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Hair Shedding with Zinc Supplements: Is is Possible?
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There are many causes of hair shedding or telogen effluvium. Common causes include intense stress, thyroid problems, crash diets with sudden weight loss, and medications. However, a wide variety of other ‘triggers’ have the potential to cause hair loss. Deficiencies in various minerals are also potential causes of telogen effluvium. Deficiencies in zinc, iron, magnesium, selenium, for example, all have the potential to trigger hair loss.
A 2004 study reminded us that testing for magnesium deficiency (“or hypomagnesemia”) may be reasonable in women presenting with concerns about diffuse hair loss and diffuse hair shedding. The normal adult value for magnesium is 1.6-2.5 mEq/L and hypomagnesemia is generally defined as a level of serum magnesium under 1.6 mEq/L or 1.5 mEq/L.
Tataru and Nicoara studied three groups of women age 16 to 40. Group A was made up of 26 women with diffuse hair loss for which the cause was unknown. Group B consisted of 14 women with diffuse hair loss for which the cause was known (seborrhoea, hormonal issues, thyroid disease). Group C consisted of 24 women without hair loss.
The authors found in the first group (group A), there were 12 cases (46.1%) with hypomagnesemia and the average magnesium level was 1.80 mEq/L. In the second group (group B), there were 3 cases (21.4%) and the average magnesium level was 1.99 mEq/L. Finally, in the control group (group C) the authors found 2 cases (8.3%) hypomagnesemia and the average level was 2.23 mEq/L These data suggested that low magnesium levels were indeed more likely to be found in women with diffuse shedding.
Check serum magnesium levels may be important to consider for some women with diffuse hair loss according to a 2004 study. Supplementation with magnesium may help some women with diffuse hair loss if levels are found to be low.
In the second part of the study, the authors evaluated the effect of providing magnesium supplementation to women in Group A and Group B. The dose was equivalent to 96 mg (8 mEq or 4 mmol) daily for 2 months. The authors observed a noticeable decrease of hair loss in 69.1% of the patients from group A (18 from 24 cases) in comparison with 35.7% (5 from 14 cases) in the group B.
This study was among the first large scale studies to document the incidence of low magnesium in women with diffuse hair loss and to show that women with diffuse loss are more likely to have low magnesium levels than women without diffuse loss. Moreover, these studies showed that supplementation magnesium may help some women reduce hair loss and shedding.
Finding the precise cause of hair loss in women with diffuse loss and hair shedding can be challenging. Ordering every single blood test is not practical and not cost effective. Sometimes the medical history can guide us, but not always.
Supplementing with magnesium is reasonable if blood tests prove that there is low magnesium. Supplements with 100-250 mg of elemental magnesium are quite reasonable for 2-3 months but I often start with every other day for 2 weeks to ensure that the patient does not experience diarrhea. Supplements with higher levels of magnesium are not typically recommended. After 3 months, I typically reduce the dose quite significant and recheck levels. Depending on the patient, the old magnesium levels, the new magnesium levels at the end of month 3 and the original suspected reason for the low magnesium, I might either continue at low doses or stop the magnesium altogether.
I have always found this to be an interesting study. I have not found a high proportion of women with hair shedding to have magnesium deficiency but am always on the look out.
Women with high intake of vitamin D may have low magnesium levels as well as other medication users. Low magnesium can give symptoms of muscle pain, fatigue, high blood pressure, irregular heart beats, osteoporosis and mood disorders so certainly we need to be particularly thinking about the possibility of low magnesium levels when this issues are present.
Im general, basic tests for women with hair shedding include:
CBC, TSH, ferritin, 25 hydroxy vitamin D, DHEAS testosterone, AM cortisol, ESR
zinc, magnesium, ANA, creatinine, AST, AST.
Consideration can given to ordering a variety of other tests depending on the exact patient history including syphilis screening, HIV, selenium, mercury and others.
A Tataru and E Nicoara. Idiopathic diffuse alopecias in young women correlated with hypomagnesemia. J Eur Acad Dermatol Venereol. 2004 May;18(3):393-4.
