Evaluation of serum ferritin, vitamin B12 and vitamin D levels as biochemical markers of chronic telogen effluvium in women
Keywords:Chronic telogen effluvium, Serum ferritin, Vitamin D, Vitamin B12
Background: Diffuse hair loss is a common complaint encountered by dermatologists in clinical practice and can be alarming to the patients. Chronic telogen effluvium (CTE) is characterized by an abrupt onset of diffuse loss of scalp hair persisting for more than six months, predominantly affecting healthy women in their fourth to fifth decade of life. Although CTE is considered to be associated with various nutritional deficiencies, currently the evidence to substantiate this assertion is conflicting.
Methods: A cross-sectional study was conducted on 100 adult non-pregnant women with CTE to document serum ferritin, B12 and vitamin D levels in an attempt to validate their role as biochemical markers using Statistical package for social sciences (SPSS) version 25:0 and Fisher’s exact test.
Results: Mean ferritin level was 31.17 ng/dL. 23% patients had serum ferritin levels lower than the normal range (13-150 ng/dL). Vitamin D levels (normal range 5.2-60.4 ng/ml, mean 21.41 ng/ml) were low (deficiency range) in 2%. Vitamin B12 levels (normal range 191-663 pg/ml, mean 239.79) were low in 35.7% patients. Other parameters like duration, family history, past history of treatment did not demonstrate any statistically significant correlation.
Conclusions: Our study detected low levels of serum ferritin and vitamin B12 in approximately one-fourth and a third of females with chronic telogen effluvium respectively with vitamin D deficiency found in only a small proportion. Although a statistically significant correlation could not be established between these nutrients and participant age or other parameters; we concur with most authors who recommend that all females with diffuse hair loss deserve a thorough screening for nutritional deficiencies to facilitate prompt recognition and timely supplementation.
Price VH. Treatment of hair loss. Wood AJJ, editor. N Engl J Med. 1999;341:964-973.
Mirmirani P. Managing hair loss in midlife women. Maturitas. 2013;74:119-122.
Mysore V, Parthasaradhi A, Kharkar R D, Ghoshal A K, Ganjoo A, Ravichandran G et al. Expert consensus on the management of telogen effluvium in India. Int J Trichol. 2019;11:107-12.
Kligman AM. Pathologic dynamics of hair loss.1. Telogen effluvium. Arch Dermatol. 1961;83:175-98.
Headington JT. Telogen effluvium: New concepts and views. Arch Dermatol. 1993;129:356-63.
Feidler VC, Hafeez A. Diffuse alopecia: telogen hair loss. In: Olsen EA, editor. Disorders of hairs growth. Diagnosis and treatment. 2nd ed. New york: McGraw- Hill. 2003;301-21.
Shapiro J. Clinical practice Hair loss in women. N Engl J Med. 2007;357(16):1620-1630.
Gg A. Diffuse alopecia; nutritional factors and supplements. Turkderm-Turk Arch Dermatol Venerol. 2014;48(Suppl 1):45-47.
Mason JB. Vitamins, trace minerals, and other micronutrients. In: Goldman L., Schafer AI, editors. Goldman-Cecil Medicine. 25 ed. Philadelphia, PA: Saunders, an imprint of Elsevier Inc. 2016;1445-1455.e1441.
Institute of Medicine. Food and Nutrition Board. Dietary reference intakes: thiamin, riboflavin, niacin, vitamin b6, folate, vitamin b12, pantothenic acid, biotin, and choline. Washington, DC: National Academy Press. 1998.
Institute of Medicine (US) Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its Panel on Folate, Other B Vitamins, and Choline. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington (DC). National Academies Press (US). 1998;9.
Cheung EJ, Sink JR, English Iii JC. Vitamin and Mineral Deficiencies in Patients With Telogen Effluvium: A Retrospective Cross-Sectional Study. J Drugs Dermatol. 2016;15(10):1235-1237.
Durusoy C, Ozenli Y, Adiguzel A, Budakoglu IY, Tugal O, Arikan S et al. The role of psychological factors and serum zinc, folate and vitamin B12 levels in the aetiology of trichodynia: a case-control study. Clin Exp Dermatol. 2009;34(7):789-92.
Zlotogorski A, Hochberg Z, Mirmirani P, Metzker A, Ben-Amitai D, Martinez-Mir A, et al. Clinical and pathologic correlations in genetically distinct forms of atrichia. Arch Dermatol. 2003;139:1591-6.
Reichel H, Koeffler HP, Norman AW. The role of the Vitamin D endocrine system in health and disease. N Engl J Med. 1989;320:980-91.
