What To Know About Anagen Effluvium

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Anagen effluvium is not often talked about. But it is something that affects many people, especially those who are receiving chemo or radiotherapy. In this guide, you’ll learn more about the causes, treatments, symptoms and reversibility of anagen hair loss. 

What Is Anagen Effluvium? 

Anagen effluvium is a non-scarring alopecia in which hair growth is abnormally interrupted during the anagen (growth) phase. 

It’s also known as chemotherapy-induced hair loss because chemotherapy drugs are the most common cause of this type of hair loss. 

In anagen effluvium, hair breaks rather than sheds. And the intensity of hair loss varies depending on the actual trigger, its dosage and the duration of exposure. This kind of hair loss doesn’t progress in a distinct pattern. In fact, it can strike quite suddenly and cause diffuse or patchy alopecia. 

Additionally, anagen effluvium can affect all the hair-bearing areas on the body, including the eyebrows, eyelashes, moustache, beard, armpit and pubic hair. Still, it’s the most noticeable on the scalp because that’s where the majority of the hair (~90%) is normally in the anagen phase. 

Anagen effluvium can affect anyone at any age, and it affects both men and women equally. 

Types Of Anagen Effluvium 

There are two different types of anagen effluvium, which are as follows: 

• Dystrophic anagen effluvium: This occurs when a “toxic or inflammatory insult” results in the breaking of the hair shaft, as noted in StatPearls; chemotherapy is a common cause of this type of hair loss. 
• Loose anagen syndrome: In this condition, the hair is loosely attached to the follicle, resulting in it being easily pulled out. Loose anagen syndrome is a result of certain genetic mutations.  

What Are The Symptoms Of Anagen Effluvium? 

Anagen effluvium symptoms can include:

• Sudden hair loss, though it can also be gradual
• Hair loss is diffuse and not limited to just one area of the scalp 
• The base of the hair is tapered. 

Close examination of the scalp can also reveal the presence of “black dots, yellow dots,” and  “Pohl Pinkus constriction,” which means monilethrix-like hairs, as has been reported. 

What Causes Anagen Effluvium?

Anagen effluvium occurs due to an injury (from a drug, toxin or inflammation) to the hair bulb. This bulb contains the hair matrix, which has the cells to form the shaft of growing hair. 

In the event of an injury, the cells in the hair bulb matrix stop undergoing what’s known as “mitosis.” Mitosis is the process by which cells divide and duplicate to allow the hair to grow and develop. 

However, once that stops, the hair shaft is narrowed, weakened and damaged. As a result, it breaks and falls off. On being pulled, you can see the dystrophic hair (misshapen bulb and no root sheath) with a pencil-pointed end.  

This effluvium can happen 1-3 weeks after the injury. And it will affect the hair in the active anagen phase. 

Any of the following factors can disrupt cell division in the hair matrix. 

Chemotherapy 

As mentioned above, chemotherapy is the most common cause of anagen effluvium; Around 65% of the patients experience “thinning or loss of hair” as a result of chemotherapy, as has been reported. 

Chemotherapy treatment contains drugs that inhibit cell division (mitosis) and interfere with the metabolic activity of the cells in the hair. The alkylating agents in it damage the DNA of the cells, which stops them from making copies of themselves. All this can cause anagen effluvium. 

Chemo drugs that are known to cause this include: 

• Doxorubicin
• Bleomycin 
• Cyclophosphamide
• Methotrexate
• Nitrosoureas
• Fluorouracil
• Daunorubicin
• Dactinomycin

Keep in mind that the severity of hair loss can vary depending on the drugs, their dosage, and the duration of treatment.

Malakar SS, Mehta PR, Malakar SS. Tulipoid Hair: Anagen Effluvium Marker! Int J Trichology. 2018 Jul-Aug;10(4):188-190. doi: 10.4103/ijt.ijt_98_17. PMID: 30386082; PMCID: PMC6192241/CC BY-NC-SA 4.0

Hair loss usually begins 2 weeks after chemotherapy begins, and patients can lose all their hair within 2 to 3 months. While this hair loss is usually temporary, sometimes, it can be permanent. 