Hair loss for most is due to changes happening within the tiny hair follicles deep under the scalp. There may be a difference in the expression of certain genes or their may be different levels of inflammation surrounding hairs. It comes as a surprise to many patients that blood tests are often normal.
We require blood tests because there are many mimickers of hair loss and many conditions associated with abnormal blood tests are asymptomatic. If we could tell with 100% certainty that a given patient had low iron or had a thyroid problem just by listening to their story or examining their scalp, we would not need blood tests. The reality is that we can't. Many systemic conditions that can contribute to hair loss are asymptomatic. Low iron, thyroid abnormalities, zinc abnormalities, autoimmune markers, hormonal changes - these can frequently be asymptomatic.
It makes a lot of sense when one pauses and reflects on what is happening for most people. As mentioned earlier, hair loss for most patients is due to changes happening within the tiny hair follicles deep under the scalp. There may be a difference in the expression of certain genes or their may be different levels of inflammation surrounding hairs. The key tests that we need are therefore 'hair tests' not blood tests. In the present day and age, we don't have very sophisticated "hair tests."
I often use several analogies with my patients. If your arm was hurting and your doctor sent you for a chest x-ray, you wouldn't be surprised if your chest x-ray results came back normal. it is certainly possible that something in the chest is causing arm pain, but not very likely for most. What you need are tests on the arm - not tests of the chest. If you have chronic headaches and your physician sends you for an MRI of the foot, you won't be surprised if the MRI results of the foot come back normal. Blood tests may also be important in patients with chronic headaches - and sometimes these blood tests do reveal a cause of the headaches. But more often than not what is needed is tests specifically targeting to the brain - such as an MRI, CT or other related tests.
Every patient with hair loss needs blood tests to rule out a range of conditions that can cause hair loss and be asymptomatic. The typical blood tests that I recommend as a starting option are found in the following link.
One should always be prepared for the possibility (and likelihood that blood tests will come back normal for many patients. We have only a limited number of "hair tests" in the present day. These include punch biopsies, clinical examinations, trichoscopy, pull tests, pluck tests, hair collections. and hair mineral analyses (which are not useful for most), and hair toxicology screens (which are not relevant for most). We do not have an ability to easily tests the thousands and thousand of different genes expressed deep down inside the hair follicle and therefore rely on the above ancillary tests to get a sense of what might be happening inside of a tiny hair follicle.
Nowadays, do-it-yourself (DIY) projects are very popular. A "DIY" Project is an activity that one undertakes without directly seeking the help of an expert. You're probably well aware that DIY is particularly popular among individuals interested in home renovation. There are countless numbers number of books and videos to guide the lay person to renovate their home from top to bottom, inside and out. DIY need not be limited to home decor; the concept of DIY extends broadly into so many aspects of our lives nowadays. The internet is full of DIY projects.
On account of the internet, DIY also extends into medicine. The public is increasingly looking to take control of their health and in the same light to have more autonomy to decide how they receive advice on their health. We are all familiar with the power of modern search engines. My patients often joke about what they learned form "Dr. Google". However, the reality is clear: patients are spending more and more time looking for reliable information from the internet. We know that a vast majority of patients search for health information online. Various studies have suggested that 25-50 % of individuals seek the internet for self diagnosis.
I'm not a great fan of self diagnosis (i.e. DIY diagnosis) when it comes to hair loss. In my opinion, attempting to self diagnose the cause of one's own hair loss is rarely wise. Unless an individual has had a comprehensive review of their medical history, a full examination of their scalp (including use of dermoscopy) and had blood tests, they have not yet begun to properly investigate their hair loss.
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There are many reasons why individuals want to diagnose their own medical health, including hair loss. It's certainly much faster and more convenient to look on the internet than take the time to go to a doctor. For many, it may also present a considerable cost savings as well. For others, there is a tremendous amount of fear that surfaces when one needs to face their own health issues with a doctor. It's easier for a person with hair loss to avoid this by trying to solve one's health issues themselves. For others, looking at information on the internet provides a much needed sense of autonomy over health-related decision making. The public increasingly wants control over their health and how decisions get made and who makes them. When it comes to hair loss, however, it's often a false sense of control.
