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QUESTION OF HAIR BLOGS

Filtering by Category: Blood Tests

Do I just need patience or is my hair density not going to fully return?

June 07, 2021

Is my hair density going to return?

I’ve selected this question below for this week’s question of the week. It allows us to the review some key concepts in the diagnosis of hair loss in the early stages.

QUESTION

I am a 40 year old female. I have always had a lot of hair, and coarse hair. I have always been a shedder, but it never made a difference on how dense my hair was. Until now. I had my "normal to me" hair up until August/September 2020. But, in September/October, I started to see a lot more hair coming out in the shower/brushing afterwards/when blowdrying.

Handfuls would come out in the shower when in the shower. It was definitely the worst/at it's peak in November 2020.

I remember after one shower the entire wall was covered with the hair I collected. By this time I started to freak out a bit. It was definitely making a difference on my head now as far as density. I went to my family doc, and he did blood work. My ferritin came back at 21, but my hemoglobin was ok. I started taking iron supplements at the end of November. At the end of Jan 2021 I went to see a dermatologist. She only had a physical look at my scalp, did not do a biopsy and did not look at my scalp with any sort of magnifying tool or anything. She said based on my story she thought it was either Androgenetic Alopecia or Telogen Effluvium. She had my vitamin D tested. It was a bit low, so I started taking 2000IU of vitamin D daily. The hair shedding continued like this until end of February-ish/beginning of March. (The lost hair was mostly long hairs, some medium length, barely any short hairs)

In March/April 2021 the hair fall slowed down a lot, and now I would say it is back to a normal amount with each wash.

But, I can definitely see a difference on my head. It is most noticeable on the top/sides of my head, and down the back of my head (I have weird parts all along the back of my head). It also sort of looks like I lost hair at the nape of my neck. My part has not gotten wider at all, but sparser. I do have a lot of new growth at the top and back of my head, but it doesn't seem like enough to make a difference in terms of overall thickness, even when it grows longer.

My scalp hurts often, as if it has been in a super tight ponytail, even though it has not. Sort of hurts to move it around. My scalp can be quite dry/itchy at time (always has been like this, even before hair loss)

I am still taking iron supplements, as when I was re-tested in February my ferritin had only gone up to 30. I am also still taking the vitamin D daily. I should mention I take 2.5 or Ramipril daily.

My question is … would Androgenetic Alopecia happen that quickly and then taper off that quickly? And, if it is Telogen Effluvium would I expect to have more re-growth by now? Or, is there any chance I could have some sort of diffuse Alopecia Areata, based on what is happening at the nape of my neck and the weird parts down the back of my head? I have attached some photos. I am trying to be patient, as I know hair takes a long time to grow.

Thank you for your input!!

Image 1. Hair density in the central part.

ANSWER

Thanks for the great question. The short answer is that many diagnoses are possible for you. I’ll get into these in just a moment.

I would need to see your scalp and know more about your full story to tell you which diagnosis (or diagnoses) you actually have…. but the 6 possibilities are outlined below. Each of these possibilities has different probabilities for being your actual diagnosis. If I was to see your scalp, these ‘estimated’ probabilities would change. However, with the information provided, we have six scenarios. The most likely is scenario 1 and 2 followed by scenario 3.

Six Possible Scenarios for Your Hair Loss

There are six possible scenarios for your hair loss. The most likely is scenario 1 and 2 followed by scenario 3.

Scenario 1) You have a telogen effluvium due to low iron or low vitamin D. This has now been fixed and you need to give it until October/November in order for your density is going to come back.

Scenario 2) You have a telogen effluvium for some other reason (other than simply low iron and vitamin D) and it has now somewhat resolved and you need to give it until Oct/November in order for your density is going to come back. Causes of telogen effluvium that could be relevant for you would include stress last summer 2020, low iron (which you might have), thyroid problems, medications started last summer, weight loss last summer, COVID infection last summer. Other causes are possible too.

Scenario 3) You have actually had a hint of subtle “subclinical” androgenetic alopecia for a while and this recent telogen effluvium has “unmasked” the subtle androgenetic alopecia. Your density is going to improve by the Fall 2021 now that your telogen effluvium is resolving but you might or might not get back all your density - but you may come pretty close.

Scenario 4) You have an inflammatory scalp condition that has been present for a while and is now acting up to give periods of hair shedding. The iron and vitamin D are unrelated in this particular scenario and are simply a true red herrings. Your inflammatory scalp condition has now settled again but you need to give it until November/December to see if things will fully settle. Such inflammatory condition could include seborrheic dermatitis, psoriasis, scarring alopecia or contact allergy (ie to some ingredient in a shampoo, conditioner, hairstyling product or dye). This scenario number 4 carries a risk of flare again.

Scenario 5) You have an inflammatory scalp condition that has been present for a while but it’s not enough to give hair loss. A new telogen effluvium has come along that will resolve and time will tell whether the inflammatory scalp condition also settles fully. If the inflammatory scalp condition is a low grade scarring alopecia, density won’t come back fully but still will improve to some degree when the current telogen effluvium resolves.

Scenario 6) You have an inflammatory scalp condition that has been present for a while but it’s not enough to give hair loss. You also have a subtle amount of androgenetic alopecia that has now been unmasked by the new telogen effluvium. If the inflammatory scalp condition or androgenetic alopecia is active enough it may prevent density from coming back to your full normal by Fall 2021.

Detailed Review of the INITIAL Situation (August 2020 to Dec 2020)

Let’s go further into the situation that you describe in your question. Before we do, let me point out that there are three stages of hair loss for most people. At least that’s a helpful way that I view hair loss. These stages are important to appreciate because it impacts how I approach your question.

In “stage 1” of hair loss, the patient has hair loss but doesn’t really know it. For all practical purposes, the patient feels the hair looks the same as it always did and feels the same as it always did. Perhaps when they look at a photo from years gone by they might say something like “Wow, I can’t believe how much hair I had back then!” Otherwise stage 1 of hair loss is unrecognizable by anyone - patient, doctor, specialist or hairstylist.

In “stage 2” of hair loss, patients themselves realize they have hair loss - but others around them don’t believe it or don’t realize it. The patient feels the pony tail is smaller or the scalp is more see through or something is just not the same. A spouse, sister, parent, daughter, son, barber, hairstylist or friend usually say the same thing - “You’re exaggerating ! Everything looks fine to me! Sometimes that sentence is delivered by the doctor or other hair expert that has been asked to help.

Stage 2 is sometimes frustrating and lonely and anxiety provoking. Patients feel something is wrong but the world around them says repeatedly that everything is just fine.

Now, some patients in stage 2 resolve their hair loss and go back into stage 1 and so they do end up feeling they were exaggerating because everything resolves itself. Some patients stay in stage 2 and eventually find an answer to their hair loss issues. If specialist A does not believe them, they move on to specialist B. If specialist B does not believe them, they move on to specialist C.

Some patients in stage 2 do progress on to stage 3 of hair loss where hair loss becomes more noticeable to others. With hairstyling and camouflage a patient in stage 3 might still be able to hide their hair loss. With treatment of course, a patient may be able to return to stage 2 or even stage 1.

With these stages in mind, let’s delve a little further into this situation you have mentioned in your question.

There are two main scenarios that may have been present before you noticed hair loss in August. The first is that your hair density was completely normal and the same as it was when you were 20. You then lost hair in the August - December period and the density went down. In other words, you went from no hair loss to stage 2. This is shown below.

The second scenario is that you felt that your hair density was completely normal but it was not, in fact, completely the same as it was 20 years ago. You then lost hair in the August - December period and the density went down. In other words, you went from stage 1 of hair loss into stage 2. This is shown below

Both of these situations above would appear identical to you. In the first situation, you had normal hair to start and then you lost density. In the second situation, you had (what you thought was) normal hair to start and then you lost hair. The only difference is that in the second sitatution you actually didn’t have quite normal hair - it just seemed that way to you (and everyone else).

Detailed Review of the RECOVERY (April 2021 to Dec 2021).

Your hair loss is now in a recovery phase. Your shedding has stopped. You are sprouting hair everywhere!

Let’s spend some time looking at the recovery of your hair loss and how the hair might respond over the next few months. The most likely are the following 2 scenarios.

If you don’t have any underlying issues that are affecting how hair grows, then it’s likely that this telogen effluvium will continue to settle and a you’ll get a return to full growth by the end of the year. In other words, you’ll go from stage 2, into stage 1 and back to full hair. The chapter on hair loss will be closed

Even if you do have some kind of “subclinical” hair loss situation happening in your scalp, there is still a good chance that you’ll recover your density by the end of the year and you’ll return feeling that your hair feels ‘full’ to you. In other words, you’ll move from stage 2 into stage 1. Stage 1 of hair loss looks just as good of having no hair loss at all so for all practical purposes it does not matter.

What happens if my density does not recover by the end of the year?

The final scenario is a bit trickier to explain. If you did in fact have some sort of subclinical hair loss situation going on in the scalp before August 2020 and this condition got a little bit worse from August 2020 through summer 2021, then you might not find that you have a full recovery by the time the Fall 2021 comes around. This could be due to several situations including

a) you had some subclinical androgenetic alopecia prior to August 2020 and the androgenetic alopecia got a bit worse from August 2020 to August 2021.

b) you had some subclinical scarring alopecia prior to August 2020 and the scarring alopecia got a bit worse from August 2020 to August 2021.

c) you had some subclinical psoriasis or contact dermatitis prior to August 2020 and the inflammatory issues got a bit worse from August 2020 to August 2021.

In these situations, it’s possible you stay in stage 2.

This final scenario is the least likely but a proper scalp examination and full review of your story is going to help me decide just how likely it is in your specific situation. For now, I estimate it as unlikely (but not zero).

What you can see here in these examples above is that you really need some definite diagnoses. If you allow time to help you with a solid diagnosis then that’s one good strategy. For example, if your density comes back perfectly to normal by the end of the year, then there’s probably no real hair issues at all that need treating or need any kind of workup. In other words, if your density returns back to full by December 2020 (and you enter stage 1 or no hair loss), it’s pretty unlikely there’s any other hair loss issue going on.

But if density does not return, I strongly believe that you need to have some formal diagnoses put on paper for BOTH the hair loss and the scalp symptoms. The reason we need different diagnoses is because every hair loss condition is treated differently. Unless we have a diagnosis, we can’t formulate the right treatment plan.

My Final Comments

Thanks again for the great question.

I’m really glad you are seeing all this hair growth sprouting everywhere as it’s a really good sign. The hairs are about 5-6 cm so it seems that the telogen effluvium you had in Aug/Sept 2020 is settling down. It could be that the iron and/or vitamin D is helping or that could just be a coincidence. It’s difficult to prove.