Xie Z, Komuves L, Yu QC, Elalieh H, Ng DC, Leary C, et al. Lack of the Vitamin D receptor is associated with reduced epidermal differentiation and hair follicle growth. J Invest Dermatol. 2002;118:11-6.
Wang J, Lu Z, Au JL. Protection against chemotherapy-induced alopecia. Pharm Res. 2006;23:2505.
Rasheed H, Mahgoub D, Hegazy R. Serum ferritin and vitamin d in female hair loss: do they play a role? Skin Pharmacol Physiol. 2013;26(2):101-107.
Banihashemi M, Nahidi Y, Meibodi NT, Jarahi L, Dolatkhah M. Serum vitamin D3 level in patients with female pattern hair loss. Int J Trichol. 2016;8(3):116-120.
Moneib HFG, Ouda A. Possible association of female-pattern hair loss with alteration in serum 25-hydroxyvitamin D levels. Egypt J Dermatol Venerol. 2014;34:15-20.
Nayak K, Garg A, Mithra P, Manjrekar P. Serum vitamin D3 levels and diffuse hair fall among the student population in South India: a Case-Control Study. Int J Trichol. 2016;8(4):160-164.
Karadag ASEDT, Tutal E, Akin KO. The role of anemia and vitamin D levels in acute and chronic telogen effluvium. Turk J Med Sci. 2011;41:827-833.
Mineral deﬁciencies in patients with Telogen Efﬂu-vium: a retrospective cross-sectional study. J Drugs Dermatol. 2016;15(10):1235.
Trost LB, Bergfeld WF, Calogeras E. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J Am Acad Dermatol. 2006;54(5):824-844.
2Shrivastava SB. Diffuse hair loss in an adult female: approach to diagnosis and management. Indian J Dermatol Venereol Leprol. 2009;75(1):20-27.
Walters GO, Miller FM, Worwood M. Serum ferritin concentration and iron stores in normal subjects. J Clin Pathol. 1973;26(10):770-772.
Rushton DH. Nutritional factors and hair loss. Clin Exp Dermatol. 2002;27(5):396-404.
Sinclair R. There is no clear association between low serum ferritin and chronic diffuse telogen hair loss. Br J Dermatol. 2002;147(5):982-984.
Coenen JL, van Dieijen-Visser MP, van Pelt J. Measurements of serum ferritin used to predict concentrations of iron in bone marrow in anemia of chronic disease. Clin Chem. 1991;37(4):560-563.
Rushton DH, Ramsay ID. The importance of adequate serum ferritin levels during oral cyproterone acetate and ethinyl oestradiol treatment of diffuse androgen-dependent alopecia in women. Clin Endocrinol (Oxf). 1992;36(4):421-427.
Milman N, Kirchhoff M. Iron stores in 1359, 30- to 60-year-old Danish women: evaluation by serum ferritin and hemoglobin. Ann Hematol. 1992;64(1):22-27.
Hallberg L, Bengtsson C, Lapidus L, Lindstedt G, Lundberg PA, Hulten L. Screening for iron deficiency: an analysis based on bone-marrow examinations and serum ferritin determinations in a population sample of women. Br J Haematol. 1993;85(4):787-798.
Punnonen K, Irjala K, Rajamaki A. Serum transferrin receptor and its ratio to serum ferritin in the diagnosis of iron deficiency. Blood. 1997;89(3):1052-1057.
Mast AE, Blinder MA, Gronowski AM, Chumley C, Scott MG. Clinical utility of the soluble transferrin receptor and comparison with serum ferritin in several populations. Clin Chem. 1998;44(1):45-51.
St Pierre SA, Vercellotti GM, Donovan JC, Hordinsky MK. Iron deficiency and diffuse nonscarring scalp alopecia in women: more pieces to the puzzle. J Am Acad Dermatol. 2010;63(6):1070-1076.
Kantor J, Kessler LJ, Brooks DG, Cotsarelis G. Decreased serum ferritin is associated with alopecia in women. J Invest Dermatol. 2003;121(5):985-988.
Harrison S, Sinclair R. Telogen effluvium. Clin Exp Dermatol. 2002;27(5):389-395.
Sinclair R: Diffuse hair loss. Int J Dermatol 1999;38(suppl 1):8-18.
Olsen EA, Reed KB, Cacchio PB, Caudill L. Iron deficiency in female pattern hair loss, chronic telogen effluvium, and control groups. J Am Acad Dermatol. 2010;63(6):991-999.
Gowda D, Premalatha V, Imtiyaz DB. Prevalence of nutritional deficiencies in hair loss among Indian participants: results of a Cross-sectional Study. Int J Trichol. 2017;9(3):101-104.