Localized Donor Area Acute Telogen Effluvium following Follicular Unit Extraction: Key Trichoscopic Findings

Abstract

Introduction

Telogen effluvium is a form of non-scarring alopecia characterized by an increased hair shedding rate induced by mechanical or inflammatory factors.

Case Report

A 27-year-old healthy male patient presented with several itchy alopecic patches in the occipital region. The patient had undergone a follicular unit extraction 6 weeks before with complete recovery after 1 week. Upon trichoscopy, we found empty follicular openings, short regrowing hairs, and coudability hairs. A diagnosis of acute telogen effluvium was made, and the patient was started on betamethasone lotion for daily use as a means to treat pruritus. After 1 month, the patient presented an almost complete response.

Conclusion

While acute telogen effluvium is commonly seen in the receptor area after a hair transplant, the incidence of the donor region as a presentation is unknown. Common trichoscopic findings in telogen effluvium include empty follicular openings, short regrowing hairs, and lack of other signs usually seen in other types of alopecia. This description was consistent with what we found in our patient. Trichoscopic findings can help in the diagnosis, and understanding its natural course, physicians can reassure the patient about the self-resolutive outcome of this condition.

Established Facts

• •Telogen effluvium is a common cause of temporary hair loss due to an increased hair shedding rate after some shock to the system.
• •Acute telogen effluvium is commonly seen in the receptor area after a hair transplant.

Novel Insights

• •Acute telogen effluvium in the donor area following a hair transplant is an entity whose incidence is unknown.
• •Trichoscopic findings including empty follicular opening, short regrowing hairs, and coudability hairs in telogen effluvium lead to distinction among other alopecias.

Introduction/Literature Review

Telogen effluvium is a form of non-scarring alopecia characterized by an increased hair shedding rate induced by mechanical or inflammatory factors, and common causes include drugs, trauma, physiologic stress, and emotional stress [1, 2]. Literature has described the apparition of this entity only in a few cases after hair restoration; consequently, trichoscopy description has not been clearly defined. We present the clinical course of a telogen effluvium case following follicular unit extraction (FUE) and its trichoscopic findings.

Case Report

A 27-year-old healthy male patient presented to our clinic with several itchy alopecic patches in the occipital region. The patient had undergone a FUE procedure 6 weeks before, where a total of 2,100 grafts were extracted at a 1:4 ratio and implanted in the frontal area with complete donor area recovery after 1 week (shown in Fig. 1a).

Fig. 1.

a Patches of hair loss 2 months after. b Trichoscopic image showing empty follicular ostia (blue arrows), short regrowing hairs (red arrows) and coudability hair (*).

Upon trichoscopy, we found empty follicular openings, short regrowing hairs, and coudability hairs (shown in Fig. 1b). A diagnosis of acute telogen effluvium was made, and the patient was started on betamethasone lotion for daily use as a means to treat pruritus. After 1 month, the patient presented an almost complete response, with no evidence of absent or abnormal hair growth upon trichoscopy.

Discussion

While acute telogen effluvium, also known as “shock loss,” is commonly seen in the receptor area after a hair transplant [1], the donor region as a presentation site has only been reported a few times, and its real incidence is unknown [1, 3]. Local trauma seems to disrupt hair follicle growth as it has also been seen in localized forms after a face-lift surgery [4].

Common trichoscopic findings in telogen effluvium include empty follicular openings, short regrowing hairs, and lack of other signs usually seen in other types of alopecia [5]. This description was consistent with what we found in our patient. The coudability hair, which is usually seen in patients with alopecia areata, was also observed in this case, indicating an abrupt arrest of the metabolic and mitotic activity of the hair follicle [5]. While one publication reported trichoscopy findings simulating alopecia areata [1], we found none of such signs in this patient. Patients with anagen effluvium, however, can show a trichoscopy similar to what is usually observed in alopecia areata [5]. One recent study also reported the presence of short dystrophic hairs [2], which could be a sign of either localized effluvium or physical trauma caused by the FUE procedure.

Although no standard treatment for this condition is known due to its low incidence, there are several studies proving the efficacy of topical and oral minoxidil in patients with telogen effluvium. Though uncommon, acute donor area telogen effluvium can occur even after moderate hair restoration surgeries and can distress both patients and doctors. Trichoscopic findings can help in the diagnosis, and understanding its natural course, physicians can reassure the patient about the self-resolutive outcome of this condition.

Statement of Ethics

This research complies with the guidelines for human studies welfare regulations and was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Ethical approval is not required for this study in accordance with local and national guidelines.

Conflict of Interest Statement

The authors have no conflicts of interest to disclose.

Funding Sources

No funding was received for the preparation of this manuscript.

Author Contributions

Guillermo A. Guerrero-González, MD: idea conception, clinical and dermatoscopic examinations, detailed trichoscopic findings, editing, and revision of the final manuscript. Gerardo González-Martínez, MD: writing of the original draft, writing, bibliographic review, editing, and revision of the final manuscript. Jair Alejandro Valdez-Zertuche: writing, bibliographic review, editing, and revision of the final manuscript. All authors agreed to submit to the current journal, gave final approval of the version to be published, and accepted to be accountable for all aspects of the work.

Funding Statement

No funding was received for the preparation of this manuscript.

Data Availability Statement

All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.