I do feel your scalp symptoms (dry, itchy, hurts to move) needs a formal diagnosis. Your scalp symptoms need a name of some kind. Now, keep in mind that the diagnosis of that situation might not be anything concerning given how long you have had it, but it still needs a formal diagnosis. If nobody is sure of what to call your itching and soreness, then you need a scalp biopsy. That is pretty clear in my mind. There is flaking present in some of your photos so there is some kind of inflammatory issue present. I would need to see the scalp up close to give a diagnosis. Please be sure to follow up on that.

I am glad you are taking photos as that will be key over the next 6 months. If you feel by November/December 2021 that you are really happy with your hair and how the density has returned, then this chapter of your hair story is likely done: you had a telogen effluvium and it resolved. It went away. In this situation, it’s unlikely there is some subclinical androgenetic alopecia present but it does not really matter much. I wouldn’t treat hair loss if you go back to feeling good about your hair. I’d simply repeat photos in 1 year. Put the shedding episode behind you for now.

If your density does not return to normal by the end of the year, then there is a good chance that there is some androgenetic alopecia that has entered the picture. No, it’s not 100% but that becomes increasingly likely. There’s very small chance that another diagnosis besides androgenetic alopecia is responsible but that’s pretty rare. Of course, the itching and tender issues on your scalp need to be diagnosed properly. That may or may not have any role here. But someone needs to give it a name.

But if you are pleased with your density in November/December 2021 and your shedding is completely back to normal (and stays normal), and your scalp symptoms are not worrisome to you and your doctors …I would put it all to rest and simply take a photos again in 1 year. It’s helpful to have your doctors follow you closely but nobody really knows their hair better than you. If you feel your hair has not returned back to normal, then you have remained in stage 2 and need a solid convincing diagnosis.

I hope this helps.

Many thanks for the question.

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What is the reason for my hair loss?

April 11, 2021

Why am I shedding ?

I’ve selected this question below for this week’s question of the week. It allows us to discuss shedding issues in women with hair loss.

QUESTION

Hi!

I am a 42 year old women and have been shedding about 200 hairs a day since March, 2020. I have seen 4 dermatologists and my General Practitioner and they have different diagnoses from TE to FPHL or a combination of both. Prior to March, 2020 I was under extreme stress which started in November 2019. In March 2020 my hair loss was sudden and I have had diffuse shedding since then for the past 10 months. I have always had full, thick and healthy hair and no issues with my hair until the past 10 months. There is no family history of hair loss and my bloodwork came out normal.

I have been taking vitamins, biotin and Lysine (since June 2020) daily. I am washing my hair every other day, air dry my hair and do not use styling or heating products and eat healthy. I am also taking spirolactone since December 2020 (one month as of today). My dermatologist suggested I take spirolactone (50 mg twice a day) because I have irregular periods. My hair loss slowed down in September 2020 to about 100 hairs a day and went back up to 200 plus in November 2020. I am experiencing itchiness, pins and needles sensation on my scalp and my hair texture changed from straight to wavy for the past 10 months. My hair is also now flat, dull and I have some dandruff that comes and goes. My middle part is widening (compared to pre-March 2020 before the shedding) and with the ongoing shed the part has somewhat looked the same since March.

I lost about 30% of my hair and cannot style it the way I used to because of the thinning in the front. The last two dermatologists I saw performed a pull test and scalp examination and one of them said it is CTE and that there is nothing I can do but wait it out. The other doctor said it's FPHL and that she can tell just by looking at the front of my hair because of the way its thinning. I do see hair growth and my hair is full of static with short hairs coming out but I am also losing a lot of hair in all different lengths including short ones every day. I am frustrated because it has been 10 months and my shedding is not stopping. I do not know which diagnosis is right and what treatment I should start. Also It would be great for the itching and "pins and needle" feeling on my scalp to go away...

Thank you for reading and I'm so happy to find this website.

ANSWER

Thanks for the question.

I’d like to discuss several important things in the question you ask and the information you have submitted.

Before we do go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s story

2) the findings uncovered during the process of the scalp examination including trichoscopy

3) the results of relevant blood tests.

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

There is lots more to your story that I need. I would want to know exactly what your lab tests showed and which ones were tested. In about 20 % of patients who tell me they had blood tests and all came out normal, the labs are either insufficient (more are needed based on their story and examination) or the labs are not in fact really normal. I always like to see the labs. I would want to know about other symptoms like joint pains, headaches, fatigue, weight loss, eyebrow changes, eyelashes changes, body hair changes, nail changes, and rashes.

I strongly suspect that androgenetic alopecia with seborrheic dermatitis are part of the diagnoses. The 2 key questions here in your case are:

Do you have really have telogen effluvium as well ?
What really is the reason for the ‘pins and needles’ sensation ?

Let’s look at a few key points.

POINT 1. Androgenetic alopecia (female pattern hair loss) appears to be at least one of the diagnoses.

I do think that at least one of the diagnoses here is androgenetic alopecia (also called female pattern hair loss, FPHL). The widening of the part does not itself mean the diagnosis is AGA. however, the pattern of the part widening is not the same front to back. There is a slight increase in thinning noted in the mid scalp and crown compared to the frontal one third of the scalp. This leads me to believe there is a patterned nature of the hair loss. I’m open to the possibility that some of the hair loss is diffuse in nature (ie all over) but some is likely not. In other words, I don’t think this is entirely a diffuse type of hair loss.

Also, when I look up close at the images, it’s clear that some follicles are thinner than others. This is a phenomenon called anisotrichosis and is a feature of AGA. Some hair follicles are miniaturization (getting thinner).

Women with AGA often experience shedding of hair in the early stages and shedding can fluctuate in intensity. Other hair loss conditions can cause shedding as well so we’ll address that in just a moment. Women with AGA often notice that the texture of hair changes. There are many such patterns of texture change and a change from straighter to curlier is quite common as you too have described.

The fact that you note increasing numbers of short hairs is not confirmatory for a diagnosis of AGA but certainly is supportive of this diagnosis.

POINT 2: Seborrheic dermatitis/dandruff is likely another diagnosis.

I agree with you that dandruff (or its close cousin called seborrheic dermatitis) is likely present. Flakes are noted in some of the photos. I’d need to perform trichoscopy to confirm this diagnosis but it appears to be a component of the issues present. Mild dandruff is not usually a cause of hair loss but it certainly can cause all sorts of scalp symptoms. To eliminate the possibility that dandruff or seborrheic dermatitis is contributing to symptoms, I often encourage my own patients to aggressively treat their seborrheic dermatitis so we can remove this as a factor. Shampoos with zinc pyrithione, ketoconazole, selenium sulphide or ciclopirox can be used 2 times per week and left on 90 to 120 seconds before being rinsed off. The duration that these shampoos are left on the scalp can certainly be increased but I don’t recommend that to start with as many antidandruff shampoos can be drying and then the dryness starts causing itching and symptoms. I often recommend to my own patients that 5-10 drops of betamethasone valerate lotion 0.1 % can be applied in the scalp after their hair is shampooed and dried. This is a weak steroid and can be safely used for 2 week periods to help settle itching. If the use of shampoos settles the itching, tingling and pins and needles, then it’s not needed.

POINT 3: Telogen effluvium could be present.

Telogen effluvium is one of those conditions that can come and go. Sometimes it’s easy to prove a TE is present and sometimes it’s a bit more challenging. It could be that a TE was present when your AGA first started. You were under extreme stress in November 2019 and yes this could most definitively give shedding in March 2020. Telogen effluvium usually follows 2-3 month after some kind of trigger and can last 3-6 months or more. Other causes of telogen effluvium are low ferritin levels, thyroid issues, medications, diets, weight loss and internal illness. I don’t really have enough information to evaluate these other issues so I’ll go with your assessment that your blood tests were normal. Hopefully you had a reasonable set of tests including TSH, ferritin, CBC. With your irregular periods you describe it would make sense to have FSH, DHEAS, testosterone. One needs to consider whether you are entering a perimenopausal transition and how this could contribute to hair shedding and AGA. With any pins and needles sensation, it’s nice to know that liver enzymes (AST, ALT) are normal and that kidney function is normal (creatinine).

Telogen effluvium can sometimes precipitate or accelerate an underlying AGA. This is a well accepted phenomenon. it does not happen to all women with AGA. However, women with shedding who have AGA that is about to begin (ie very early onset AGA) often find that the AGA component of the hair loss gets sent into a more rapid speed of development if a TE is present. This could be a feature here.

With your normal blood tests, it’s unlikely that a TE is still driving hair loss all this time. Not impossible of course, but unlikely. What is more likely is that AGA is not fully being treated. Spironolactone helps but does not fully suppress AGA in all women at 50 mg twice daily. Sometimes higher doses are needed OR other treatments for AGA are needed (other anti androgens, laser, minoxidil, etc)

POINT 4: If you want to assess the degree to which AGA and TE are present, you could have a biopsy or 5 day modified hair wash test (or a proper trichoscopic examination). I don’t think these are really needed.

For your physicians/specialists who think that AGA is not a diagnosis here for you, a biopsy or 5 day modified hair wash test could help prove them wrong (… or prove them right!). This is a wonderful test but adds to the stress of collecting hairs so I’m not always in favour of it. Biopsies leave scars but if interpretted by a knowledgable dermatapathologist, they can be very helpful.

But, let’s be clear. A biopsy showing a terminal to vellus hair ratio of less than 4:1 taken from your mid scalp area puts to rest any argument about whether AGA its present of not. End of discussion. A 5 day modified hair wash test (done properly !) showing less than 100 hairs and more than 10% hairs being tiny 3 cm hairs also points to an underlying AGA.

Of course, simply examining the scalp with trichoscopy can also confirm this diagnosis but not all specialists are skilled with trichoscopy. If a specialist knows how to use a handheld dermatoscope, we don’t even need biopsies or hair collections to diagnose AGA. If they don’t then yes, we need to go to the extra effort to prove it.

POINT 5: The ‘pins and needles’ is a bit trickier given how many conditions can cause this.

There are a very large number of conditions that can cause pins and needles in the scalp. Stress can cause it. AGA can cause it. TE can cause it. Alopecia areata can cause it. Dandruff can cause it. Scarring alopecias cn cause it. The list is long and includes issues even outside the scalp like cervical spine disease.

I would need to know more about your story and carefully examine the scalp and eyebrows and eyelashes and nails to get a sense of what is causing this.

For pins and needles sensations, I usually advise treating any dandruff or seborrheic dermatitis and using a few drop of betamethasone lotion as outlined above. If it’s still there and the patient has AGA, I usually recommend treating the AGA more aggressively. This often help stop pins and needles. Low level laser, minoxidil and other antiandrogens can be considered.

Conclusion/Summary

Thanks for the question. I hope this helps you in your search for answers and helps with further discussion with your doctors. I think it’s really important for you and your doctors to feel confident with the diagnosis and not proceed with any sort of “maybe.” It would appear that AGA is a component of the issues here but if there is any doubt, a trichoscopic examination, biopsy or 5 day modified hair wash test can help confirm this.