Radiotherapy 

Radiotherapy to the head can also cause anagen effluvium in the treatment area.

Occipito-vertical alopecia after radiation exposure. Verma S, Srinivas C, Thomas M. Radiation-induced temporary alopecia after embolization of cerebral aneurysm. Indian J Dermatol. 2014 Nov;59(6):633. doi: 10.4103/0019-5154.143584. PMID: 25484428; PMCID: PMC4248536/CC BY-NC-SA 3.0

As one study notes, radiation-induced alopecia starts 1 to 3 weeks following the first radiation session, however, regrowth begins 2 to 6 months after the last treatment. 

But bear in mind that with radiation therapy, hair follicle stem cells can also be affected along with the cells in the hair bulb matrix. As a result, you might experience permanent hair loss (not always, though). 

Whether or not you experience permanent hair loss can depend on the radiation dose. According to research, the amount of radiation that has been reported to cause permanent hair loss can range from “more than 5 Gy in a single dose to more than 50-60 Gy in fractions of 1.8 or 2 Gy.” 

Medication 

The intake of certain medications can also cause anagen effluvium.

These include:

• Levodopa – commonly prescribed for Parkinson’s
• Cyclosporine – typically used to prevent organ transplant rejection but also prescribed for the treatment of autoimmune conditions 
• Colchicine – usually taken for treatment or prevention of gout and treating familial Mediterranean fever (FMF)
• Albendazole – used for treating worm infections 
• Isoniazid – commonly used for the treatment of tuberculosis 
• Strontium ranelate – taken for treating osteoporosis
• Azathioprine – usually used for the treatment of rheumatoid arthritis and preventing transplant rejection

Balasubramanian P, Jagadeesan S, Anjaneyan G, Thomas J. An Interesting Case Report of Azathioprine-Induced Anagen Effluvium. Indian J Dermatol. 2015 May-Jun;60(3):324. doi: 10.4103/0019-5154.156471. PMID: 26120190; PMCID: PMC4458977/CC BY-NC-SA 3.0

Toxic Heavy Metals

Intoxication from heavy metals can also cause anagen effluvium. 

According to different research and case studies, toxic exposure to the following metals can cause this type of hair loss:

• Bismuth 
• Arsenic 
• Thallium 
• Cadmium
• Lead
• Boron 
• Mercury 
• Arsenic 

Health Problems 

Certain illnesses can also interrupt the anagen phase of hair growth. For instance, inflammation from alopecia areata can cause dystrophic anagen. Autoimmune diseases like lupus and pemphigus vulgaris can also do the same. 

Additionally, anagen effluvium has been reported in infectious diseases like syphilis and COVID.  

Protein-Energy Undernutrition (PEU) 

Protein-energy undernutrition, also known as protein-energy malnutrition, is a condition that results from a deficiency of dietary protein. This can also lead to anagen effluvium.  

Can stress cause anagen effluvium? 

No, stress does not cause anagen effluvium. However, stress can cause another type of hair loss called telogen effluvium, which also results in diffuse shedding, typically 3-4 months after the stressful event has occurred. The stress, in this case, can be physical and/or psychological.

How Long Does Anagen Effluvium Last? 

The effects of anagen effluvium can last for as long as the causative agent(s) are present. Hair loss can start just days to weeks after exposure, and it can last for a couple of months or even longer. Eventually, you might have no hair left. However, this hair loss may stop once the underlying problem is treated. 

Is Anagen Effluvium Reversible?

Anagen effluvium is usually reversible. That’s because this condition spares the hair follicle stem cells, so your hair can start to regrow just after a few weeks. It might become more noticeable to you after 1-3 months. 

Some people, however, regrow their hair with different texture, colour and thickness. For instance, if you had wavy or curly hair, it might grow out straight. Or it can also change colour and become grey. Keep in mind that these hair changes can be permanent. 

Unfortunately, in some cases, anagen effluvium can lead to permanent hair loss as can happen in radio or chemotherapy. 

How Is Anagen Effluvium Diagnosed?

To diagnose anagen effluvium, your doctor will probably ask questions about your medical history, health, general life, and diet. They will also perform a physical exam. 

