TITLE:
Diagnostic Spectrum in Acute Diffuse Hair Shedding: A Clinical, Trichoscopic, Histopathological, and Immunohistochemical Study at Banadir Hospital, Mogadishu, Somalia
AUTHORS:
Emmanuel Duna Forcham, Paul Itor, Abdulkadir Aweis Ahmed Roble, Lukong Hubert Shalanyuy
KEYWORDS:
Telogen Effluvium, Female Pattern Hair Loss, Trichoscopy, Scalp Biopsy, CD3, Diffuse Hair Shedding, Alopecia
JOURNAL NAME:
Open Access Library Journal,
Vol.13 No.10,
October
16,
2026
ABSTRACT: Background: Acute diffuse hair shedding in women is a diagnostically challenging presentation because telogen effluvium (TE), female pattern hair loss (FPHL), combined TE/FPHL, and diffuse forms of alopecia areata may present with overlapping clinical features. Trichoscopy, histopathology, and immunohistochemistry (IHC) may provide complementary diagnostic information, but their relative contributions in acute diffuse hair shedding remain incompletely characterized, particularly in African populations. The main objective of this study was to characterize the clinical and diagnostic spectrum of acute diffuse hair shedding in women and evaluate the complementary value of clinical assessment, trichoscopy, histopathology, and CD3 immunohistochemistry in differentiating TE, FPHL, and combined TE/FPHL, while assessing for features of alopecia areata incognita (AAI). Methods: A hospital-based cross-sectional study was conducted among 80 women aged ≥ 18 years who presented consecutively to Banadir Hospital, Mogadishu, Somalia, with acute diffuse hair shedding of ≤6 months’ duration. Participants underwent standardized clinical assessment, hair-pull testing, trichoscopy using a FotoFinder Medicam 1000 videodermoscope, and scalp biopsy with histopathological and CD3 immunohistochemical assessment. Participants were classified into telogen effluvium, female pattern hair loss, or combined telogen effluvium/female pattern hair loss based on predefined clinical and trichoscopic findings. Statistical analyses were performed using IBM SPSS Statistics version 27.0, with statistical significance set at p Results: The mean duration of hair shedding was 3.75 ± 1.0 months. Sudden onset occurred in 46 (57.5%) participants, while frontal and frontoparietal involvement accounted for 47.5% and 42.5%, respectively. TE was diagnosed in 40 (50.0%) participants, FPHL in 27 (33.8%), and combined TE/FPHL in 13 (16.3%). Significant differences were observed in several trichoscopic features. Hair-diameter diversity ≥ 20% occurred in 5.0% of TE, 37.0% of FPHL, and 46.2% of combined cases (p = 0.019). Single-hair follicular units were present in 5.0%, 63.0%, and 46.2%, respectively (p = 0.008), while hair-shaft diameter differences occurred in 5.0%, 29.6%, and 61.5% (p = 0.011). Numerous frontal vellus hairs were observed in 0%, 37.0%, and 46.2% (p = 0.009), whereas short regrowing hairs occurred in 75.0% of TE, 0% of FPHL, and 76.9% of combined cases (p = 0.004). Peripilar signs were present in 22.2% of FPHL compared with none of the TE or combined cases (p = 0.021), while empty frontal follicles occurred in 29.6% of FPHL, 15.4% of combined cases, and none of the TE cases (p = 0.031). Multiple upright regrowing hairs occurred exclusively in the combined group (30.8%; p = 0.024). Quantitatively, mean hair-shaft diameter decreased progressively from TE to FPHL and combined TE/FPHL (64.8 ± 8.0, 58.3 ± 8.0, and 55.6 ± 4.0 µm, respectively; p = 0.016), while the number of thick hairs > 50 µm also differed significantly (p = 0.041). Histopathology showed predominantly mild lymphocytic infiltration without significant differences in inflammatory distribution among diagnostic groups. CD3 immunohistochemistry demonstrated T-lymphocytic infiltration across multiple tissue compartments but did not significantly discriminate the diagnostic groups. No participant fulfilled the predefined criteria for AAI. Conclusion: Acute diffuse hair shedding in women represents a heterogeneous diagnostic phenotype, with TE, FPHL, and combined TE/FPHL comprising the major diagnostic categories. Trichoscopy provided the strongest discriminatory information, particularly through assessment of hair-diameter variability, follicular-unit composition, frontal vellus hairs, regrowing hairs, and shaft caliber, despite similar overall hair density. Histopathology demonstrated predominantly mild and nonspecific inflammation, while CD3 immunohistochemistry did not significantly differentiate the diagnostic groups. An integrated clinical and trichoscopic approach, supplemented by histopathology and IHC when clinically indicated, may improve diagnostic characterization of women presenting with acute diffuse hair shedding.