Photos are really important moving forward to document changes - hopefully for the better.

if spironolactone is not fully helping then you and your dermatologists might discuss together whether or not to increase the dose or whether other treatments need to be considered. These include topical minoxidil, oral minoxidil other topical or oral antiandrogens and low level laser. PRP can be considered too. The important thing to note about minoxidil, laser and PRP is that if there is any amount of chronic shedding issue present these treatments can help promote more normal shedding patterns. This is assuming all your blood tests are normal. If any of your blood tests are abnormal and if, in fact, you have not had a proper work up then those issues need to be addressed first. it sounds like you’ve had a good set of blood tests through all the doctors you have seen.

Thank you.

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Elevated DHEAS with Hair Shedding: What might be going on?

January 25, 2021

Persistent Shedding, Elevated DHEAS and Ongoing Hair Loss

I’ve selected this question below for this week’s question of the week. It allows us to discuss persistent shedding in young women in the setting of elevated DHEAS.

QUESTION

I am a female in my mid 20s. In March 2020, I began to notice my hair shedding more than normal. I related it to stress of moving to a new town, and possible TE following local anasthesia from a breast augmentation in late summer 2019. Fast forward to October 2020. I was still experiencing a significant amount of shedding that had not lessened or improved. Therefore, I made an appt with a Dermatologist. He did a pull test which came back as negative. I also had Blood work done which all came back as normal except for the following: ferritin of 48, DHEAS high at 404, and free T high at 4.3. When I followed up with the dermatologist in the Fall 2020, he interpreted my blood work for me. He said that it was likely that I have AGA due to the high androgens, and could possibly have an iron deficiency which is causing the thinning. At that visit, he recommended that I supplement with iron. He also suggested starting spironolactone. I inquired about the continuous shedding considering AGA is a hair loss diagnosis and not a hair shedding diagnosis, and he suggested that I could also have a CTE.

Moving forward I have decided to begin supplementing with iron once daily as recommended. However I am on the fence about spironolactone due to side effects. Also I did not get a definitive diagnosis and he did not recommend a scalp biopsy. My question for you is would you have the same recommendations? At this time in January 2021, I am continuing to experience significant amount of shedding, a density decrease in my overall hair, and thinning at my crown and middle part that is more noticeable with bright lights. Thank you!

Mid 20s Female with elevated androgens and persistent shedding

ANSWER

Thanks for the question.

I’d like to discuss several important things in the question you ask and the information you have submitted.

1) the patient’s story

2) the findings uncovered during the process of the scalp examination including trichoscopy

3) the results of relevant blood tests.

The key question here in your case is whether or not you have androgenetic alopecia. The only way I can really confidently determine that is with an up close examination (or review the results or a biopsy which you have not had). So, I cannot yet say whether you have androgenetic alopecia or not.

Let’s go further into your story.

You are correct that some of these things you mention like moving to a new town and having surgery could trigger TE, but the timing is a bit off. Having a breast augmentation in summer 2019 causes shedding in the late fall not way into March of 2020. So this is unlikely linked especially since the shedding in Oct 2020 is pretty much the same. . Furthermore you still kept shedding in October and now into January 2021. Those events of 2019 are probably not all that close related.

There are a few possibilities for what’s going on:

a) you have androgenetic alopecia

b) you have telogen effluvium and nobody has found the cause

c) you have another diagnosis altogether.

Let’s take a look at these…..

a) Do you have androgenetic alopecia ?

It’s possible you have androgenetic alopecia. I would like to point out that AGA most certainly is a ‘hair shedding’ diagnosis so don’t let that confuse you. Women with early AGA experience increased shedding. It is incorrect to link that because you have shedding you are looking for some list of hair shedding causes for which androgenetic alopecia is not on the list. It’s on the list. You have persistent shedding despite fairly normal blood tests for typical triggers of telogen effluvium. You are seeing your crown and mid scalp more visible in bright lights. What’s the most common reason for this? Androgenetic alopecia.

We don’t diagnose AGA by blood tests. Having a high DHEAS or free T does not mean you have AGA. No way. If you have a variation in the caliber of your hairs when your scalp is examined up close with trichsoscopy, that is suggestive of AGA. Or if you have a terminal to vellus ratio of less than 4:1 if you ever did a biopsy that would be suggestive of AGA. I have many patients with elevated DHEAS who don’t have AGA!!!! So that’s not the key point that its going to nail down the diagnosis. A proper scalp exam (or biopsy) is!

I do think it’s really important for anyone with elevated androgen hormones to figure out if there is any underlying condition that can give a slightly elevated DHEAS or Free T. Some women with PCOS have elevated androgens and some women with late onset congenital adrenal hyperplasia (CAH) have elevated androgens. It’s going to be very important for your physicians to understand whether or not your periods are regular or not and whether any of these diagnoses might be present. If you have irregular periods you’ll want speak with your dermatologist about having an extended panel of blood tests the 3rd to 5th day of your menstrual cycle. (These tests need to be done off all oral medications). Your DHEAS is not high enough to worry about adrenal gland tumors in case that’s something you have read about yourself. It’s only slightly elevated. But even though you think you’ve had all the blood tests you need, it’s important to keep in mind you might not have. For some women with increased DHEAS, a compressive blood test panel includes TSH, prolactin, AM cortisol and 17 hydroxprogesterone. Again this should be done on day 3-5 of the cycle.

b) Do you have telogen effluvium and nobody has found the cause?

There are hundreds of reasons to shed hair. The common causes are stress, low iron, thyroid problems, medications, diets, etc. But there are so many other causes too - and it’s going to be important for your doctors to ask you oodles of questions to make sure you don’t have another cases. I can’t go into all the questions because there are so many but it’s essentially a head to toe understanding if there are concerns. With a ferritin of 48, I don’t think it’s likely that iron is an issue here at all. A ferritin of 48 is not associated with hair shedding issues for 99 % of people.

For persistant shedding in a patient with NORMAL basic blood tests, we want to know 1) does this patient have an autoimmune disease Iike lupus ? or another autoimmune disease? 2) is there an infectious disease present (syphilis, COVID, lyme)? 3) does the person have gastrointestinal disease affecting absorption of micronutrients ? 4) is there a supplement or drug the patient is using? If there are other features present like fatigue, headaches, muscle pain, poor sleep, depression then you are your doctors may need to review the concept of breast implant illness. It’s a rare consideration for hair shedding but certainly part of a comprehensive approach to investigation of the cause of your hair loss. The answers to these questions will influence whether blood tests like ANA, RPR, zinc, Sars-COV-2 antibodies and others get ordered. The panel of blood tests can be quite large but the specific tests to order depend on the answer you give to a lot of detailed questions.

CTE is misdiagnosed often and this is not something you likely have. CTE is a condition of women 35- 70 with chronic shedding for no good reason. That’s the key to CTE. It’s not just shedding that goes on and on without figuring out common causes. If you have androgenetic alopecia in the end, then your shedding is from AGA most likely. Your story is not a typical CTE story! The diagnosis fo CTE gets thrown out way too easily in my opinion. You either have an acute telogen effluvium that nobody has found that diagnosis to, or you have androgenic alopecia or you have another diagnosis altogether that has been missed. I would favour that you have AGA.

c) Do you have another diagnosis altogether?

I don’t have all your story information … but I would imagine that a lot of other answers would be negative. I’m assuming that if you did have scalp itching or burning you’d include it in your question. I would imagine if your scalp was tender you’d include that too. But maybe not. We have to be open to the possibility that autoimmune diseases like lichen planopilaris could be present and give chronic shedding. I would highly doubt it though as LPP s not something that I see in your scalp based on the one photo I have.

Summary.

Thanks again for submitting your question. I would need to see your scalp up close to guide you further. It’s the scalp examination that is going to help figure out if you have AGA not the blood tests. We don’t diagnose hair loss from blood tests! If you have miniaturization of follicles on examination then you likely have AGA. Or if you get a biopsy and if captures the miniaturization in the biopsy (with a terminal to velds ratio less than 4:1) you likely have AGA.

Not everyone needs a scalp biopsy but it’s helpful if there s doubt from anyone - patient or doctor.

If you have AGA, minoxidil, spironolactone, laser, and PRP are options. If you have AGA with elevated androgens and have no other underlying endocrine issues spironolactone can be a good option. You are correct that spironolactone can have side effects. Fortunately, most side effects are mild and less than 4 % of users actually stop spironolactone due to side effects. But people who do not wish to use spironolactone can consider laser, PRP, topical minoxidil, oral minoxidil and other treatments too.

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Excessive Shedding in the 30's: Why is my hair still shedding?

October 12, 2020

Excessive hair shedding in the early 30s: What are the reasons?

I’ve selected this question below for this week’s question of the week. It allows us to discuss diagnosis of hair loss in women 30-40 years of age with chronic shedding. Here is the question….

QUESTION

Can oral vitamin + iron supplementation increase shedding the way minoxidil does?

I am a 35 years old female. I have always been under a lot of stress, especially in 2016-2017. In spring 2018 I noticed my hair got thinner (I always had rather fine hair); my scalp could be seen under direct light. I used castor oil and took spiruline tablets hoping it would improve; got the impression it did so I stopped. I was vegetarian then, too. I got preoccupied with the fear of getting bald, did a lot of research on the Internet that frightenend me even more and finally I got the courage to get an appointment with a dermatologist this summer (2020). She didn't notice hair loss (pull test); said my density was normal and scalp looked ok. She said it didn't look like AGA at all. She prescribed my iron supplementation (low ferritin (24)) and advised me to change my diet. I lack vitamin B12 too. From the end of July onwards I've been taking iron, spiruline, biotin and B12 supplementation. Since I didn't agree with the diagnosis ("no visible hair loss") I began counting the hair I'm shedding each day. The amount is horrible: it's more than 200 hair/day! The supplementation I'm taking and the changes I made to my diet don't seem to decrease the shedding at all. I've booked a appointment with anonther dermatologist for a second opinion (I'm truly terrified: my scalp feels strange; a bit of itching and burning + "crawling" sensations; my hair keeps falling out and for my dermatologist there's no problem...!) I'm surprised I still have hair left on my scalp when I see the amount that's falling every day...
I have read that those who use Minoxidil experience shedding in the first months which is a sign that new hair is on the way (I do see regrowth but it doesn't make my hair volume look any better). So I am wondering: can oral supplementation cause a similar shedding, which proves that the treatment is working? If not, what should I do? I got no "real" dagnosis; from what I read on the internet it seems to look like TE but how can I be sure?

I would like to add that from time to time I have small pimples on my scalp that come and go. Not a lot of them though, but they can be itchy. My skin (on face) is oily, I have the same sort of sores on my face from time to time too. I don't know if this information is important.

Thank you for reading and I hope you'll be able to answer my question since my own dermatologist doesn't seem to take my problem seriously...I think the thinning is all over, but mostly noticable on the top of my scalp and at the temples. My hair become very flat, no volume at all. I wash it daily because it greases very fast (eversince I was in my early teens).

