testing for hair loss

Question
QUESTION: Hi Dr. P., You have helped me so much in the past that I was hoping I could trouble you for another question.  I am going to see my endo this week to check my blood to make sure my Spiro isn't causing problems.  What else should I have her test?  We test for Serum Ferritin every visit - I am usually b/n 4-11 every time and can't seem to bring it up!!  She has checked my thyroid too, but I'm wondering if there is an aspect of the thyroid test that she is missing.  Generally, my Endo checks the "obvious" things.  I wanted to know if there is some other underlying problem that we're not addressing.  I am currently on Spiro, a high estrogen dose bcp and Rogaine.  I'm see lots of new growth in the last 3 months, but wonder if it is more to do with increased estrogen than anything else.  Any thoughts on what tests to make sure I have done this week?  Thanks so much.  -carla



ANSWER: I do not know why you are wondering about other tests when your serum ferritin has shown you are TOO LOW. Your serum ferritin should be over 60 as a minimum. If you can not get it up to that level with the supplements you are taking you may need iron shots but I would suggest you see a "Hematologist" to find out why you are so low. I would not be looking for other causes and would not do repeated thyroid tests. The "obvious" things only need to be checked once and you now have an "obvious" cause for you loss. What is not "obvious" is the reason you have such a low serum ferritin and you need a blood specialist for that, or perhaps a gastroenterologist to find out why you are not absorbing the iron.



---------- FOLLOW-UP ----------



QUESTION: I hear what you are saying about my ferritin levels and I will certainly see a hemtologist to figure out why it is so low; but I have seen a dozen doctors and no one has picked up on my low ferritin levels.  I have tried to discuss it with my derm and he blows me off.  My iron levels are normal but my iron stores are super low.  Just had some blood work done today after being on iron for 2 months so I'll see if it helped.  The problem with iron is that is gives me incredible constipation that I can't seem to control. So I don't use iron supplements for very long.  If you recommend something to help with that side effect, please let me know.  I have slow fe iron supplements just waiting in my cabinet...  Thanks for your reply Dr. P, I'll look into setting an appt with a hematologist.  Maybe that has been my problem all along... :(  -carla



ANSWER: I may have already sent you a handout I give to women with low serum ferritin and thinning hair but if not here are three other references you can give to your doctors.  If you have a persistent low serum ferritin then you should be seeing a specialist in that area. Given a choice most women will find a way to get their ferritin up to normal rather than have thin hair.

The diagnosis and treatment of iron deficiency and its potential relationship to hair loss.



Trost LB, Bergfeld WF, Calogeras E.



J Am Acad Dermatol. 2006 May;54(5):824-44. Review.PMID: 16635664





Decreased serum ferritin is associated with alopecia in women.



Kantor J, Kessler LJ, Brooks DG, Cotsarelis G.



J Invest Dermatol. 2003 Nov;121(5):985-8.PMID: 14708596 [PubMed - indexed for MEDLINE]Related articlesFree article

3.



Decreased serum ferritin and alopecia in women.



Rushton DH.



J Invest Dermatol. 2003 Nov;121(5):xvii-xviii.  PMID: 14708588





---------- FOLLOW-UP ----------



QUESTION: Thanks!! I've known about the relationship between hl and low ferritin levels for years but my doctors usually blow it off and recommend Rogaine.  I'm doing more research right now and will look at your references too.  I have beta thalasemia minor which probably doesn't help matters!!  Your recommendation that I see a hematologist is a good one and I'll do that as soon as my blood test results come back next week. If your handout on low ferritin is additionally helpful, please pass it along to me. Thanks Dr. Panagotacos - I'm learning more from you than a dozen doctors over the last 20 years!!  -carla


Answer
Here are two other pieces of info- my handout is a shortened version of this:

Ferritin and hair loss





Decreased serum ferritin is associated with alopecia in women.  This

concept was presented on the list in 1996 by James Baumgaertner and

validated in 2003 by an article in JID



We found that the mean ferritin level (ng per ml [95% confidence

intervals]) in patients with androgenetic alopecia (37.3 128.4, 46.1]) and

alopecia areata (24.9 [17.2, 32.6]) were statistically significantly lower

than in normals without hair loss (59.5 [40.8, 78.1]).

Kantor J, Kessler LJ, Brooks DG, Cotsarelis G.

Decreased serum ferritin is associated with alopecia in women.

J Invest Dermatol. 2003 Nov;121(5):985-8.

PMID: 14708596





Presentation

Women who have a chronic telogen effluvium, with or without pruritus,  may

have an underlying iron deficiency.   Iron supplementation may stop and

sometimes even reverse the alopecia.





Interpreting ferritin levels relative to alopecia



Hemoglobin is actually an insensitive screening test for iron deficiency.