I realize that patients generally want to try to figure out the cause of their own hair loss by themselves. Fundamentally, this is good. Most of us are naturally interested to understand our own health. What concerns me is when individuals attempt to diagnosis their hair loss without the help of an expert (by definition, a DIY Project). There are several considerations I'd like patients to think about as they consider going down one of these paths to self diagnosis.
'Bias' is a term that means that we have a tendency to make certain decisions based on our previous life experiences. Essentially, the way our brains are wired based on all our collective life experiences and previous knowledge makes it more likely for us to make certain decisions than others. For example, when you see your child fall to the ground crying while playing with a group of children, your instinct may gear you up to look for the exact child that could have pushed your child. This is bias. The reality could be that your child could have tripped on an untied shoelace. We are wired to think certain ways.
When it comes to thinking about the causes of our hair loss, we have biases. For example, most of us really don't want to be diagnosed with genetic hair loss, so our bias could easily cause some of us to consider other diagnoses as the top choice. For example, you remember a family member with balding or someone you saw in the grocery store with hair loss, and your own emotions tell you that this is not what you want to have as a diagnosis. You have a natural bias to think you might have another diagnosis than genetic hair loss.
"There is absolutely no one in my family with balding, so my hair loss must be from stress"
This is bias. Bias is all around us. We are all humans and we are all filled with bias. But as a physician, I am likely filled with less bias when examining a patient's hair loss than the patient is
It's normal to be biased because after all, we're human. Bias can sometimes be a good thing, and certainly the instinctive reactions that come with bias sometimes do help us. In the example above, the bias we have when we hear our children cry helps us protect our children. But time and time again, I have witnessed how bias leads to some components of information to be forgotten.
The the past few years, I have made it a priority to have patients in my clinic complete a very detailed questionnaire about their hair loss long before meeting me. Most of my patients complete this questionnaire in the comfort of their own home, days or weeks before their appointment date. My hope in doing so is to reduce the bias that comes from face-to-face meetings with a physician. Although it's true that 'white coat syndrome' itself can influence what patients remember about their health, there many other aspects of the visit to the clinic introduce bias.
Since introducing the questionnaire some years ago, there has been a significant reduction in phone calls and emails after the appointment from patient's that 'forgot' to tell me certain pieces of information. My hope is that, by using this questionnaire, we're cutting down on bias that exists in standard patient-doctor interviews.
I too am filled with bias. When a close friend asks me about their hair loss, my 'gut reaction' is that I don't want them to have some systemic illness that is contributing to their hair loss. I don't want the strands of hair they pull from their scalp to be due to some serious disease. I need to recognize that I have bias and do my best to remove this from the decision making algorithms.
In fact, when discussing hair loss with friends and family, it's really best that I remove myself from the situation altogether. Legally and ethically, most physicians are not permitted to offer diagnostic or treatment advice to their closest friends and family. Medicine has recognized that physicians have bias and they are not able to properly evaluate an individual who close to the physician. If one of my family of friends has hair loss, I'm supposed to ask them to see a colleague. Sounds strange, but real bias is real!
Self diagnosis (hair loss DIY diagnosis) is also dangerous because there is often an assumption by the individual that they appreciate all the various causes of hair loss that exist and simply need to choose which one fits best. To the individual, they mistakenly feel that all the cards are on the table and they just need to pick the right one. The reality is that most patients considering their own diagnosis do not in fact appreciate all the 100 causes of hair loss. Instead of choosing from a list of 100 causes, many individuals with hair loss are trying to choose from a short list of common causes of hair loss. Fortunately, many patients will get their diagnosis right (because common hair loss conditions are common), but unfortunately too many patients get it wrong.
if you've never seen a zebra before, you'll be quite likely to call it some type of horse. Perhaps a striped horse. Dog owners with more exotic breeds will tell you that few people ever get their dog's breed correct. If you've never seen or heard of the hair loss condition 'pseudopelade', you're likely to incorrectly call a circular patch of hair loss 'alopecia areata'. If a patient has never seen folliculitis decalvans, then they are likely to go on battling what they think is stubborn folliculitis for a long time. If a patient has never heard of the condition lichen planopilaris, they may be continually searching for newer strategies for treating their stubborn dandruff or eczema.
