Low ALP Levels and Hair Loss

Are there underlying conditions associated with low ALP that could be worsening my hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to low serum alkaline phosphatase (ALP).

QUESTION

I am 40 yrs old and have been diagnosed with androgenetic alopecia. I am currently on spironolactone (200 mg), oral min (2.5 mg), topical minox and finasteride solution, and keto shampoo, I think I am at least maintaining on this protocol. I just had blood work completed and noticed the only thing out of range (with the exception of my total cholesterol) is my alkaline phosphatase, which is low and has been low or below 4 out of 6 years that I have been tested. Could this show a deficiency in b12/zinc/etc that could be worsening my condition?

ANSWER

Thanks for the question. There are many reasons to have a low ALP. Whether or not the ALP is potentially worsening your condition will depend on the cause of the low ALP. Good questioning and a good examination done by your doctor can help uncover the cause. Some of these causes will have nothing to do with hair loss and some will. First, you’d need to figure out the cause of the low ALP.

What is ALP?

Alkaline phosphatase is an enzyme. It was first discovered about 100 years ago. It’s made in many parts of the body including the liver (main source) as well as the bones, intestines, kidneys and pancreas.

ALP LEVELS: What is a normal range?

ALP levels are normally in the range 30-115 IU/L. When levels are well below this cut off, once starts to think about a variety of causes. The exact range of ALP will differ between various laboratories - and some even have a lower cut off of 20 IU/L.

In one study, issues associated with low ALP included cardiac surgery and cardiopulmonary bypass (26.5%), malnutrition (12.0%), magnesium deficiency (4.8%), hypothyroidism (2.4%), and severe anaemia (1.2%), zinc deficiency, hypophosphatasia, pernicious anemia, vitamin C deficiency, estrogen therapy, chronic renal osteodystrophy, excess intake of vitamin D, celiac disease, hypoparathryoidism. Genetic conditions like hypophosphatasia need to be considered too - as it’s underdiagnosed and easily missed.

Evaluating Low ALP Starts with A Good History and Good Examination

What is needed for anyone with abnormal blood tests is a really good history and really good examination done by the practitioner. Information about prior surgeries, dental issues and gum issues, dietary intake, fatigue, weight loss or gain, tremors, neurological issues, diarrhea, constipation, bone pain, broken bones, muscle and joint pains, abdominal pain, blood pressure issues, mental health issues, fatigue need to be obtained by the practitioner.

Additional Blood Tests for Patients with Low ALP

Additional blood tests may be helpful for patients wth low ALP but the exact tests to order really depends on what information was uncovered during the questioning by the practitioner (i.e. the “medical history”). These may include one or more of the following: serum albumin, zinc, creatinine, urinalysis, serum ascorbic acid, TSH, complete blood count, ferritin, serum phosphate, B12, B6, 25 hydroxy vitamin D, calcium, AST, ALT, bilirubin, PTH and anti-tissue transglutaminase. Other tests may also be helpful depending on the exact medical history of the patient. For example serum copper and ceruloplasmin are to be ordered if Wilson’s disease is a consideration.

For many patients, a bone x ray and/or bone mineral density test will also be ordered - but that needs to be reviewed on a case by case basis with each patient. There are mild genetic and metabolic conditions that can cause bone issues and sometimes teeth issues that cause low ALP. Again, a full history and full examination can help uncover causes.

Conclusion and Summary

There are many causes of low ALP ranging from nutritional issues to medical conditions to drug related causes to rare genetic conditions. A full history and examination is needed. Some of the causes of low ALP have no impact on hair loss whereas others do. Hypothyroidism, zinc deficiency, nutritional issues, celiac disease, anemias are among the causes of low ALP most likely to impact hair.

I would suggest that you see your primary care to have a baseline history and examination and labs drawn. He or she can decide what other blood tests or urine tests or bone scans are relevant. Speaking with an endocrinologist could make sense if most tests turn up normal in order to rule out mild cases of adult hypophosphatasia. Otherwise, treating the abnormality that turns up with the additional blood tests may be the way to go (ie the zinc deficiency or the celiac disease or the anemia or the nutritional issues).

One important tip as to whether there could be a contributor to hair loss is shedding. If a patient has normal daily shedding rates and constant improvement with therapy for the androgenetic alopecia (like oral minoxidil and spironolactone, etc) - it becomes less and less likely that the low ALP is reflective of an underlying cause that affects the hair. if shedding rates are elevated above normal or there has been a poor or suboptimal response to treatment, it becomes more and more likely that the low ALP is related to some cause that gives hair loss.

Thanks again for the question.

REFERENCE

Lum G et al. Significance of low serum alkaline phosphatase activity in a predominantly adult male population. Clin Chem. 1995 Apr;41(4):515-8.