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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 10-14

An analytical study of serum ferritin, vitamin D, and thyroid function in females with diffuse hair loss


1 Department of Dermatology, Dr RMLH, ABVIMS, New Delhi, India
2 Department of Biochemistry, Dr RMLH, ABVIMS, New Delhi, India

Date of Submission15-Feb-2021
Date of Decision01-Jun-2022
Date of Acceptance11-Jul-2022
Date of Web Publication26-Oct-2022

Correspondence Address:
Seema Rani
Department of Dermatology, Dr RMLH, ABVIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdpdd.ijdpdd_19_21

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  Abstract 

Objective: Women with diffuse hair loss need to be screened for possible causes or factors responsible for increased hair shedding and also to exclude factors that can increase hair shedding and aggravate the disease. Material and Methods: A prospective cross-sectional study of 40 cases (18–45years) of diffuse hair loss and 40 healthy females were included. The diagnosis was based on the detailed history, clinical examination to rule out pattern hair loss, and hair pull test. Complete hemogram, serum ferritin, vitamin D, and thyroid function tests (T3, T4, thyroid-stimulating hormone [TSH]) along with all routine investigations were determined for each participant. A diet history of vegetarians and non-vegetarians was also taken. Results: On screening, serum ferritin in cases ranged from 3.92 to 104 ng/mL with a mean of 22.36±23.10 ng/mL and that in controls ranged from 5.5 to115 ng/mL with a mean of 29.97±45.72 ng/mL. The serum ferritin level in cases was lower, at a cut-off value of 10 ng/mL, which is statistically significant (p= 0.027). For those with serum ferritin level >10 ng/mL, the mean concentration of hemoglobin was 11.65 ± 0.79 gm%, whereas for the <10 ng/mL serum ferritin level, the mean concentration of hemoglobin was 11 ± 1.1 gm% with a significant statistical difference (p= 0.027). The serum level of vitamin D in cases ranged from 8 to 57.4 IU/dL with a mean of 20.24±11.98 IU/dL while that in controls ranged from 11.1 to 42.6 IU/dL with a mean of 22.42±9.29 IU/dL, which was statistically significant difference (p= 0.003). We found no association of thyroid dysfunction with diffuse hair loss. On dietary evaluation, significant statistical association among vegetarians (67.5% cases and 40% controls) and non-vegetarians (32.5% cases and 60% controls) was observed (p= 0.024); however, we could not find any statistical significant association of diet with ferritin and vitamin D. Conclusion: Low ferritin and vitamin D may contribute to diffuse hair loss.

Keywords: Hair loss, serum ferritin, serum vitamin D


How to cite this article:
Rani S, Chitkara A, Sharma PK, Sinha S, Sharma P. An analytical study of serum ferritin, vitamin D, and thyroid function in females with diffuse hair loss. Indian J Dermatopathol Diagn Dermatol 2022;9:10-4

How to cite this URL:
Rani S, Chitkara A, Sharma PK, Sinha S, Sharma P. An analytical study of serum ferritin, vitamin D, and thyroid function in females with diffuse hair loss. Indian J Dermatopathol Diagn Dermatol [serial online] 2022 [cited 2023 Feb 8];9:10-4. Available from: https://www.ijdpdd.com/text.asp?2022/9/1/10/359688




  Introduction Top


Hair loss is one of the most common complaints among all patients consulting a dermatologist and is usually associated with severe psychological disturbances, distress, and symptoms of depression.[1] The two most common causes of diffuse hair loss are female pattern hair loss (FPHL) and telogen effluvium (TE). While some patients present with typical features of one of these conditions, many present with overlapping features, especially those with chronic diffuse hair loss and thinning. Other causes, such as anagen effluvium, loose anagen hair syndrome, diffuse type of alopecia areata, congenital atrichia, congenital hypotrichosis, and hair shaft abnormalities, are not so common and can be diagnosed through history and examination.[1]