Attempting to self diagnosis one's hair loss can be challenging if one does not know all the potential entities on the list.
In my experience, everyone with hair loss is on the lookout for the cause of their hair loss. However, very few people take the time to consider that they could have more than one cause for their hair loss. For many patients, it's not so much of a decision as to whether they have androgenetic alopecia or telogen effluvium but rather what proportion of the patient's hair loss is from androgenetic alopecia and what proportion if from telogen effluvium. Many patients have both! It's possible to have one, two three, four or even five causes contributing to one's hair loss.
The hair follicle is incredible. It's also incredibly complex. There are 20 different cell types in the hair follicle and 100,000 hairs on the scalp (2-4 million on the entire body). Added together there are trillions and trillions of cells working together in the scalp. Can one really try to sort through the actions (or inactions) of trillions and trillions of cells themselves?
It's difficult to think in terms of such large numbers, so let's go smaller. A car, they say, has over 30,000 parts when you consider all the tiny components. Few of us venture to even guess what's gone wrong when our car breaks down. We (hopefully) seek an expert. I often say to patients that if my car was making strange, strange noises and blowing black smoke out the back and front, I would likely be told to get an automobile mechanic to check things over. Any attempt at self-diagnosis and fixing the car oneself would not be wise, at least for most people. It certainly would not be wise for me. When my car breaks down, I need someone who works with cars and knows exactly how things go wrong. I need an expert.
It is important to keep in mind that some diagnoses can only come from a biopsy and some diagnoses can only come from blood tests. Individuals attempting to diagnose the cause of their own hair loss may never reach their diagnosis unless they have these specific tests performed. A patient with hair shedding may think they have a vitamin deficiency or some other cause of telogen effluvium. However, a biopsy could reveal that the hair loss was actually from a scarring alopecia. Similarly, a patient with hair shedding may think their hair loss is simply from stress when the reality is that they have low iron levels from a life-threatening bleeding stomach ulcer.
In these cases, any attempt to try to self diagnose one's hair loss simply leads to a delay in getting the appropriate medical attention that is needed. Rarely, this delay in diagnosis can have serious consequences.
Finally, a high proportion of individuals who attempt self diagnosis end up spending hundreds and sometimes thousands of dollars on products and supplements they have seen online. The patient's vulnerable state makes them very susceptible to consider buying anything that could help. Online marketing is remarkably powerful. Supplements, pills, shampoos, vitamins, tonics can all be bought with a click of a button. And often are.
I've read many Do-it-Yourself books on various topics and I'm all for liberating people to take on new challenges. DIY self diagnosis, however, is rarely a good idea.
I'm not one to judge how patients want to access their health care. Certainly patients are spending more and more time looking for reliable information from the internet and there are many reasons why individuals want to self diagnose the reasons for their own hair loss. However, properly diagnose hair loss one needs the full story, not the abbreviated version. And to properly diagnosis hair loss one needs the story told with as little bias as possible. Second, a full examination of their scalp (including use of dermoscopy) is needed. There are many mimickers of hair loss and one needs to know all the potential mimickers to make a proper diagnosis. Finally, one needs to have blood tests to complete the basic work up.
1; Danielle Ofri, MD What Patients Say, What Doctors Hear (Beacon Press, 2017). Reprinted with permission from Beacon Press.
2. Jerome Groopman. How Doctors Think. Houghton Mifflin 2007
Every now and then there are some unusually challenging cases of hair loss that cause me to sit quietly at the end of the day and rethink the best means to treat me it. I'm talking about patients with alopecia unversalis who do not improve with any treatment, including the most potent of oral immunosuppressives. I'm talking about patients with scarring alopecia who continue to have symptoms and lose hair despite the most aggressive treatments. I'm talking about patients with early onset androgenetic alopecia who progress despite anti-androgens, minoxidil, laser and more. Is there anything we can do in these situations? Fortunately there usually is. Here are some practical tips.