ANSWER

Thanks for the question. There’s really two very good ways to determine the cause of your hair loss - and that is to share your story with a hair specialist and have him or her

1) Evaluate your scalp up close with “trichsocopy” (magnified imaging)

2) Perform a 4 mm scalp biopsy

So there is a way for you to get your answer.

I’d like to discuss several important things in the question you ask and the information you have submitted. Let’s get to it.

1) the patient’s story

2) the findings uncovered during the process of the scalp examination including trichoscopy

3) the results of relevant blood tests.

AGA must be the Default Diagnosis in Women 30-40 with Increased Hair Shedding

I would need to examine your scalp to determine if you have androgenetic alopecia or telogen effluvium or both …. or some other diagnosis.

However, I strongly believe that the first diagnosis that must be ruled in or ruled out in any female patient with hair loss in the 30s is androgenetic alopecia. One must not move on until this issue has been fully settled. Once that it settled one can determine if the patient has or does not have telogen effluvium (with AGA or by itself ) and whether or not the patient has some other hair loss condition.

How does AGA present or ‘announce itself in women’? With shedding ! .. and with thinning in the top or often also diffusely!

How does telogen effluvium TE present itself or announce itself? With shedding ! …and with thinning diffusely !

It’s important to be aware that TE and AGA can look identical - at least at first glance.

What’s the most likely cause of hair loss in a 30-35 year old female with hair loss for 3 years and shedding and thinning? Androgenetic alopecia by far.

Of course, I can’t say what you have as I have not examined your scalp. But these are the principles that guide the entire discussion.

Therefore, the key question that must be asked in your story is “Does this patient have androgenetic alopecia (AGA)?” That’s the key question. That’s the number one question. The key question should not be what supplement can this patient take? ….. or what shampoo should this patient use? The key question is “does this patient have androgenetic alopecia?”

What is needed now is proof that you do have AGA or proof that you don’t have AGA. One should not rest until this question has been solved. Once we solve that question, we can move on to figuring out if any other diagnosis is present.

For now, we need to determine if AGA is present. That is what is needed now. Your doctors might be able to solve this with trichoscopy or they might need to solve it with a biopsy.

We can not always solve it with simply looking at the scalp from afar.

Only you know what your hair looked like before and your doctors do not. If you hair looks thinner to you but just fine to another person - then guess what? You still have hair loss.

The Three Stages of Hair Loss

There are 3 stages of hair loss that I describe for patient’s with androgenetic alopecia. What is so important in your case is to determine once and for all as to whether you are in stage 2 AGA or whether you don’t even have AGA at all. Here are the stages.

Stage 1 of Androgenetic Alopecia

In stage 1, hair density is slowly reducing but the patient is unaware. There may be a slight increase in hair being shed in the shower or coming out daily in the brush. However, this generally goes by unnoticed by the patient. A biopsy can sometimes (but not always) capture a T:V ratio below 4:1 and some degree of miniaturization (and anisotrichosis) may be present. Much of the time it's challenging to confidently diagnose AGA in this stage. Some stay in stage 1 for a very long time; others just a matter of months.

Stage 2 of Androgenetic Alopecia

In stage 2, the patient first becomes aware that something is not quite right. They may see a bit more scalp showing when they look in the mirror. They may feel the hair does not feels as thick when they run their fingers through the hair. Under bright lights they may feel a bit more aware of these changes. When the hair is wet, the thinning is evident.

Nevertheless, in this second stage everyone else tells the patient they look fine. Some patients are told they are "crazy". Even some physicians will tell the patient they "look fine" and need not worry. Patients often feel isolated in this stage because nobody believes them when they say they are losing hair! A biopsy definitely shows a T:V ratio less than 4:1 and miniaturization is clearly seen in more than 20 % of hairs. Many never progress to stage 3 especially those with onset of AGA later in life.

Stage 3 of Androgenetic Alopecia

In stage 3, the hair loss has progressed to a stage where hair loss may become evident not only to the patient but also to others. Of course with use of various hairstyles, products, camouflaging agents it may still be possible to hide one's hair loss from others. As stage 3 progresses it becomes more and more difficult to hide hair loss.

Understanding the Patterns of Hair Loss

Both AGA and TE can cause hair to look thinner. With AGA is typically affects the middle of the scalp whereas with TE is affects all of the scalp fairly equally. We call this a ‘diffuse’ pattern. AGA can sometimes have a diffuse pattern too but very often than not it affects the middle more than other areas. In addition, AGA often affects some areas of the middle a bit more than others.

Your photos show the hair parted in the middle. These types of photos are great for evaluating the scalp. If your part width at the back of the scalp seems smaller than the front of the scalp, the chances start to increase that you might have AGA. By part width, we simply mean the amount of scalp showing when you part your hair in the middle.

In your photos, it’s difficult to get a sense of the exact patterns because I only have photos of the middle. But when I look at these photos I do wonder whether the density towards the crown is a bit less than the density up front. In other words, it seems that even in the mid scalp the density is not reduced equally.

Summary: Putting it All Together

Thanks again for the question. Let’s review everything again.

1. You first asked if oral vitamins can increase shedding like minoxidil does. That answer is not usually. The mechanism is different.

2. You have high shedding rates so something is probably different with your hair cycles than it was 20 years ago.. One can shed 200 hairs daily in AGA and 200 hairs daily in TE so this information is not helpful to actually get to the diagnosis. You could have one, You could have both. You might have neither. Statistically speaking, a 30-35 year old female with shedding has either AGA or TE and with your history AGA is far more likely to be a diagnosis. Of course, we are not statistics and each person requires a proper examination.

3. You mention increased oiliness of the face so one needs to also consider whether you have a component of “seborrheic dermatitis”. This can increase these scalp sensations like you describe - and so can telogen effluvium. Your doctors can determine if you have SD by carefully examining your scalp.

4. Overall, it may be that you’ve had TE at some point in time - and perhaps you also have it now too. It may be that stress was a trigger before for a TE and perhaps maybe now you have different triggers that are causing a TE (such as lower iron). I suspect there was some component of TE back in 2016-2017 when your hair shedding stopped. Your doctors can evaluate these ‘triggers’ for shedding in greater detail. You may or may not need more blood tests but your doctors can review that in detail.

A full work up is needed at this point. You may need more blood tests. However, what you do need next is a thorough scalp examination with trichoscopy. If there is significant “anisotichosis” on trichoscopy then you may have AGA. I can’t tell these with your photos - it needs an up close examination. If it’s still difficult for your doctors to determine with trichsosopy, then a scalp biopsy (with use of horizontal sections) is going to be helpful. The pathologist can determine the number of large terminal hairs and tiny vellus hairs and the number of telogen hairs. A terminal to vellus hair ratio of less than 4:1 usually signals a diagnosis of AGA in women. You can review more about scalp biopsies here Scalp Biopsy Interpretation

I hope this helps and thank you again for the question.

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What options are left for my hair loss?

August 02, 2020

What should I do about my hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the advanced management of non scarring alopecia.

Here is the question….

QUESTION

Dr. Donovan I have been following your blogs and articles for quite some time and decided to tell my hair loss story and hopefully get some answers. I am a 58 year old very healthy female with no nutritional issues and an avid runner for many years. At 48 my hair started thin but underneath and at the mid back scalp in a diffuse pattern. I was put on Yaz birth control and finasteride which helped tremendously for 3 yrs. At 51 my gynecologist took me off birth control at which time I started to see similar issues recur. I started topical minoxidil, traditional HRT but nothing worked. I saw a dermatologist and she diagnosed me with AGA and started me on Climen, HRT in addition to finasteride and topical minoxidil. Within a few months I saw another dermatologist who added spironolactone 100 mg. This combo seemed to bring back my hair growth and density within 6-9 months. After a year or so my creatinine levels were in the high range and my gynecologist advised me to stop the spiro. Within a year or so after stopping I noticed significant shedding, less density mid scalp to bottom of my hair and dry hair that looked like a broom. I had numerous PRP sessions, laser cap and started various combos of low dose oral minoxidil, topical and the Climen.

I have no visible scalp anywhere but a lot of different layers and short pieces of fine hair and no bottom to my hair. Dry hair of varying lengths mostly underneath hair. The hair has changed from long straight to short and curly with no density. Cutting has not made any difference in the fullness. From the ear down the hair is thin fine and basically see through. I do not know why there is no improvement in my condition. I have no itching or burning.

I am currently on oral minoxidil 2.5 mg once daily, Avodart, topical minoxidil, spironolactone 100 mg daily in addition to HRT estrogen patches and micronized progesterone 15 days every 3 months. I am still shedding enough to create concern and my hair won’t grow longer. The top of my hair is much fuller than the bottom which is wispy and thin. I have included my biopsy and photos for your review.

BLOOD TESTS

All blood results are normal and ferritin has ranged from 40-50. The only red herring is a positive ANA of 1:80 for 5 years with no symptoms. I would appreciate your opinion.

BIOPSY

Biopsy showed a non-scarring pattern with follicular miniaturization, anisotrichosis, and increase telogen hairs.

ANSWER

Many thanks for your question. Of course, I’d need the full story from A to Z , more photos and to review all your blood tests to give a complete opinion. It’s clear you have androgenetic alopecia (AGA) and a telogen effluvium (TE). In your case, I think it’s worth still looking for a trigger of your TE rather than explaining it simply by a chronic TE with no underlying cause. I think there are two important points to consider here:

1) Maximizing/Optimizing Anti-androgen Therapy

First - your hair loss has been quite responsive to anti-androgens in the past. Yaz and finasteride have helped you and Climen and spironolactone have helped you. I do think that it will be important to review with your dermatologists if there is more that can be done to maximize treatment in this big category of antiandrogens.. You are on spironolactone and dutasteride. Increasing spironolactone is not going to be a good option given your kidney (creatinine) concerns. However, brining on board other antiandrogens just might.

You and your doctors may want to carefully review if the drug bicalutamide might be considered. Bicalutamide can be used with dutasteride and spironolactone and it might even be introduced 2 or 3 times weekly if you are still going to continued on dutasteride and spironolactone. Bicalutamide is an antiandrogen (androgen receptor blocker) which is used for the treatment of male prostate cancer. It has been used off label in women for the treatment of hair loss, as well as other androgen related issues such as hirsutism (hair growth on the face). It tends to be just as well tolerated for most of my patients as dutasteride so side effects overall are low. Side effects include elevated liver enzymes, peripheral edema and gastrointestinal side effects (diarrhea, constipation, nausea). Other side effects like itching can rarely occur. General antiandrogen side effects like decreased libido, breast tenderness, breast enlargement, mood changes (depression) can occur although seem to be quite uncommon. These are the same side effects that dutasteride, finasteride and spironolactone can cause. Mood changes with bicalutamide are not common. Bicalutamide has not been associated with a decrease in bone mass (osteoporosis). An increase in liver enzymes (3 % to 11 % of patients) is quite rare although monitoring of liver enzymes for the first 2 months is recommended.