Metabolic causes of diffuse hair loss in women include hypothyroidism and severe iron deficiency anemia[2]; other metabolic disturbances, such as liver disorders and chronic renal failure, are also known to cause sparse scalp hair. Nutritional causes of diffuse telogen hair loss are zinc deficiency and iron deficiency.[3] Severe protein, fatty acid, and caloric restriction with chronic starvation[3] and crash dieting can also induce diffuse telogen hair loss. Iron deficiency with no anemia or only mild anemia and chronic diffuse hair loss are, however, more complex and controversial.[4],[5] Serum ferritin concentration can be used to confirm diagnosis of iron deficiency. Vitamin D is an essential vitamin in cell growth and promotes hair follicle (HF) differentiation, without affecting proliferation. Its deficiency may be associated with diffuse hair loss.[6] Thyroid hormones T3 and T4 are essential for normal growth of all tissues including skin, hair, and nails. Both hypothyroidism and hyperthyroidism can cause diffuse telogen hair loss that is usually reversible once the euthyroid state is restored.[3],[6] Finding the cause, or trigger, of the hair loss requires a thorough history and examination and will enable appropriate treatment. As there is a paucity of studies on direct association of biochemical analysis in diffuse hair loss in females in the Indian population, the aim of this study was to evaluate or screen the possible causative factors in diffuse hair loss, in order to validate the role they play and underline the value of supplementing them.


  Material and Methods Top


A prospective cross-sectional study was approved by the Research Ethics Committee of the Institute. It was carried out in the Departments of Dermatology and Biochemistry from August 2017 to January 2018. Written informed consent was obtained from all the patients before their participation in the study.

Forty women (18–45years) with diffuse hair loss and 40 age-matched healthy women with no hair loss were included in the study. Diagnosis was based on the detailed history, clinical examination in the form of scalp examination, and hair pull test. Scalp examination was done to rule out pattern hair loss and to exclude alopecia areata, trichotillomania, cicatricial alopecia, hair shaft abnormality, folliculitis, seborrheic dermatitis, psoriasis, and lichen planus. The hair pull test was conducted at different sites of the scalp (anterior, vertex, left and right parietal, occipital). Quantity of hair per pull was approximately 50–60 hairs in any examined area (positive hair pull test shows >6 hairs/site). Exclusion criteria were presence of any systemic chronic illness and scalp disease that might be related to hair loss. Subjects on medication that could be related to hair loss (e.g., anticoagulants, retinoids, anticonvulsants and antidepressants, anticancer, antitubercular, oral steroid, antiviral, oral contraceptive), or subjects receiving drugs containing vitamin Dand iron supplements were also excluded. Pregnant, lactating, and menopausal women were also excluded. A detailed history about onset, duration of hair loss, past illness, any drug intake, menstrual cycle, pregnancy, family history, and diet intake whether vegetarian or non-vegetarian was noted for each participant.

General and local examinations were carried out to determine any systemic or local dermatological condition that might be related to hair loss and thus preclude participation.

Examination of the scalp was performed for the detection of any scalp abnormality and to determine the type and pattern of hair loss. Patients with significant diffuse hair shedding meaning more than 100–150 hair loss per day were taken for the study.

An aliquot of 10 mL of venous blood sample of all the cases and controls in an empty stomach was collected at the Department of Biochemistry in a sterile plain tube and allowed to stand for 30 min at room temperature and then centrifuged for 5 min. Sera were immediately separated and processed for thyroid profile, 25OH Vit D3, and serum ferritin using chemiluminescence by Vitros Orthoclinical Diagnostic Equipment (VITROS ECi).The kit supplier is Orthoclinical Diagnostic by Johnson and Johnson. The measured value for serum ferritin was in the range of 6.40–464 ng/mL. For vitamin D, deficiency is <10 IU/dL, insufficiency 10–30 IU/dL, and normal>30 IU/dL. For thyroid profile, the measured values were as follows: free T32–4.4 pg/mL, free T40.6–2.2 ng/mL, and TSH0.5–5 mIU/L.

Other laboratory tests including complete hemogram along with peripheral smear, serum calcium (Ca), liver function test, and kidney function tests were performed for all participants. Since serum ferritin is an acute phase reactant, it can be elevated under infectious and inflammatory conditions, to avoid confounding results. C-reactive protein (CRP) was done for all cases and controls, using the latex method and enzyme-linked immunosorbent assay.

Statistical analysis

For demographic and other clinical variables, we used descriptive statistics (mean ± standard deviation and percentage). On all parameters, cases and controls were compared by the Mann–Whitney U-test. Categorical parameters were compared using the χ2 test. A P-value of less than 0.05 was considered statistically significant. All the analyses have been done using standard statistical software SPSS version20.