1. If the diagnosis is at all in question, a scalp biopsy should be done and possibly two. Blood tests should have been checked prior to the appointment but if not, basic screens are appropriate.
2. If a patient's diet is poor, one might look at ways to improve it.
3. If stress and emotional issues are high, it might be worthwhile to address these. Stress is clearly relevant for some people.
4. Consideration needs to be given to whether a current treatment is actually causing the hair loss to worsen. Stopping treatment for a period may be useful in some situations.
5. A complete health check should be done by the patient's regular physician. Routine screening exams (mammograms, colonoscopies) should be up to date according to age appropriate screening.
6. One should always at least ask if patients are using their recommended treatment. Every now and then there are some incredible surprises.
7. If a different route of administration is possible this should be considered. Some oral drugs might be compounded topically. Some topicals may be available in oral form.
If a physician sees enough patients with hair loss, he or she will encounter cases of hair loss that don't seem to respond to anything. An organized approach in these situations is needed. Every so often some surprising improvements can finally occur!
That answer, in my opinion, is a resounding - "yes." All women with concerns about hair loss need blood tests. The reason is simple: there are a great number of similar looking hair loss conditions in women and if one thinks they can confidently, with 100% certainty, rule out any particular condition just by looking at the scalp they are wrong. One can not exclude a contribution from low iron or a thyroid disorder even in a woman presenting with classic androgenetic alopecia. Let's take a closer look why blood tests are needed.
For a review of blood tests typically recommend as part of a screening work up click on the following
SCREENING BLOOD TESTS FOR WOMEN WITH HAIR LOSS.
About 1 out of every 5 women age 18-45 have iron deficiency. It's common. Given that low iron levels may be associated with a variety of different hair loss conditions, it is important to test for it and supplement iron in women whose blood tests show low iron. Even if one were to argue that low iron levels are seldom really a true factor in hair loss, studies have also shown that supplementation with iron may allow other treatments to work better.
In 1992, Drs Rushton and Ramsay conducted a study looking at women with genetic hair loss who were being treated with an antiandrogen medication (called cyproterone acetate). The researchers showed that women with iron levels above 40 had much better results with the antiandrogen pill than women who had iron levels below 40.
Ordering a basic blood count (for levels of red cells, white cells) is important. It's not a very specific test, but when the levels come back abnormal, it signals something may be wrong. A common reason for low hemoglobin and a low number of red cells levels is iron deficiency. But a variety of internal illness also have as part of their presentations low blood counts. A basic screen is helpful.
My work up is very different when a female with hair loss has an abnormal blood count. A 31 year old female with low hemoglobin and low ferritin, may have this result from heavy menstrual cycles, but may also have this from celiac disease as well. Depending on the patient and specific details, I may order a so called 'celiac panel' as well. A 66 year old female with low hemoglobin and low ferritin who comes into my clinic for hair loss may need a comprehensive work up by her physician to rule out a cancer.
About 1 out of every 15-20 individuals will be diagnosed with a thyroid disorder in their lifetime. These thyroid conditions are 8 times more common among women. While it's true that many with thyroid disease will notice symptoms, about one half will not notice any problems at first. Hair loss is frequently part of the collection of symptoms that come with thyroid dysfunction. Testing for thyroid disease in women with hair loss is important.
Vitamin D deficiency is common. Here in Canada, studies have shown that about two-thirds of the population is low in vitamin D and levels tend to be lower in winter than summer. The exact role of vitamin D in hair loss is still being worked out but it's clear that individuals with alopecia areata and genetic hair loss have lower vitamin D levels than individuals without hair loss.
Zinc deficiency is not common in North America. Nevertheless, zinc deficiency does exist in a number of subgroups in the North American population and is likely more common than appreciated. About 12 % of the general population and up to 40-50 % of the elderly are at risk for zinc depletion in North America. In many parts of the world, zinc deficiency is extremely common. In North America, zinc deficiency is frequently asymptomatic - meaning that individuals with low zinc don't necessarily have symptoms. Zinc deficiency can be associated with hair loss as well as a variety of issues related to immune system function and infection. The recommended amount daily is 11 mg for men and 8 mg for women.