For my patients who are on anti androgens like duasteride and spironolactone already, I generally start ¼ pill (12.5 mg) for 2-3 months and then increase to ½ pill (25 mg) after that. Sometimes I start every other day. Liver enzymes are evaluated after the 4-6 weeks and then again at week 12.

2) Evaluating the Telogen Effluvium

The increased proportion of telogen hairs in your biopsy is very interesting in my opinion. I would need to know a lot more about your story and review all your blood tests, but it would seem based on the information you have provided that this needs to be explored further to make sure that we’re not missing a potential cause of shedding. There are an enormous number of triggers of shedding.

They key to evaluating shedding is to perform a search for possible triggers and if anything comes up suggestive that it could be a trigger - then this needs to be pursued fully.

Your ANA result may or may not have any relevance. It’s low and many people in the population (5-7%) have a low level ANA like this without any consequence. However, given that you are still shedding I think that you and your doctors might consider pursuing further evaluation in this area. Because your ANA is positive, further work up might be discussed with your physicians if it has not been already. The exact tests to order depends on your history (your medical story), but might include ENA, ESR, C3, C4 and CK. If there is any suggestion of rheumatological disease, referral to a rheumatologist would be advised. With chronic shedding, I always encourage patents to make sure their age appropriate screening examinations have been done. You and your primary care doctors can review if colonoscopies, and mamograms are up to date.

The full causes of telogen effluvium including stress, low iron, thyroid problems, medications, diets, weight loss and internal diseases. I understand based on your comments above that your iron and thyroid labs are normal. I’m assuming your vitamin D levels were normal. The remainder of your TE triggers need careful evaluation. If there are any other mediations you have started, those need to be reviewed. Furthermore, if there are any other symptoms those need careful evaluation as well. The symptoms I ask about are shown in the table below. One really needs to go head to toe when dealing with chronic shedding issues. If anything comes up - it gets explored fully. The issues that I’m most interested to ask about in a patient with positive ANA and increased telogen proportion on biopsy are whether the patient has dry mouth, dry eyes, joint pains, fatigue, weight loss, and muscle weakness.

Conclusion/Summary

Thanks again for submitting your question. I hope this was helpful in some way. I think overall you need to figure out if any more detective work needs to be done as far as your shedding goes, or has it all been done. Sometimes the detective work has all been done and we’re left with AGA and shedding. In these cases, treating the AGA fully as mentioned above is going to be important. Use of a multivitamin is going to be important. In tough cases, I may add biotin 2000 -5000 micrograms daily and a good antidandruff shampooing regimen. Of course, if there are any deficiencies that were identified they need to be fixed.

If something does turn up positive on the investigations I mentioned above, it needs to be explored fully and completely. If the clinical picture does suggest an autoimmune issue, then low doses of hydroxychloroquine are used.

If anything changes in the scalp in terms of new symptoms, massively increased shedding, a repeat biopsy should also be considered.

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Why am I shedding with zinc supplements?

May 24, 2020

Localized Shedding with zinc supplements

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of zinc on the human body and how to approach atypical or unexpected reactions in the human body.

Here is the question….

QUESTION

I shed hair when taking zinc supplements. I cannot find any information on this at all. Most suggest zinc helps the hair cycle not cut it short and shed. The shedding appears to occur in locations that already had issues. It is not global (all over the body). Is zinc connected to the hair growth/shed cycle or is it inflammation? Thank you.

ANSWER

This is a terrific question. Not one that I encounter often - but a fascinating one. There’s a lot to review with this question, so let’s get to it!

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp Examination and

3) the results of relevant blood tests.

I’d like to know a lot more about this story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information. It could be relevant if the patient takes zinc for one weekend because they heard it was good to boost their immune system or took zinc for one year to finish the bottle that they purchased one day on sale. It could matter if the patient is obese or thin, malnourished or well nourished and elderly or young. It could matter if the patients knows their actual zinc levels through blood tests or not. Finally, it could matter and probably does matter if the patient has early staged adnrogenetic alopecia, mid staged androgenetic alopecia or advanced androgenetic alopecia. All these things matter in fully answering these questions.

With that behind us, let's return to our question of the week again.

WHAT’S THE MOST LIKELY EXPLANATION FOR SHEDDING WITH ZINC?

Well, the most likely explanation (given that I don’t know anything else about you), is that:

1) you have some male pattern balding and you are not using finasteride or dutasteride to treat your male balding and that zinc has trigger a mild effluvium of hairs that are in the early balding phase. We call this phenomenon immediate telogen release and it’s common with every treatment that acts on male balding including minoxidil, laser therapy, PRP therapy, finasteride therapy …. and sometimes zinc.

2) The second explanation is that you actually do have diffuse loss of hair on the scalp and you are just noticing it more in the areas that are already thin. In this scenario, the male balding has nothing to do with the discussion, it just so happens you notice hair loss more in areas that are already thinner.

3) The third explanation is that you have something else going on that is not related at all.

It zinc related to my hair loss? A Closer Look at the Naranjo Scale

Before we go further, I’d like to introduce you and readers to a wonderful system of determining how likely it is that a person’s rare observation is linked to the drug or supplement they are taking. It’s called the Naranjo Scale. I always refer to the Naranjo scoring system when some observation a patient is experiencing is uncommon because it helps to get a better sense of just how plausible things really are. If someone tells me their new supplement is causing hair loss, I might pull up the Naranjo Scale. If someone tells me their new cat is causing them hair loss, I might pull up the Naranjo Scale. We’ll take a look at this scale in a moment.

Now, it seems pretty obvious that if you say that when you take zinc you get more shedding that I believe you that zinc is causing your hair shedding. First off, I believe you. I have seen this phenomenon before so I’m not introducing the Naranjo scale as a way to prove whether you are correct in your observation or not. Rather, the Naranjo Scale helps us look at causation with a little greater precision - something a bit more scientific.

The Naranjo scale involves use of 10 simple question. You might want to try it yourself. The questions are below and I’ve worded each questions specifically to pertain to zinc although the Naranjo scarring system itself pertains to any drug not just zinc. You answer “yes", "no" or "don't know" and different points are assigned to each answer (-1, 0, +1, +2).

Typical Questions in the Naranjo Scale

1. Are there previous conclusive reports of zinc causing hair loss from areas that already have an issue?

Yes (+1) No (0) Do not know or not done (0)

2. Did the shedding appear after zinc was given?

Yes (+2) No (-1) Do not know or not done (0)

3. Did the shedding improve when the zinc was discontinued ?

Yes (+1) No (0) Do not know or not done (0)

4. Did the shedding appear when the zinc was readministered?

Yes (+2) No (-1) Do not know or not done (0)

5. Are there alternative causes that could have caused the shedding?

Yes (-1) No (+2) Do not know or not done (0)

6. Did the shedding reappear when a placebo was given?

Yes (-1) No (+1) Do not know or not done (0)

7. Was the zinc detected in the blood at higher levels?

Yes (+1) No (0) Do not know or not done (0)

8. Was the shedding more severe when the zinc dose was increased, or less severe when the zinc dose was decreased?

Yes (+1) No (0) Do not know or not done (0)

9. Did the patient have a similar shedding to the same or similar zinc pills in any previous exposure?

Yes (+1) No (0) Do not know or not done (0)

10. Was the adverse event confirmed by any objective evidence?

Yes (+1) No (0) Do not know or not done (0)

Determining the Naranjo Score

Scores for the Naranjo Scale can range from -4 to + 13. A score of 0 or less means the likelihood of the drug causing the side effect is doubtful, a score 1 to 4 indicates it is 'possible', a score 5 to 8 means it is 'probable' and a score 9 to 13 means it is 'definite'. The website http://www.pmidcalc.org/index.php provides a free online calculator for clinicians to calculate the Naranjo Score. It is easy to use and has been embedded below as an example. Individuals wanting to know if a specific drug caused hair loss should be sure to speak to their dermatologist. For you, I’m guessing you are somewhere between 5 and 8 and probably and 6 or 7. This just simply reinforces that what you are experiencing is probable.

What are the effects of zinc on the body and on hair ?

Zinc is well known to affect the human body in about 50 different ways. Actually, it’s best to say that there are at least these are the 50 different ways that have been studied. There are probably 250 ways that zinc affects the human body - we just haven’t studied them all. Here are some of the more common effects of zinc under different conditions. You can see that zinc has a profound effect on many hormones, inflammatory markers and immune system components.

Zinc and Hormones.

Zinc has a complex relationship with hormones. Zinc supplementation seems act as an anti androgen in most scenarios. In women with PCOS, it’s clear that zinc supplementation helps PCOS and reduces hirsutism and improves hair loss. However actually hormone levels (DHEAS) don't seem affected. In prostate cancer cells grown in the lab, it’s clear that zinc acts as an androgen receptor blocker. Zinc blocks male hormones.

Zinc containing shampoos have a positive effect on male balding. In a 2003 study, Berger et al showed a benefit for 1 % zinc pyrithione (found in Head and Shoulders and other shampoos). The researchers performed a 6 month randomized study in healthy men 18-49 with Hamilton Norwood type III vertex or type IV baldness to assess the benefits of daily use of 1 % ZP shampoo. The researchers compared growth with zinc pyrithione shampoo compared with three other groups: 1) those using minoxidil 5 % twice daily, 2) those using a placebo shampoo, and 3) those using a combination of minoxidil and the 1 % ZPC shampoo. The results of the study showed hair growth with zinc pyrithione shampoo alone was almost as good as with minoxidil. Whether these effects are due to the anti-inflammatory effects of zinc on yeast and Malassezia (the causes of dandruff and seborrheic dermatitis) or specific zinc effects on the scalp are not clear.

Depsite all the studies showing zinc has antiandrogenic effects, there are studies showing that zinc supplementation may have the effect to increase testosterone. Zinc supplementation to subfertile men increased testosterone and DHT levels and improved the chances that the female partners of these men became pregnant.

SUMMARY AND FINAL CONCLUSION

There is a lot we have learned about zinc so far and here is a lot we still need to learn when it comes to zinc.

For most people, taking zinc doesn’t have any effect on the hair in any way. However, there will be some people who experience a reduction in daily shedding - especially if they had low zinc to begin with. For a very small proportion a bit of shedding might occur for 1-4 weeks but this is not something that is seen commonly. We do see it in patients with early androgenetic balding - but again even then it’s not common. Most individuals with androgenetic hair loss who use zinc either have no effects or experience a slight improvement.

Your question suggests you have a degree of underlying androgenetic alopecia (male balding) and what you are experiencing is a telogen effluvium of the hairs in that area. Of course a dermatologist can help confirm this.

Hairs that are found in the balding areas of the scalp are notiously more loose than hairs that are found in other areas. They wiggle out of the scalp very easily. We refer to this medically by saying that the hairs are in the telogen phase. Taking zinc supplements certainly gives the hairs some 50 to 250 reasons to wiggle out (or shed) but why this happens for some people and not other is not clear.