Other than that, a hair pull test and some blood tests might also be done to get an accurate diagnosis. A scalp dermoscopy may also be done to rule out other similarly presenting alopecias.

A biopsy will probably not be needed, but it may be taken as well. These biopsies can show the ratio of anagen to telogen (resting stage) hair (which comes out to be normal if it’s anagen effluvium).  

How Do You Fix Anagen Effluvium?

No treatment is reported to be 100% effective for preventing or inhibiting anagen effluvium. Nevertheless, certain treatments do seem to help, including: 

• Minoxidil: One study found the application of 2% topical minoxidil shortened the “period of baldness” by almost 50 days in chemotherapy-induced alopecia. Though it won’t prevent this type of hair loss, minoxidil can be helpful in promoting the regrowth of hair. 
• Bimatoprost: This drug has been FDA-approved for the treatment of hypotrichosis of the eyelashes (a condition in which the eyelash hair is inadequate). Specifically, bimatoprost is also believed to have potential for regrowing hair in those experiencing anagen effluvium, according to a recent research. 

To stop hair loss in the first place, it’s important to seek the advice of a medical professional. The good news is that this hair loss is usually reversible, so your hair will likely grow back. 

Anagen Effluvium vs. Telogen Effluvium: What Is The Difference? 

The key difference between anagen and telogen effluvium is the phase of hair growth in which shedding occurs. 

In anagen effluvium, hair fractures while it’s still in the active anagen phase. However, in telogen effluvium, the hair shifts abnormally from the growing (anagen) phase to the resting (telogen) phase.

Anagen hair with the pointed distal end to the left and Telogen hair to the right. Occipito-vertical alopecia after radiation exposure. Verma S, Srinivas C, Thomas M. Radiation-induced temporary alopecia after embolization of cerebral aneurysm. Indian J Dermatol. 2014 Nov;59(6):633. doi: 10.4103/0019-5154.143584. PMID: 25484428; PMCID: PMC4248536/CC BY-NC-SA 3.0.

Anagen effluvium can cause sudden hair loss. While in the case of telogen effluvium, hair loss occurs 3-4 months after the stressful event. 

However, keep in mind that it is possible for you to experience hair loss due to both at the same time. 

Here’s a summary of the differences between the two types of hair loss:

	Anagen Effluvium	Telogen Effluvium
Causes	Chemotherapy, radiotherapy, medication, toxic heavy metals, health problems, and protein deficiency	Physical and emotional stressors, such as surgery, malnutrition, illness, childbirth, drugs, stress, diet, hormonal imbalance, etc.
Hair Appearance	Pencil-point	Club-shaped
Duration of Hair Loss	Until the hair follicle is affected by the causative agents	3-6 months (unless chronic)
Start of Hair Loss	Days to weeks after the injury	3-4 months after the stressful event
Hair regrowth	After 3-6 months	After 3-6 months
Reversibility	Usually completely reversible, although, rarely, it can be permanent	Temporary and reversible
Treatment	Minoxidil may be recommended to help with regrowth	None required though minoxidil may be recommended

How Do You Prevent Anagen Effluvium?

It’s not possible to prevent anagen effluvium in all instances. However, there are certain devices that may help in some situations. These are as follows: 

• Scalp Tourniquet: It’s an inflatable hairband that goes around the scalp and aims to reduce the blood flow to the scalp — the idea is that chemo drugs won’t reach the follicles and cause hair loss. 
• Cooling Caps: The purpose of these caps is to induce scalp hypothermia by cooling it down to less than 24°C. This reduces blood flow to the scalp and hence the amount of chemo drugs reaching the scalp.

These devices have certain downsides. For instance, it’s feared that if you’re wearing devices, it may not get rid of cancer in the scalp area. 

What you can do is make sure that you’re practising very gentle hair care. This should mean avoiding the use of styling tools or chemical dyes. Your shampoo should also have a mild formula, and you shouldn’t brush your hair too hard. 

One of the ways in which many people cope with this kind of hair loss is camouflage. You can consider wearing scarves, caps, bandanas, hairpieces, etc. 

Experiencing Hair Loss?

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