Ferritin is often a better indicator, however ferritin is an acute phase

reactant and levels are associated with inflammation.  Although a low

hemoglobin (9 or 10) has a high correlation with a low ferritin, a normal

or even relatively high hemoglobin (15+) does not rule out clinically

significant iron deficiency.



The laboratory normal range for ferritin may be 10-230.   In terms of hair

loss associated with iron deficiency, ferritin levels below 30 in a woman

with telogen effluvium may stop shedding and possibly regain hair with 6

months of  iron supplementation.   Also check ESR (sedimentation rate), as

ferritin is an acute phase reactant, and therefore may read higher than

actual in the face of inflammation.



A ferritin  level less than 5 means marked iron deficiency that is likely

to be symptomatic and with symptoms that will improve (sometimes rapidly)

with iron supplementation.  Levels between 5 and 20 are also usually

symptomatic and responsive to supplementation. Levels between 20 and 35

are borderline, and above 35 it is much less likely that the symptoms

(hair loss, tiredness, depression) are going to respond to iron

supplementation (unless there was a recent drop in the ferritin secondary

to blood loss).







Causes of low iron and low ferritin other than menstrual blood loss



Postmenopausal women who have iron deficiency may need to be worked up for

GI iron loss.  In addition to tumors, a frequently overlooked cause for

hypoferremia is gluten enteropathy.  Check the anti-endomysial antibody

level and ask about a personal and family history for gluten enteropathy,

irritable bowel, abdominal cramping, and so on.  Other causes of low iron

include GI loss, lymphoma, and low-iron diet (some vegetarians).





Treatment guidelines



Appropriate dose of ferrous sulfate is about 300mg daily (that is ~65mg of

elemental iron). In cases of true anemia, the dose can be TID, but there

are more side effects and risk of over supplementation.  Absorption of

iron can be enhanced by concomitantly taking vitamin C (500-1000mg) daily.

Calcium supplements may compete with iron for absorption, therefore they

may need to be taken at different times.  Iron products should not be

taken directly with several other meds and compounds, including

tetracycline and others.  Antacids and H2 blockers will decrease iron

absorption.



Ferrous gluconate (325mg/day)  seems to be better tolerated than ferrous

sulfate in some patients.  Some patients may be non-absorbers of ferrous

suflate, but not many.  In those patients it is recommended to use  iron

supplementation either with an iron salt (ferrous/ferric gluconate) or

with carbonyl iron (Feosol Caplets) which are much safer and with milder

side effects (less tarry stools, less GI irritation).  Usually it takes

about 6 months of supplementation to restock the iron stores.



Recommended ferretin levels vary by practitioner.  With oral iron

supplementation, it may be difficult to get the ferritin above 50 or 60.

A level of 50 seems to be the goal for several discussants, but the range

was from above 30 to above 70.  When oral supplementation fails to raise

the ferritin levels,  a patient may be referred to a hematologist for IM

or IV iron administration, which is much more effective.





Monitoring ferritin vs. hemoglobin or serum iron



Ferritin may be a better indicator of iron stores than hemoglobin or serum

iron.



QUESTION FROM A DERMATOLOGIST

I have a lady, 55 years old, with what appears to be androgenetic

alopecia.  She has uncharacteristic itching for a few years also of the

scalp, but normal exam otherwise.  When I first saw her, her ferritin was

10.  Daily iron supplementation seemed to stop her itch, and may have lead

to less shedding. Ferritin came up to 24 and her internist ordered an iron

level and it is 163 ug/dl (nl 35-160).  She was told to stop iron

supplements immediately.  Her itch is back in full force and she wants to

know what to do.  Can I continue iron supplements?  How high is too high

for iron. I told her to take the iron 2-3 times per week and we can

monitor her iron.  If iron is high, why doesn't ferritin get any higher?

I need a little education in the basic science of it all.  Any help?



ANSWER FROM HEMATOLOGIST

Thanks for requesting my opinion. Itching, generalized or localized is a

well known but uncommon feature of iron deficiency, related to the

epithelial cell damage that arises when many iron-containing enzymes such

as catalases and cytochromes become functionally affected. This

manifestation as well as the low ferritin suggest and long-standing iron

depletion. In a 55-year old woman I would search for a bleeding site in

her GI tract including perhaps ( according to other clinical features) a

small bowel study to rule our malabsorption. oral iron intolerance or

deficient absorption is not uncommon and may be overcome by changing

preparations, (using liquid ones) or giving an adequate total dose

parenterally (IM). if low iron and or ferritin persist after adequate

replacement i would look into very rare possible genetic defects in

relation to transferrin, or iron binding. these last ones can only be

performed in a specialized research lab.