There are many different so called genetic polymorphisms that people are born with hat affect how they process zinc and what zinc does to the body. These too have been researched over the years. Polymorphisms in IL6 (IL 6 -174) and ZIP2 Lue- (Arg43Arg) are all examples of genetic changes inside of a person’s DNA that affect how they respond to zinc and why one person might respond differently than another person.

If you have used treatments for male balding before (like laser, minoxidil, finasteride, PRP) and developed some shedding when you started these treatments, you are likely to be experiencing the same sort of phenomenon with your zinc. Although it is unusual to shed hair with zinc supplementation, I must add that it is extremely unusual for males who are currently on finasteride to shed hair with zinc supplements given that the androgens pathways inside hairs are so effectively suppressed. Not impossible but unusual in my experience.

If you shed more with higher doses of zinc and less with lower doses of zinc, and stop shedding completely when you stop the zinc pills, the Naranjo score tells us you are onto something. The fact that you shed when you start zinc does not necessarily mean you will continue to shed forever. Just like with finasteride, laser, PRP, minoxidil, most shedding when related to male balding actually settles down in 6-8 weeks. So most men who continue zinc will find their shedding eventually slows down.

I’m not a fan of my patients taking zinc forever. Zinc level should be kept above 85 µg/dL (13 mmol/L) and below 118 µg/dL (18 mmol/L). Excessive zinc causes copper deficiency which is also a rare cause of hair loss. Long term copper deficiency leads to a great number of problems in the body. Zinc should always be taken with the goal to measure zinc levels over time. If you notice shedding every time you take zinc for a few days, that’s one thing, but if you notice shedding everytime you take zinc for months at a time, that’s a different thing. If zinc is causing a pure telogen effluvium due to low copper for example, it is never going to settle down.

As mentioned in the opening it is going to matter if the zinc is taken for the weekend or for one year. The longer the zinc is used (beyond 4 months), the less likely the shedding is due to helpful actions on the balding process and more likely this zinc is detrimental (or something else entirely is going on). It could matter if the patient is obese or thin, malnourished or well nourished and elderly or young. The more obese the patient is (above a BMI of 30) the more likely the zinc supplementation is going to significantly change hormones, insulin sensitivity and lipid metabolism. Mind you, these changes are probably for the good, but there is a chance they are going to set off some shedding in these patients. It could matter if the patients knows their actual zinc levels through blood tests or not. If one is taking zinc, and the levels skyrocket above 150 ug/dl (23 mmol/L) we often see zinc issues with the hair.

Finally, I hope I’ve made the point that all of this probably does matter if the patient has early staged androgenetic alopecia, mid staged androgenetic alopecia or advanced androgenetic alopecia. The earlier the AGA the more likely that zinc is going to cause a bit of temporary shedding. It’s still an uncommon phenomenon overall - but it’s the patients with early AGA that are the most likely to report shedding with zinc supplements in our clinic.

I hope this helps. It’s an interesting question and you and your doctor may want to consider how zinc is potentially affecting the androgenetic hair loss issues on the scalp and how the levels of zinc are changing over time when you supplement. The actual levels of testosterone and DHT may or may not have any relevance because some people could have slight elevations without it actually causing hair loss (or actually inhibiting hair loss as time goes by.

Thank again for the question.

Reference

Barnett et al. Effect of Zinc Supplementation on Serum Zinc Concentration and T Cell Proliferation in Nursing Home Elderly: A Randomized, Double-Blind, Placebo-Controlled Trial. Am J Clin Nutr 2016 Mar;103(3):942-51.

Ebrahimi et al. The Effects of Magnesium and Zinc Co-Supplementation on Biomarkers of Inflammation and Oxidative Stress, and Gene Expression Related to Inflammation in Polycystic Ovary Syndrome: A Randomized Controlled Clinical Trial. Biol Trace Elem Res 2018 Aug;184(2):300-307.

Foroozanfard et al. Effects of Zinc Supplementation on Markers of Insulin Resistance and Lipid Profiles in Women With Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial. Clin Endocrinol Diabetes. 2015 Apr;123(4):215-20.

Giacconi et al. Effect of ZIP2 Gln/Arg/Leu (rs2234632) Polymorphism on Zinc Homeostasis and Inflammatory Response Following Zinc Supplementation. Biofactors.. Nov-Dec 2015;41(6):414-23.

Hosui et al. Long-Term Zinc Supplementation Improves Liver Function and Decreases the Risk of Developing Hepatocellular Carcinoma. Nutrients. 2018 Dec 10;10(12):1955

Jamillan et al. Effects of Zinc Supplementation on Endocrine Outcomes in Women With Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled TrialTrace Elem Res. 2016 Apr;170(2):271-8.

Kahmann et al. Zinc Supplementation in the Elderly Reduces Spontaneous Inflammatory Cytokine Release and Restores T Cell Functions. Rejuvenation Res. . 2008 Feb;11(1):227-37.

Kim et al. Effect of Zinc Supplementation on Inflammatory Markers and Adipokines in Young Obese Women.Biological Trace Element Research 2014 Feb;157(2):101-6.

Lomagno et al. Increasing Iron and Zinc in Pre-Menopausal Women and Its Effects on Mood and Cognition: A Systematic Review. Nutrients. 2014 Nov 14;6(11):5117-41.

Mariani et al. Effect of Zinc Supplementation on Plasma IL-6 and MCP-1 Production and NK Cell Function in Healthy Elderly: Interactive Influence of +647 MT1a and -174 IL-6 Polymorphic Alleles. Exp Geront. 2008 May;43(5):462-71.

Mocchegiani et al. Zinc: Dietary Intake and Impact of Supplementation on Immune Function in Elderly. Age. 2013 Jun;35(3):839-60.

Ranasinghe et al . Zinc Supplementation in Prediabetes: A Randomized Double-Blind Placebo-Controlled Clinical Trial. J Diabetes. 2018 May;10(5):386-397.

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Hair shedding after a low calorie diet

May 18, 2020

My diet is done but when is my hair shedding going to stop?

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of telogen effluvium from dieting.

Here is the question….

QUESTION

Hi! I have a quick question regarding my hair loss. For the past few months I have been on a very low calorie diet, and i’m now noticing a lot of my hair falling and thinning. I therefore changed my diet and am eating more calories now. But when will my hair stop falling? …. and is there anything i can do to stop it? I am a female 5’5, and weigh 123 pounds. I was consuming about 800-1,000 calories a day.. but burning about 500.

ANSWER

This is a terrific question. For most people, the answer is simple. For some, however, it’s a little more involved as we will see.

1) the patient’s Story

2) the findings uncovered during the process of the scalp Examination and

3) the results of relevant blood tests.

With that behind us, let's return to our question of the week again.

WHAT’S THE MOST LIKELY EXPLANATION?

First, it’s quite likely that you are experiencing what we term a “telogen effluvium” and in your case this is occurring from dieting. Anytime a person consumes less than 1300 calories per day the chances of telogen effluvium increase.

Telogen effluvium (TE) Is a hair shedding disorder whereby the patient experiences more daily hair loss than they may have in the past. Mild effluviums may lead to 50-100 hairs loss daily whereas more severe effluvium may be associated with several hundreds. Many forms of TE occur 2-3 months after a so called triggering event. A trigger in January, for example, causes hair loss in March. A trigger that occurs in March causes hair shedding in May. Common triggers include low iron, such as low iron, stress, thyroid abnormality, initiation (or cessation) of a new medication, or weight loss. Hundreds of other examples of triggers exist as well. In many cases a trigger cannot be found and the TE resolves on its own. Most telogen effluviums resolve about 9-12 months after the trigger has been completely corrected. Many patients with shedding disorders have scalp symptoms of itching, burning, tenderness, and feeling of something moving in the scalp. This is referred to as trichodynia.

Your story is quite typical for Telogen effluvium. Let’s suppose for the sake of this question that you started your diet in February. When would I expect you to start noticing shedding? The answer is April. How long will your shedding last? That answer is 6-9 months from the time that you started eating a normal 1500 calorie balanced nutritional diet AND provided your diet did not leave you with any nutritional deficiencies that keep you chronically depleted.

TYPICAL COURSE OF HAIR SHEDDING FOLLOWING A DIET

The typical course of hair shedding would follow something like this. Shedding would start 2 months after the diet and then worsen. In your case, I would not be surprised if shedding worsens in May and June and July even if the diet stopped in May. But over the course of the late summer and Fall, shedding should start reducing again and by the end of the year hair shedding should be back to ‘normal.’ It’s normal to shed 20-60 hairs per day and for some a bit more.

Your current weight tell me that your body mass index is now in a healthy range. Body mass index is something that I calculate for all my patients to get a sense of whether their weight is right for them. It’s not a perfect scale but gives a sense of where things should be Your BMI is 20.5 which is a healthy weight.

Does hair shedding always stop people who go back to eating a normal amount of calories?

For most people, shedding goes back to normal in a few months of eating a healthy number of calories. For some people however, that’s not the case. There are several reasons why shedding does not slow down including.

1. There were deficiencies created by the diet which have not been corrected.

A diet can create all sorts of deficiencies in vitamins and minerals. We only need small amounts of most vitamins and minerals anyways so once a health diet resumes, most people can make up for any losses and the body will absorb what it needs. However, for some people levels of vitamins and minerals don’t get replenished like they need to be. A good vitamin and mineral supplement can help but I often recommend testing potential deficiencies like iron, zinc, selenium, magnesium, B12, vitamin A, folate, vitamin D in addition to the usual tests for anyone with hair loss (CBC and TSH).

2. There are other reasons for the shedding which were forgotten about.

It’s possible for a person to shed because of diet. But sometimes a person can think they are shedding from a diet but that’s not really the reason they are shedding at all! Shedding can happen from over 100 causes so a broad approach is needed.

See Top 10 Causes of Telogen Effluvium

Thyroid abnormalities, stress, medications, illnesses in the body can cause shedding. In addition, many conditions mimic telogen effluvium and so the patient is actually shedding from a completely different condition such as alopecia areata incognito or a type of scarring alopecia.

3. The shedding has precipitated or ‘unmasked’ an andogenetic alopecia

For some people who shed, the process of shedding uncovers their slightest tendency to develop androgenetic alopecia. If a person has the underlying predisposition to develop genetic hair loss, then a shedding episode from telogen effluvium can cause the adnrogenetic alopecia to be set in motion. Even though the person’s telogen effluvium from the diet ends - they are faced with a new hair issue - androgenetic alopecia.

See Why Won’t My Shedding Stop?

Telogen Effluvium: Why is my density not returning to normal?

