Why am I shedding with zinc supplements?
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.
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.
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.