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

QUESTION

iron levels

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:

ferritin

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

QUESTION

blood tests

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. 

 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). One must always consider syphilis screening in all patients as rates are increasing worldwide.

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

QUESTION

ana

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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