_________________________________________________________________________________________

Journal of Investigative Dermatology (2003) 121, xvii?xviii; doi:10.1046/j.1523-1747.2003.12581.x

Decreased Serum Ferritin and Alopecia in Women



See related article on page 985



D Hugh Rushton



School of Pharmacy & Biomedical Sciences, University of Portsmouth, Portsmouth, Hampshire, UK



Alopecia is a non-life-threatening condition, which may seem trivial to the unaffected. However, those physicians who see patients with hair loss know all too well the devastating impact it can have on an individual's quality of life. The studyof Kantoret al in this issue of the journal (2003) not only has significant implications for dermatology but other areas of biology. While they show a strong trend for those with alopecia to be at the low end of the serum ferritin scale, they raise some fascinating questions about the role of iron in basic biology. Why women with alopecia have low serum ferritin concentrations is of concern to dermatologists, other groups with an interest in conditions that have rapid cell proliferation should also consider the implication of a low serum ferritin. While the effect of iron on blood is relatively well known, its role in other systems is only just emerging.



Although the association between iron and hair loss was first postulated byH?rd (1963), it was not until the early 1990s that the significance of low iron stores as assessed by serum ferritin concentrations in women with diffuse hair loss (androgenetic alopecia, AGA) (Rushton et al, 1990) was first demonstrated (Rushton and Ramsay, 1992;Rushton and Fenton, 1992). Since then the role of serum ferritin in female hair loss has been a controversial topic fiercely debated at international hair meetings. The report by Kantor et al is the first study, based on sound epidemiological principles, to clearly demonstrate an association between low serum ferritin and alopecia. Some may argue the sample sizes are too small, but significant differences were found, adding to the growing body of evidence that serum ferritin is important in hair biology and supporting the largely anecdotal evidence of its role in persistent excessive hair shedding (chronic telogen effluvium, CTE). Whether a low serum ferritin is causative remains to be seen.



Iron is stored mainly in the liver, within the iron storage proteins ferritin and hemosiderin. Many of the key biological functions of iron in living systems rely on the high redox potential enabling rapid conversion between Fe2+ and Fe3+. Iron stimulates the liver to make ferritin, and serum ferritin provides a reliable estimate of body iron stores (Cook et al, 1974). The majority of functional iron within the body is present in haem proteins, which are involved in oxygen transport and mitochondrial electron transfer. Total body iron averages approximately 3.8 g in men and 2.3 g in women. This difference is reflected in the lower reference ranges for hemoglobin and serum ferritin in "normal" adult females which we have argued could represent pathological iron deficiency (Rushton et al, 2001). This hypothesis has been supported by a large-scale US study that found 38% of women in the San Diego area to be iron deficient (Rushton et al, 2002), confirming a problem far more common than many physicians appreciate.Hobbs (1961), in a different area of medicine, sug-gested the "normal" adult female range for hemoglobin was not physiological and iron therapy should be instituted in all women with a hemoglobin level below 136 g/L; the current lower limit is 120 g/L. Kantor et al's findings of a significantly lower hemoglobin and serum ferritin concentrations in women with telogen effluvium (TE) under the age of 40 compared with controls is noteworthy.



The deleterious effects of iron deficiency are partly due to impaired delivery of oxygen to the tissues and to a deficiency of iron-containing compounds (Hallberg, 1982). Clinical features include restlessness and irritability (Dillmann et al, 1979), lower IQ scores in adolescent girls (Bruner et al, 1996;Nelson, 1999), fatigue in nonanaemic women (Verdon et al, 2003), and perhaps more significant, abnormalities in response to infection and impaired T-cell proliferation (Dallman, 1986). The latter is particularly relevant in view of the surprise finding of a significantly lower mean serum ferritin concentration in women with alopecia areata (AA), when they would have been expected to have had higher values due to AA being regarded as an inflammatory condition. This certainly raises some interesting questions, not least: why do those with alopecia totalis/universalis have higher serum ferritin concentrations? The authors speculate on this observation and explain their findings by a "threshold theory," but further investigation is needed. Whether increasing the serum ferritin level will have any meaningful impact on the natural course of AA or if there is a beneficial influence on therapeutic regimens needs to be studied. Further, what are the frequencies of AA, TE, CTE, and AGA in female patients with iron excess, e.g., hemochromatosis? Clearly, answers to these questions are eagerly awaited.



The importance of the Kantor et al work and the potential impact for female alopecia sufferers is clear to see. The evidence that serum ferritin plays an important role in hair loss is becoming more evident. Any guidance that helps the dermatologist deal with patients complaining of hair loss is most welcome, as is understanding the mechanisms involved. The optimal serum ferritin range in women with alopecia has yet to be established. While we await this data, it might be prudent to use parameters obtained from studies of iron staining in the bone marrow, which suggest a serum ferritin concentration of between 30 and 70 mug/L, in the absence of inflammation, would be appropriate. Kantor et al provide a firm basis for future research and, if their findings are confirmed, current dermatological practises and investigations involving therapeutic agents will need to be reviewed.