Most women with hair loss do not require complex and extensive hormonal work-ups that so often are seen. However women with irregular periods, acne, excessive hair growth on the face (hirsutism), difficulty conceiving/infertility, early menopause and abnormal or rapid hair loss do require hormone tests.
Complete blood counts, along with tests for iron status (ferritin test) and thyroid status (TSH) are among the most important tests for all women with concerns about hair loss. Other tests may also be important for any particular individual but the exact test to order depends on the information obtained during the patient interview. Too often I hear it said that a female patient does not need blood tests. For example, I often hear it said that a female presenting with classic androgenetic alopecia does not need blood tests because classic androgenetic alopecia is not associated with blood test abnormalities. Here, one needs to consider that classic androgenetic alopecia may be associated with low vitamin D and research has even shown that it may be associated with cholesterol abnormalities as well (low HDL, high LDL). If one feels they can exclude with certainty that this patient does not have iron deficiency or a thyroid disorder, they are incorrect.
All women with hair loss need blood tests.
REFERENCE
Rushton DH, et al. The importance of adequate serum ferritin levels during oral cyproterone acetate and ethinyl oestradiol treatment of diffuse androgen-dependent alopecia in women. Clinical Trial. Clin Endocrinol (Oxf). 1992.
There are literally dozens and dozens of blood tests that one could order for a patient with hair loss. Which ones should we order? Which ones are likely a "waste"? I enjoyed this article in the Medical Post about a newer organization in Canada called Choosing Wisely which serves to help clinicians become more aware of what tests are unnecessary.
In the world of hair loss, this concept is important. Is ordering a reverse T3 likely to add much in a patient with normal TSH? Probably not. What about an ANA level in a very healthy male with patterned hair loss - is that helpful? Probably not at all. What about ordering a transferrin saturation in patient with a ferritin of 76? Seems wasteful.
There are times when an ANA, reverse T3 and transferrin saturation are important and it is important to know when to order various tests and when not to! If one is not likely to change management of the patient if a test comes back, normal or abnormal then it makes little sense to order the test.
Basic tests in hair loss include CBC, TSH, ferritin, 25 hydroxyvitamin D and possibly extended to include zinc. Rarely hormonal tests and ANA are included but not routinely. Additional tests are really ordered on a case by case basis. For a list of tests I recommend see the following link
Hydroxychloroquine is an oral medication used in a variety of autoimmune conditions. Side effects have been discussed previously but today we will focus on eye side effects. A number of side effects are possible ranging from vision changes to double vision to asymptomatic changes in various parts of the eye.
"Retinopathy" is one of the more worrisome side effects of Hydroxychloroquine. At appropriate doses, studies show that the risk appears to be about 1 % of patients at 5 years of use and 2 % at 10 years. After 20 years, the risk may rise to 20 %. Once the retinal toxicity from hydroxychloroquine occurs, it is believed that the changes in the retina are permanent. Furthermore, the disease can even progress even if hydroxychloroquine is stopped.
Retinal damage can occur in anyone. However, the risk may be increased if the following risk factors are present
It's clear that taking the appropriate dose reduces (but does not eliminate) the chance of side effects. The optimal dose is 6.5 mg for every kg of lean body weight (not simply what the patient weighs). "Lean body weight" is essentially the patients expected weight for their height and gender - it does not include the "extra" weight that some might carry. Instead of calculating lean body weight, some clinicians advocate simply using the patient's true body weight and multiplying by 5 (instead of 6.5). In our clinic we typically dose hydroxychloroquine according to the following grid:
The risk of eye related toxicity is low in the first 5-10 years of hydroxychloroquine use provided the dosing is respected. This study has had great importance as it has further helped to define risk and has encouraged changes in screening guidelines. These guidelines now include an initial examination but dedicated yearly screening to begin only after 5 years in otherwise healthy individuals deemed at low risk for eye problems.
Reference
(1) Melles & Marmor. The Risk of Toxic Retinopathy in Patients on Long-term Hydroxychloroquine Therapy. JAMA Ophthalmolol. 2014;132(12):1453–1460.