4. The patient has developed a chronic shedding issue.

Finally, some patients with shedding develop chronic shedding problems even though the original trigger has been identified, corrected and is long behind them. This is known as a form of chronic telogen effluvium

FINAL SUMMARY

Thanks again for the great question. I’d encourage you to see your dermatologist if the shedding does not improve. For most with shedding problems that come after dieting, the shedding gets worse for a few months and then progressively gets better and better until shedding rates go back to normal in 6-9 months. In some people though, this is not the story, and issues like androgenetic alopecia, chronic nutritional deficiencies, and other hair issues like chronic telogen effluvium need to be explored in greater detail.

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Treatments for Scalp Dysesthesias

December 03, 2018

Question:

I have been to over 7 dermatologists and several other doctors as well. I have been told I have a diagnosis of ‘scalp dysesthesia.’ For almost two years, I have had severe scalp burning and hair loss. My doctors put me on several benzodiazepines but it makes my shedding worse. I have had no luck.

Do you have any suggestions?

Answer

Thank you for your question. The scalp dysesthesias are a group of conditions that are associated with marked scalp symptoms in the absence of any underlying obvious disease of the scalp. When hair loss is present together with the scalp symptoms one must strongly consider the possibility that the scalp symptoms could be due to the hair loss condition as well or perhaps even solely from the hair condition.

There are many causes of scalp dysesthesias rather than a single cause. Cervical spine disease, neurological disease, depression are some of possible the underlying causes. It seems that patients worsen with stress. When hair loss is present one must always consider whether a primary scalp issue is the reason for the symptoms. A full review of a patient’s medical history as careful examination of the scalp is necessary to rule out primary causes such as scarring alopecia, psoriasis, seborrheic dermatitis, telogen effluvium. Blood tests for vitamin, mineral and hormonal abnormalities are needed and if any doubt exists a biopsy may be needed as well. Patch testing may be needed if allergic contact dermatitis is considered.

There are many possible treatments for scalp dysesthesias including antidepressants (SSRI, tricyclic antidepressants), oral gabapentin, and oral prebagalin (Lyrica). Topical agents such as topical gabapentin or topical TKAL (ketamine, amitriptyline, lidocaine) can be considered as well.

There are a variety of non-pharmacological techniques that can be used to combat the scalp symptoms that patient’s with scalp dysesthesias experience as well. These include:

1. Ice packs or Cool water

Ice packs, frozen peas and cool towels are useful for many individuals with challenging scalp syndromes. These are safe to use provided they are not too cold and not left on too long.

2. Apple cider vinegar

Apple cider vinegar rinses are helpful for individuals with many different scalp syndromes including itching, burning and pain. Most often the apple cider vinegar is diluted 1:4 in water and applied to the scalp for 5-10 minutes before rinsing off.

3. Witch hazel

Several herbal ingredients are proposed to have an anti-irritant tendency and can be helpful in scalp pain syndromes. These include chamomile (Marticaria chamomilla), heart seed (Cardiospermum halicacabum), peony (Paeonia lactiflora), and the virginian witch hazel (Hamamelis virginiana). Witch hazel in particular has received great attention. We generally recommend application of pure witch hazel with a cotton ball for periods of 5-10 minutes before rinsing off. Many patients find relief from these agents.

4. Allergen free shampoos

Although contact allergy must be considered in patients with scalp symptoms, a variety of allergen free shampoos can be considered even in the absence of any evidence of a true scalp allergy. A list of helpful low allergen shampoos is provided in the link below

ALLERGEN FREE SHAMPOOS

5. Vitamin C

Vitamin C or ascorbic acid occasionally helps some individuals with scalp nerve and pain syndromes. The dose is 500 mg daily.

6. Low level laser therapy.

Low level laser therapy (LLLT) involves the application of red light therapy to the scalp. The treatments were originally designed for use in androgneetic alopecia but have helped many patients with scalp dysesthesia. Some patients, however, find that the warmth of these devices makes their scalps feel worse. Therefore LLLT is not helpful for everyone.

7. Menthol

Products with menthol have a cooling effect and help some patients. Many of our paitents have found relief from a tea tree oil menthol – peppermint product from Holista products. These are available on amazon as well. Ingredients include denatured alcohol, water, glycerin, Melaleuca alternifolia (Tea Tree) leaf oil, menthol, Mentha piperita (Peppermint) oil. We recommend 3-4 sprays up to three times daily

8. Relaxation, medication, yoga and tai chi

Many of our patients have experienced tremendous benefit from the practice of a variety of techniques.

Conclusion and Summary

I would need to examine your scalp and obtain a great deal more information to determine how best to proceed. The fact that you have hair loss makes it important to make sure there is not one or more hair conditions present as well. As mentioned above, many hair and scalp disorders are associated with scalp symptoms. If this is the case, it may or may not be appropriate to actually use the term scalp dysesthesia.

Blood tests are essential in anyone with scalp symptoms. Typical tests to consider include CBC, TSH, ferritin, zinc, ANA, ESR. Other blood tests may be important as well depending on the precise story. In your case, as well as with all patients with scalp dysesthesia, a scalp biopsy and consideration of patch testing needs to be discussed. These are certainly not appropriate for everyone but they must be considered. Evaluation for potential cervical spine disease (with x-ray +/- magnetic resonance imaging) and a detailed specialist evaluation for potential neurological, rheumatological

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Why isn't my hair loss improving despite improving my iron?

October 01, 2018

QUESTION

I was told that my hair loss was from my low iron levels. However, after working hard for the past 6 months to bring my ferritin levels up from 23 to 55…… I am still not seeing any improvement with my hair at all. Is my hair loss related to iron or not?

Answer

Thanks for the question. It’s certainly a possibility that a person’s iron levels are related to their hair loss. It’s just that they are not implicated as often as most people think. For every one patient I meet with whose lower iron levels are truly related to their hair loss, there are 6 or 7 others where the lower iron levels don’t really seem to be playing role. It’s common to hear stories from patients that they were told their low iron is the reason for their hair loss. Many such patients spend months trying to improve their iron only to find that their hair density has not improved even after correcting their iron.

The short answer is that the lower a person’s ferritin is - the more likely it’s related to the hair loss they are experiencing. It’s a scale from “very likely related” when the ferritin is down below 15 to very like unrelated. I often think in terms of the following table:

With a ferritin of 23 you described, there is a good chance it will help. But it’s far from 100 %. In fact, as you’ll see in the studies I discuss below, almost one half of people in the general population with ferritin levels of 23 will have no hair loss problems.

Hypoferritinemia without anemia (HWA): Is it consistently implicated ?

Ferritin is a measure of iron storage levels in body. In order to get a sense of a patient’s iron status, we measure “ferritin” levels rather than iron. Males tend to have higher ferritin levels than females. Premenopausal women tend to have lower ferritin levels than post menopausal women. Extremely low ferritin levels have many potential side effect and may prevent the body from making hemoglobin - a condition which is called ‘anemia’. However, many patients have low ferritin levels without actually having an anemia. This condition is sometimes called hypoferritinemia without anemia or HWA.

Borderline ferritin levels: Evidence for direct role remains poor

The discussion of ferritin levels and hair loss comes down to how low one must go before the low ferritin levels start impacting hair loss. Many females have ferritin levels 20-40 without hair loss. In fact, if you were to measure iron levels (i.e. the ferritin test) in all women between ages 20-40, you'd find many with ferritin 28, 32. 44. You'd find very few with ferritin levels above 50. You'd find a number with ferritin levels 6, 12, 19.

While it’s often said that one needs to have a ferritin level above 40 (or above 70) for healthy hair growth, this rule is far too simple. We often "aim" for that level in the hair clinic …. but it is completely wrong to say that anytime ferritin is less than 40 there is a problem.

Ferritin levels below 15

Once the iron levels start going low enough, it is true that there is a higher likelihood now that the patient will experience some hair loss an account of those low iron levels. However, it’s now a definite yes or no. It's quite unusual for patient to have normal hair growth with a ferritin of 2 but not completely impossible. However, it’s still within the realm of possibilities for a patient to have normal hair growth with a ferritin of 18.

The biggest challenge is knowing when a patient should be strongly encouraged to increase their iron levels. The simplest rule, as mentioned above, is to recommend to all people with ferritin less than 40. But one must keep in mind that there will be many people with ferritin levels in their 20s and and 30s who are not going to get any benefit from their efforts to increase iron.

FOUR KEY IRON STUDIES TO KNOW ABOUT

As we think about the relationship between low iron and hair loss, there are 4 key studies that everyone should be aware of.

STUDY 1

AUTHOR: Sinclair et al. British Journal of Dermatology

TITLE: There is no clear association between low serum ferritin and chronic diffuse telogen hair loss.

DATE: 2002

Sinclair and colleagues set out to evaluate the relationship between low serum ferritin (</=20 micro g L-1) and chronic diffuse telogen hair loss in women. He analyzed nearly 200 women who presented with chronic hair loss. 12 women had ferritin levels less than 20 ug/L. In 5 women with pure chronic telogen effluvium (and no evidence of androgenetic alopecia), iron supplementation was recommended to bring ferritin levels up above 20. None of these women experienced improvements in their hair with iron supplementation.

STUDY 2

AUTHOR: Deloche et al European Journal of Dermatology

TITLE: Low iron stores: a risk factor for excessive hair loss in non-menopausal women.

DATE: 2007

Deloche and colleagues assessed the relationship in a very large population of 5110 women aged between 35 and 60 years. Hair loss was evaluated using a standardized questionnaire and iron status was assessed by a serum ferritin assay. patients were categorized into three categories acceding to whether they had an "absence of hair loss" (43%), "moderate hair loss" (48%) or "excessive hair loss" (9%). While it was generally found that women affected by excessive hair loss were more often affected by low iron stores, (59 % vs 48 % in the other two groups), this study reminds us that many patients with no hair loss still have low iron levels.

11.4 % of pre-menopausal women who had concerns about ‘excessive hair loss’ had ferritin levels less than 40 ug/L and 10.2 % had ferritin levels less than 15 ug/L. This compares to just 6.8 % of women with ferritin above 70. This information certainly suggests a link between iron and hair loss. However, one must keep in mind that many patients in the study with low ferritin did not have hair loss. Of all premenopausal women with ferritin levels less than 15 ug/L, about 40 % had no concerns about hair loss at all. This is an important reminder that low ferritin levels are not related to hair loss in all patients.

STUDY 3

AUTHOR: Rasheed et al (Skin Pharmacol Physiol.)

TITLE: Serum ferritin and vitamin d in female hair loss: do they play a role?

DATE: 2013

Rasheed and colleagues set out to study the role of several blood tests including iron levels in 80 females (18 to 45 years old) with telogen effluvium (TE) or androgenetic alopecia (FPHL) and compared levels of iron to 40 age-matched females with no hair loss.

Rasheed found that serum ferritin levels were lower in patients with TE (14.7 ± 22.1 μg/l) and FPHL (23.9 ± 38.5 μg/l) compared to the controls (43.5 ± 20.4 μg/l). Interestingly, these levels seemed to decrease with increased disease severity. While these studies suggested a role of low ferritin levels in hair loss the study did not include any investigation as to whether supplementing with iron was a helpful treatment strategy. That was not part of the study.