  Results Top


This study included 40 women of diffuse hair loss (mean±SD 26.30±6.15) and 40 healthy controls (mean±SD 26.13±5.92), age ranging from 18 to 45 years. Duration of the hair fall in cases was minimum 2 months to maximum 48 months with a mean value of 9.20 ± 10.64. The value of serum ferritin in cases was found to be in the range of 3.92–104 ng/mL, with a mean of 22.36±23.10 ng/mL, whereas the value in controls was in the range of 5.5–115 ng/mL, with a mean of 29.97±45.72 ng/mL.We have taken the cutoff value of serum ferritin at 10 ng/mL and values less than 10 ng/mL were taken as decrease in serum ferritin in both cases and controls. Among cases, 13 (32.5%) had serum ferritin levels <10 and 27 (67.5%) had>10 (n = 40), whereas in controls, only 4 (10%) had serum ferritin level <10 and 36 (90%) had>10 (n = 40). There was significant statistical difference at this level of ferritin (p= 0.027). The level of serum vitamin D(25OH vitD3) in cases ranged from 8 to 57.04 IU/dL, with a mean of 20.24±11.98 IU/dL, whereas in controls the level ranged from 11.2 to 42.6 IU/dL, with a mean of 22.42±9.29 IU/dL. On categorical analysis between cases and controls, among cases, deficiency of vitamin D (<10) was detected in 9(22.5%) and insufficiency (<30) was detected in 27(67.5%), whereas in controls none was found to be deficient and 31(77.5%) had insufficient level of vitamin D. Only 4(10%) in cases and 9(22.5%) in control had normal level of vitamin D (>30). The statistical difference was significant (p= 0.003) [Table 1].
Table 1: Association of categorical parameters with cases and controls

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The mean TSH in cases was 1.91±1.36, while in controls it was 2.59±1.17, with a significant statistical difference (p= 0.005). The mean T4 in cases was 1.61±1.56, whereas in controls it was1.22±0.23, without any significant statistical difference. The mean T3 in cases was 3.08±0.54, whereas in controls it was3.17±0.77 without any significant statistical differences [Table 2]. In the categorical analysis between cases and controls, TSH was raised in only one case and decreased in two cases and none of the controls had raised value. T4 was detected high in only one case, whereas in controls none had raised value and without any statistical differences. There was no significant change in the mean serum freeT3 levels when compared with the controls.
Table 2: Level of continuous parameters compared between cases and controls

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On dietary evaluation, we found that 27(67.5%) cases (n = 40) and 16(40%) controls (n = 40) were vegetarians, whereas 13(32.5%) cases and 24(60%) controls were non-vegetarians with a significant statistical difference (p= 0.024) [Table 1]. But we did not observe any significant statistical association of diets with serum ferritin at cut-off level 10 and also with serum vitamin D among cases and controls.

The mean of hemoglobin in cases was 11.70 ± 1.05 and in controls was 11.32±.702, with a significant statistical difference (P= 0.030). The mean of serum calcium in cases was 8.99 ± 0.274 and in controls was 9.36 ± 0.419, with a significant statistical difference (P=0.000), although there was a minimal difference [Table 2]. CRP was positive in six cases and two controls without any statistical significance.


  Discussion Top


According to our findings, diffuse hair loss in females was associated with low serum levels of ferritin and vitamin D and there was no significant link with thyroid abnormality. The causes of hair loss are diverse, making it impossible to fix all variables. In this study, we tried to preclude all other factors that might be related to hair loss by following the exclusion criteria so as to be able to focus on the influence of the biochemical factors such as serum ferritin, vitamin D, and thyroid function tests. We conducted our study by recording a thorough history, answering of a questionnaire, a clinical examination, and hair pull test to confirm proper patient selection.

We have taken the cut-off value of serum ferritin level to 10 ng/mL as in women of child bearing age; using a cut-off value of 10–15 ng/mL yields a sensitivity of 75% and a specificity of 98%.[7] In a study by Bregyand Trueb,[8] they also used a cut-off of 10microg/L as the lower limit of normal for menstruating women. We found a significant statistical difference among cases when compared with controls (p= 0.027). Our study found similar results with previous reports,[9],[10] which found the association between low iron stores assessed by serum ferritin concentrations and hair loss in women. Several studies have evaluated the relationship between iron deficiency and hair loss; many of them have focussed on women.[4],[11]

In contrast, some studies demonstrated no significant link between iron deficiency and hair loss.[5],[12]

The existence of several variables such as the study designs adopted, the variability of the definition of a normal serum ferritin level in women, and the different reference ranges used by different laboratories are some factors that could contribute to this detected discrepancy.[12] Only iron deficiency causes very low serum ferritin concentrations; therefore, a low serum ferritin concentration is specific for iron deficiency. In our study, the mean concentration of hemoglobin was lower with serum ferritin <10 when compared with those who had serum ferritin level >10, with a significant statistical difference (P=0.027).Although peripheral smear was done for all cases and controls, it was not compared with the value of serum ferritin. Studies by Obaidat et al.,[13] Rushton et al.,[14] and Kantor et al.[10] have shown a statistically significant decrease in serum hemoglobin and serum ferritin levels in chronic tellogen effluvium patients and a significant improvement in hair loss after supplementing with iron in these patients.

