looked at the effect of prolonged life stress on healthy Caucasian female medical students 18 to 48 years of age as they prepared for and participated in a final medical exam.2

Participants in the study had all hair colors except gray and hair that was long enough to pluck. They were not allowed to dye their hair in the week prior to the first examination or during the observation period.

The study does not specify study participant hair type or offer insight on how this test would differ on African American hair.

The authors studied whether exam stress had the capacity to induce premature hair follicle regression when compared to points in time outside the exam period or to non-exam students.

They found that, “stress-induced hair growth changes are present in healthy humans exposed to major exam stress and coincide with relevant cytokine-balance changes. However, these changes are subtle and fully reversible, and therefore not pathologic.”2

Diagnosis and Treatment

According to Dr. Henry, diagnosis is key.

“I try to rule out any other medical causes of hair [loss] prior to moving forward with the diagnosis of telogen effluvium,” she says.

To do this, she takes an in-depth medical history of the patient, performs a thorough physical exam using dermoscopy, sends out bloodwork and biopsies the scalp, if needed.

Once diagnosed, telogen effluvium usually lasts around 6 months. However, cases of chronic telogen effluvium last longer.

Treatment for the condition depends on what is triggering the hair loss. Once the stressor is known and can be addressed, the hair cycle should normalize and begin growing back, according to Medical News Today.

“Sometimes, the rate of shedding slows down but does not stop entirely. In most cases, no more than 50 percent [sic] of the hair is lost,” according to the article.

Apart from telogen effluvium, which is categorized as being caused by stress, stress can be one factor in both trichotillomania and alopecia areata.

Trichotillomania, or hair pulling, is an irresistible urge to pull out hair from the scalp, eyebrows or other areas, as a way of dealing with negative emotions, such as stress, tension, loneliness or frustration.

Treatment for trichotillomania is largely linked to cognitive assistance, according to the Mayo Clinic.3

Habit reversal training is the primary treatment for trichotillomania. The patient learns how to recognize situations where they are likely to pull out hair and learn how to substitute the urge with other behaviors.

Other treatments include cognitive therapy and acceptance and commitment therapy.

Unlike telogen effluvium, alopecia areata is caused by a variety of factors, including stress, and can be permanent.

The hair loss diagnosis and treatment can be difficult and complicated, but Dr. Henry gives this advice to other physicians thinking of entering the space.

“Finetune your diagnostic skills. Collect data (blood work, biopsies and dermatoscopic images) to confirm your diagnosis,” she says. “I love custom topical compounds, intralesional steroids, platelet rich plasma and, when appropriate, hair transplantation to attain successful results.”

References:

1. Lewin, Jo. Is telogen effluvium reversible? Medical News Today. Available at: https://www.medicalnewstoday.com/articles/321590#outlook. Accessed June 15, 2020.

2. Peters EMJ, Müller Y, Snaga W, et al. Hair and stress: A pilot study of hair and cytokine balance alteration in healthy young women under major exam stress. PLoS ONE. 2017;12(4):e0175904.

3. Trichotillomania (hair-pulling disorder). Mayo Clinic. Available at: https://www.mayoclinic.org/diseases-conditions/trichotillomania/diagnosis-treatment/drc-20355193. Accessed June 5, 2020.