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