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