As ferritin is also an acute-phase reactant, it is often elevated in the course of various diseases; in our study, we used a normal CRP to exclude elevated ferritin caused by the acute-phase reaction.

In our study, vitamin D among the cases was significantly lower in comparison to that in controls (P= 0.003), which is in agreement with another study, in which the vitamin D levels in females with chronic TE or FPHL came out to be significantly lower among cases when compared with controls for both the conditions.[15],[16]

The serum level of vitamin D is one of the factors recently considered in the approach to patients with complaints of hair loss.[17],[18] In a study of Rasheed et al.[15] in 2013 in Egypt, the serum vitamin D3 level in FPHL was significantly lower than that in the control group. In the present study, the mean level of vitamin D3 in cases and controls was not statistically significant, but there was a significant difference between the categories of vitamin D (deficient and insufficient) in both the groups (P= 0.003). Individual variables are the factors affecting serum levels of vitamin D3, including age, weight, skin type, and exposure to the sun.[18] Obesity, autoimmune, gastrointestinal, hepatic, and renal diseases as well as malnutrition are conditions that can be responsible for low serum vitamin D[19] and ferritin levels as well as for hair loss.[15] A study conducted by Funda et al. found low serum levels of ferritin and 25(OH)D in the patient group when compared with control populations, and vitamin B12 and zinc deficiencies were determined in a few patients; checking vitamin B12 and zinc levels routinely in every patient complaining of diffuse hair loss is not mandatory.[20] Another study conducted on hair loss during menopause recommended diet supplementation with preparation containing Zn, Cu, Fe (especially for vegetarian people), vitamins A, D, E, niacin, B12, and biotin.[21] In women with FPHL, circulating androgens should be evaluated and measurements of blood iron studies, vitamin D, zinc, thyroid profile, and prolactin may be useful to rule out and treat other conditions that may affect hair regrowth.

Both insufficient and excess levels of thyroid hormones (T3 and T4) can result in altered hair/skin structure and function (e.g., effluvium). However, it is still unclear whether T3 and T4 exert any direct effects on human HFs (hair follicles), and if so, how exactly human hair follicles respond to T3/T4 stimulation. Prevalence of subclinical hypothyroidism in women in India has been estimated to be 9–12%.[22] In our study, one case was diagnosed with subclinical hypothyroidism, one with hyperthyroidism and two with subclinical hyperthyroidism.


  Conclusion Top


The occurrence diffuse hair loss in dermatological clinics is frequent. Women with diffuse hair loss need to be screened for possible causes of increased hair shedding. We suggest that low serum ferritin and vitamin D deficiency or insufficiency are important risk factors in the development of diffuse hair loss in women, taking into consideration the reported prevalence of a low serum ferritin level in some populations in developing countries like India. Our study highlights the importance of its evaluation, and supplementation of both iron and vitamin D can be helpful in such cases. However, because of small sample size, no direct relationship with thyroid abnormality can be established. Further large-scale studies are necessary to provide a clear picture and evaluate their role per se on hair loss.

The limitations of the study were that complaint of hair fall was subjective only; no objective tests such as dermatoscopy or trichogram were done.

Acknowledgment

The authors thank Dr Triptish Bhatia, Ph.D. Senior Research Scientist, Indo-US Projects, Department of Psychiatry, Center of Excellence in Mental Health, ABVIMS, Dr RMLH, New Delhi, India, for statistical analysis.

