Evidence based information

Written by Medical editorial team head  SIAHMSR 

Medically reviewed by Dr.Sanjana.V.B

 Postpartum telogen effluvium [Postpartum alopecia]

    Postpartum TE (PPTE) is usually reported as hair loss after delivery. Most women suffer from telogen effluvium hair loss postpartum. Hair loss typically occurring within a few months after childbirth in women is known as post-partum hair loss or telogen gravidarum. Postpartum hair loss is experienced two to four months after childbirth. It usually continues for 6 to 24 weeks but rarely persists up to 15 months. Postpartum hair loss from the scalp is diffuse but is accentuated along the anterior hair line.

To understand postpartum hair loss, it is essential to have an idea about hair cycle and factors affecting hair cycle in normal conditions as well as in unfavorable circumstances.

Hair cycle

Hair cycle in all people includes sequential phases of growth and rest that each hair follicle goes through, such as

1. anagen (active hair growth)

2. catagen (involution)

3. telogen (resting)

4. exogen [release of telogen hair] .

   In physiological conditions, on the scalp of a person 80% of hair may be in the  growing phase (anagen), 1% in the period of involution of hair follicle (catagen) and the rest of percentage is hair in the rest period (telogen).

Hair cycle and hormonal influences

It is a known fact that in humans, hair growth is not a continuous process, but it follows a successive asynchronous rhythm leading to a periodic regeneration of hair follicles. The exact cause of this asynchronous rhythm of hair growth in humans is still unclear [1].

   The hair follicle is a regenerating system. During the hair cycle, follicles pass through different phases such as anagen (active hair growth), catagen (involution) , telogen (resting)  and exogen [release of telogen hair] . The follicle shows great potential to completely regenerate itself. The anagen phase is the proliferation phase, and it occurs when the hair follicle is growing a new hair shaft.

 In the beginning of the anagen phase, the dermal papilla signals to the multipotent epithelial stem cells in the bulge. When stem cells are stimulated, the inferior segment of the hair follicle starts growing downwards, forming a bulb around the dermal papilla. At this stage, the dermal papilla can signal matrix cells in the bulb to proliferate, differentiate, and grow upwards, forming a new hair. The regeneration is happening due to the unique follicular epithelial and mesenchymal components and their interactions.

In catagen phase, cell division in the matrix ceases, and the inferior segment of the hair follicle begins to regress. The dermal papilla that has moved upwards to contact the bulge and now a club hair is formed with a white, hard node on the end in this phase of hair cycle.

The next phase of hair cycle is telogen phase or the resting phase. Now, the club hairs, which are essentially dead, are held on the scalp, for about 100 days. Eventually, these hairs are released and shed and the anagen phase starts again with a new hair growth. This is normal hair cycle.

Factors influencing hair regeneration

   The hair cycle is controlled by various hormones and local growth factors in and around the hair bulb and follicular papilla. Environmental factors also potentially affect the hair cycle. Hair growth cycle is also gender dependent. The duration of the hair cycle is influenced by age, pathology, and a wide variety of physiological factors.

About 15 to 20% of scalp hairs are usually in telogen. After three months of telogen a new anagen hair grows on the scalp. That is, in hair cycle each shedding telogen hair is ideally replaced by a new anagen hair before it is completely shed.

The hair cycle involves various cells such as endothelial cells, lymphocytes, basement membranes, proteoglycans, and the abutted constitutive cells of the epidermis, dermis, and hypodermis. The most important factor involved in the hair cycle seems to be formed from both the follicular papilla and the perifollicular matrix. These structures undergo obvious changes during the hair cycle. The follicular papilla is large in established anagen. It becomes smaller and more compact in telogen. The size of the follicular papilla is an important determinant of the  size and shape of the follicle.

The vascular structures become more prominent during the growth phase. Factors from the papillary mesenchymal cells probably act on the follicular epithelium. In the beginning of the anagen phase, factors from the papilla influence stem cells of the hair follicle that are receptive to inductive signals.

What is hair eclipse phenomenon in postpartum alopecia?