STUDY 4

AUTHOR: Kantor et al, J Invest Dermatol.

TITLE: Decreased serum ferritin is associated with alopecia in women.

DATE: 2003

One of the earlier studies investigating the role of iron was a 2003 study in the Journal of Investigative Dermatology. The authors studied patients with telogen effluvium (n = 30), androgenetic alopecia (n = 52), alopecia areata (n = 17), and alopecia areata totalis/universalis (n = 7). The normal group consisted of 11 subjects without hair loss.

The authors found that the mean ferritin level in patients with androgenetic alopecia (37.3) and alopecia areata (24.9) were statistically significantly lower than in normals without hair loss (59.5). Interestingly, the mean ferritin levels in patients with telogen effluvium (50.1) and alopecia areata totalis/universalis (52.3) were not significantly lower than in normals. This study was a good reminder that low iron may have a role in some types of hair loss but the role in telogen effluvium remained unclear.

Key summary points about iron levels and hair loss

Here's some key 'take home' messages about iron and hair loss

1. Aiming for a ferritin level above 40 is likely good idea for anyone with hair loss.

2. Aiming for a ferritin above 70 is not my recommendation and is very hard to achieve and generally has little benefit for the hair.

3. If one's ferritin is between 20-40 and they have hair loss, it must always be remembered that the ferritin levels may be just fine for that person. I'd still recommend supplementing with iron tablets, but there is not a lot of good evidence that doing so is going to help their hair

4. Ferritin levels under 15 are often associated with changes in hair cycling. If ferritin is less than 15, I recommend speaking to one's physician about iron pills

5. If ferritin levels are low and hemoglobin levels are low (something we call iron deficiency anemia), a full workup by a doctor should be booked.

6. Vitamin C helps iron absorption and taking a vitamin C rich sources with iron pills is often helpful to increase iron. Limiting the use of caffeine may also help.

7. Many females have ferritin levels 20-40 without hair loss. The ferritin level alone does not mean much without taking everything into perspective.

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Blood Tests For Patients with Hair Loss

September 24, 2018

QUESTION

Question

I am experiencing severe and non-stop hair loss for the last 6 months. I am confused about what blood tests I am supposed to get? What is the standard panel that my doctor should be ordering?

Thanks for the question. This is an important question that is too often overlooked. In general terms, blood tests are required for most women with hair loss. For men, they are usually not. However, each patient's hair loss needs to be reviewed on a case by case basis as there is not simple rule about what tests are needed. The exact tests that are needed depends on the patient’s history and their examination findings.

Women with hair loss

For women, I'll not go without blood tests. Blood tests are required for all women with hair loss. Blood tests are mandatory. Simply put there are so many mimickers of female hair loss and diagnosing female hair loss is far more complex than diagnosing hair loss in men. I will order tests for basic blood counts (CBC), thyroid (TSH) and iron (ferritin) in all women with hair loss.

For young women with acne or increased facial hair, a tests for DHEAS (hormones from the adrenal gland), androstenedione (hormones from the ovaries) as well as free and total testosterone and sex hormone binding globulin (SHBG) are ordered. Women with irregular menstrual cycles may require blood tests to evaluate polycystic ovarian syndrome including tests for LH, FSH, DHEAS, androstenedione, prolactin, estrogen, free and total testosterone and 17 hydroxyprogesterone (17OHP) and sex hormone binding globulin (SHBG). Blood sugars may also be checked.

Women with dietary restriction may also have zinc levels checked and a few other minerals as well (i.e. selenium). Sometimes vitamin D is checked depending on where the patient lives. Women with low ferritin and hemoblogin may, in some situations, benefit from celiac screening before consideration of further testing.

Similar to the discussion for men, women with potential autoimmune causes of hair loss require comprehensive evaluation including complete blood counts (CBC), thyroid (TSH), iron (ferritin), ESR, ANA, B12.

Men with hair loss

For men with male pattern balding (androgenetic alopecia), blood tests are not needed most of the time. I may check 25 hydroxyvitamin D levels depending on the background of the patent and where in the world they live. For young males with male pattern balding, I often test cholesterol level as there may an increased risk of lipid abnormalities in this patient group. This is an important and poorly recognized issue and I’ve written about it in previous articles:

CHOLESTEROL ISSUES IN YOUNG MEN

TIME IS RIPE FOR THE MEDICAL COMMUNITY TO COME TOGETHER

For men with hair loss due to various autoimmune causes (such as alopecia areata or lichen planopilaris) I often check blood tests such as basic blood counts (CBC) , thyroid (TSH), iron status (ferritin), ANA, B12, ESR. In some situations, I'll consider a free and total testosterone.

This is typically the extent of tests for most. However, should there by any suspicion of a larger systemic issue, liver tests (AST, ALT, bilirubin) might be ordered and kidney function tests (including creatinine and urinalysis) might be considered). Men with nutritional issues and weight loss, require a far more involved work up including consideration for zinc, selenium screening. Men with low ferritin and hemoglogin may warrant celiac screening before consideration of further testing. One must always consider syphilis screening in all patients as rates are increasing worldwide.

Dozens of other tests available.

There are dozens of other tests available but most of the time they are inappropriate. I see serum iron and serum TIBC ordered inappropriately much of the time. I also see free T3 and free T4 ordered in appropriately as well. There may be a role for some patients but not most.

In other situations a variety of tests can be considered. In a patient with a positive ANA result, anti-double stranded DNA might be considered (along with urinalysis, creatinine, liver function etc). Patients with suspected sarcoidosis may benefit from serum ACE. HIV testing may be appropriate in some situations as well. There are dozens of other sophisticated tests that can be ordered but are generally inappropriate to order as basic screening tests.

Conclusion

All in all, there is no standard template for ordering blood tests for a patient with hair loss. The tests that need to be ordered are determined once the patient’s story is fully understood and their scalps are examined. If certain tests are abnormal, additional tests may then be considered.

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Positive ANA Tests

September 17, 2018

QUESTION

QUESTION:

I had a positive ANA test result as part of a series of blood tests for my hair loss but feel quite healthy. Do I have an autoimmune disease? Do I need more tests?

ANSWER

Thanks for the question. Without fully knowing all the details of your health and medical history, there is no definitive “yes” or “no” answer here. However, there are some important points to consider. In general, the answer depends on the “level” of your ANA test (how high it is) and whether or not your truly have any symptoms or signs of autoimmune disease.

About 5-10% of the population has a “false positive” ANA that carries no significance for their health. This means the test result comes back looking positive but the patient has no autoimmune disease whatsoever. These are patients who are healthy but have an ANA result of 1:80 and sometimes 1:160. These completely healthy individuals answer “no” when asked questions about whether they have fatigue, joint pain, chest pain, mouth ulcers, sun sensitivity, rashes, blood clots, severe dry eyes, severe dry mouth, Reynaud’s disease, headaches, shortness of breath, repeat miscarriages (women) and other abnormal blood test results. These individuals do not have the autoimmune disease lupus or other autoimmune diseases.

Individuals who do answer “yes” to some of the above questions or who have higher ANA results such as 1:320 or 1:640 often require more specific and detailed autoimmune testing. This may involve tests such as anti double stranded DNA, ESR, blood counts, kidney and liver function, urinalysis and extractable nuclear antigen (ENA). Other tests may be important too. Patients with high ANA results and who have symptoms on questioning can be considered for referral to a rheumatologist.

In general, many physicians do not usually order tests for ANA unless there is some even small degree of suspicion of a possible autoimmune connection. (Randomly testing for ANA without a good cause is not useful for most). A positive test should be followed up with detailed questioning and possibly additional blood tests to determine if it is more likely a false positive or true indicator of underlying autoimmune disease.

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QUESTION OF THE WEEK

Dr. Donovan's Articles

QUESTION OF HAIR BLOGS

Is my hair density going to return?

QUESTION

ANSWER

Six Possible Scenarios for Your Hair Loss

Detailed Review of the RECOVERY (April 2021 to Dec 2021).

What happens if my density does not recover by the end of the year?

My Final Comments

Why am I shedding ?

QUESTION

ANSWER

POINT 1. Androgenetic alopecia (female pattern hair loss) appears to be at least one of the diagnoses.

POINT 2: Seborrheic dermatitis/dandruff is likely another diagnosis.

POINT 3: Telogen effluvium could be present.

POINT 4: If you want to assess the degree to which AGA and TE are present, you could have a biopsy or 5 day modified hair wash test (or a proper trichoscopic examination). I don’t think these are really needed.

POINT 5: The ‘pins and needles’ is a bit trickier given how many conditions can cause this.

Conclusion/Summary

Persistent Shedding, Elevated DHEAS and Ongoing Hair Loss

QUESTION

ANSWER

a) Do you have androgenetic alopecia ?

b) Do you have telogen effluvium and nobody has found the cause?

c) Do you have another diagnosis altogether?

Summary.

Excessive hair shedding in the early 30s: What are the reasons?

QUESTION

ANSWER

AGA must be the Default Diagnosis in Women 30-40 with Increased Hair Shedding

The Three Stages of Hair Loss

Stage 1 of Androgenetic Alopecia

Stage 2 of Androgenetic Alopecia

Stage 3 of Androgenetic Alopecia

Understanding the Patterns of Hair Loss

Summary: Putting it All Together

What should I do about my hair loss?

BLOOD TESTS

BIOPSY

ANSWER

Conclusion/Summary

Localized Shedding with zinc supplements

QUESTION

ANSWER

WHAT’S THE MOST LIKELY EXPLANATION FOR SHEDDING WITH ZINC?

It zinc related to my hair loss? A Closer Look at the Naranjo Scale

Typical Questions in the Naranjo Scale

Determining the Naranjo Score

What are the effects of zinc on the body and on hair ?

Zinc and Hormones.

SUMMARY AND FINAL CONCLUSION

My diet is done but when is my hair shedding going to stop?

QUESTION

ANSWER

WHAT’S THE MOST LIKELY EXPLANATION?

TYPICAL COURSE OF HAIR SHEDDING FOLLOWING A DIET

Does hair shedding always stop people who go back to eating a normal amount of calories?

1. There were deficiencies created by the diet which have not been corrected.

2. There are other reasons for the shedding which were forgotten about.

3. The shedding has precipitated or ‘unmasked’ an andogenetic alopecia

4. The patient has developed a chronic shedding issue.

Question:

Conclusion and Summary

QUESTION

Answer

Hypoferritinemia without anemia (HWA): Is it consistently implicated ?

Borderline ferritin levels: Evidence for direct role remains poor

Ferritin levels below 15

FOUR KEY IRON STUDIES TO KNOW ABOUT

STUDY 1

STUDY 2

STUDY 3

STUDY 4

Key summary points about iron levels and hair loss

QUESTION

Question

Women with hair loss

Men with hair loss

Dozens of other tests available.

Conclusion