Financial support and sponsorship

The institute/Dr RMLH funded the investigations for controls.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shrivastava SB Diffuse hair loss in an adult female: Approach to diagnosis and management. Indian J Dermatol Venereol Leprol 2009;75:20–7; quiz 27–8.  Back to cited text no. 1
    
2.
Cerio R Skin, nails and hairs. In: Glynn M, Drake WM, editors.Hutchison’s Clinical Methods: An Integrated Approach to Clinical Practice. 24th ed. Elsevier Science; 2018; p. 408-9.  Back to cited text no. 2
    
3.
Rook A, Dawber R Diffuse alopecia: Endocrine, metabolic and chemical influenceson the follicular cycle. In: Rook A, Dawber R, editors. Diseases of the Hair and Scalp. Oxford, UK: Blackwell Science Publications; 1982. p. 115-45.  Back to cited text no. 3
    
4.
Rushton DH, Ramsay ID, James KC, Norris MJ, Gilkes JJ Biochemical and trichological characterization of diffuse alopecia in women. Br J Dermatol 1990;123:187-97.  Back to cited text no. 4
    
5.
Sinclair R There is no clear association between low serum ferritin and chronicdiffuse telogen hair loss.Br J Dermatol 2002;147:982-4.  Back to cited text no. 5
    
6.
Bergfeld WF, Mulinari-Brenner F Shedding: How to manage a common cause of hair loss. Cleve Clin J Med 2001;68:256-61.  Back to cited text no. 6
    
7.
Centers for Disease Control (CDC). Recommendations to prevent and control irondeficiency in the United States. Morb Mortal Wkly Rep 1998;47:1-36.  Back to cited text no. 7
    
8.
Bregy A, Trueb RM No association between serum ferritin levels >10 microg/L and hair loss activity in women. Dermatology 2008;217:1-6.  Back to cited text no. 8
    
9.
Deloche C, Bastien P, Chadoutaud S, Galan P, Bertrais S, Hercberg S, et al. Low iron stores: A risk factor for excessive hair loss in non-menopausal women.EurJ Dermatol 2007;17:507-12.  Back to cited text no. 9
    
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Kantor J, Kessler LJ, Brooks DG, Cotsarelis G Decreased serum ferritin is associated with alopecia in women. J Invest Dermatol 2003;121:985-8.  Back to cited text no. 10
    
11.
Rushton DH Nutritional factors and hair loss. Clin Exp Dermatol 2002;27:396-404.  Back to cited text no. 11
    
12.
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;63:991-9.  Back to cited text no. 12
    
13.
Obaidat NA, Rawashdeh BT, Wreikat ARA, Awamleh AA A potential relationbetween telogen effluvium and iron deficiency in adult females. JRMS 2005;12:62-6.  Back to cited text no. 13
    
14.
Rushton DH, Norris MJ, Dover R, Busuttil N Causes of hair loss and the developments in hair rejuvenation. Int J Cosmet Sci 2002;24:17-23.  Back to cited text no. 14
    
15.
Rasheed H, Mahgoub D, Hegazy R, El-Komy M, Abdel Hay R, Hamid MA, et al. Serum ferritin and vitamin Din female hair loss: Do they play a role? Skin Pharmacol Physiol 2013;26:101-7.  Back to cited text no. 15
    
16.
Nayak K, Garg A, Mithra P, Manjrekar P Serumvitamin D3levels and diffuse hair fall among the student population in SouthIndia: A case–control study. Int J Trichol 2016;8:160-4.  Back to cited text no. 16
    
17.
Amor KT, Rashid RM, Mirmirani P Does D matter? The role of vitamin D in hair disorders and hair follicle cycling. Dermatol Online J 2010;16:3.  Back to cited text no. 17
    
18.
Mostafa WZ, Hegazy RA Vitamin D and the skin: Focus on a complex relationship: A review. J Adv Res 2015;6:793-804.  Back to cited text no. 18
    
19.
Tsiaras WG, Weinstock MA Factors influencing vitamin D status. ActaDerm Venereol 2011;91:115-24.  Back to cited text no. 19
    
20.
Tamer F, Yuksel ME, Karabag Y Serum ferritin and vitamin D levels should be evaluated in patients with diffuse hair loss prior to treatment. Postepy Dermatol Alergol 2020;37:407-11.  Back to cited text no. 20
    
21.
Goluch-Koniuszy ZS Nutrition of women with hair loss problem during the period of menopause. Prz Menopauzalny 2016;15: 56-61.  Back to cited text no. 21
    
22.
Unnikrishnan AG, Kalra S, Sahay RK, Bantwal G, John M, Tewari N Prevalence of hypothyroidism in adults: An epidemiological study in eight cities of India. Indian J Endocrinol Metab 2013;17:647-52.  Back to cited text no. 22
    



 
 
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