    In some conditions of the body the telogen hair is lost before the next anagen hair becomes visible. During the latency period, the hair follicle appears empty. A latency period may occur between hair shedding (teloptosis, exogen phase) and the early emergence of the next anagen VI stage. This lag time referred to on the hair eclipse phenomenon. It may also be prominent when microinflammation is present on the permanent portion of the hair follicle as in dandruff, seborrhoeic dermatitis, androgenic alopecia and photoageing baldness.

The hair eclipse phenomenon presents as an erratic process occurring in a series of physio pathological conditions affecting hair follicles singly or in focal to generalized patterns.It is more frequent following synchronized teloptosis [hair shedding] occurring in telogen effluvium such as a postpartum alopecia.

During pregnancy high level of circulating placental estrogen prolongs anagen phase of hair and leads to good hair growth during pregnancy. The growing hair is anagen hair.

The anagen phase is prolonged under hormonal influence during pregnancy. It last during pregnancy period.

But sudden withdrawal of these pregnancy maintaining hormones after childbirth causes all the overdue anagen hair to enter into catagen phase simultaneously. This leads to increased shedding of telogen hair.

During the first weeks of postpartum, hairs enter telogen in a synchronous wave to reach about 30% in average after nine weeks. This explains the clinical observation that postpartum hair loss is experienced two to four months after childbirth. It usually continues for 6 to 24 weeks but rarely persists up to 15 months.

Management

It is advised during postpartum to avoid any shampoo labeled as “conditioning shampoo.” These contain heavy conditioners that can weigh down the hair and make it look limp. Use a conditioner formulated for fine hair. These contain lighter formulas that will not weigh down hair. Use conditioner only on the ends of the hair. Applying conditioner to your scalp and all of your hair tends to weigh down hair. Avoid the use of intensive conditioners.

Nutritional intervention

 More than postpartum telogen effluvium hair loss the significance of nutrition is related to the general health of mother and the neonate. Inadequate maternal nutrition, and especially a deficit of essential nutrients, is associated with negative health outcomes in both the mother and the child. Therefore maternal diet is crucial not only for regeneration of hair but for the better health outcome in mother and child.

·       Include more green leafy vegetables and fruits in the diet

·       Reduce intake of refined sugars.

·       Continue the intake of iron, folic acid, vitamins and other supplements prescribed by the healthcare provider for lactation period.

·       Avoid styling and other hair treatment procedures on hair during this period. Because after telogen hair is lost new anagen hair is growing underneath it in the follicle.

·       A high-quality diet, such as the Mediterranean diet, is internationally recommended for pregnant and breastfeeding women along with supplements recommended by the healthcare provider[5].

     Link for Mediterranean diet

      http://siahmsrwellness.in/mediterranean-diet 

   Complementary &alternative system of medicine [CAM]

Homeopathy

Homeopathic medicines prescribed for postpartum hair loss include:

Calcarea carb, cantharis, carbo vegetabilis, lycopodium, natrum muriaticum, nitric acid, phosphoric acid, sepia, Sulphur etc.

Medicines are chosen after analyzing the individual or constitutional features of the person and other comorbidities.

[Disclaimer- Please take homeopathic medicines only under the guidance of a qualified homeopathic doctor in appropriate dosage. Over the counter medications may have adverse effects and we do not recommend it as homeopathy requires proper case taking, clinical examination, lab investigations , evaluation and analysis of each case in an individualized manner and selection of most appropriate remedy with proper strength &dosage for cure of any clinical condition].

References

1.    Controls of hair follicle cyclingK S Stenn 1, R Paus

https://pubmed.ncbi.nlm.nih.gov/11152763/

2.    (Neuro-)endocrinology of epithelial hair follicle stem cells

https://pubmed.ncbi.nlm.nih.gov/18423849/

3.    Mechanobiology and cell tensegrity: the root of ethnic hair curling? https://pubmed.ncbi.nlm.nih.gov/21649823/

4.    Piérard-Franchimont C, Petit L, Loussouarn G, Saint-Léger D, Piérard GE. The hair eclipse phenomenon: sharpening the focus on the hair cycle chronobiology. International Journal of Cosmetic Science. 2003;25(6):295–299  https://pubmed.ncbi.nlm.nih.gov/18494912/

5.    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7285175/

6.    https://www.aad.org/public/diseases/hair-loss/insider/new-moms

7.    Homeopathic medical repertory – Murphy -page927