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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 37  |  Issue : 2  |  Page : 56-61

Role of iron in telogen effluvium among premenopausal women


1 Department of Dermatology and Venereology, Faculty of Medicine, Tanta University, Tanta, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Tanta University, Tanta, Egypt
3 Department of Dermatology and Venereology, Kom Hamada Generalized Hospital, Kom Hamada, El-Gharbiya Governorate, Egypt

Date of Submission10-Dec-2016
Date of Acceptance01-Mar-2017
Date of Web Publication4-Aug-2017

Correspondence Address:
Yomna Mazid El-Hamd Neinaa
Department of Dermatology and Venereology, Faculty of Medicine, Tanta University, Tanta, 31527
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejdv.ejdv_64_16

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  Abstract 


Background
Telogen effluvium (TE) is the most common cause for diffuse nonscarring hair loss that is characterized by excessive loss of telogen hair. It is mainly of two types − acute TE or chronic TE. Iron deficiency has been suggested as a possible etiological factor for TE in women; however, its role is still controversial. The aim of this study was to assess the iron profile in TE among premenopausal women, to throw light on its possible role in the pathogenesis of this disease.
Patients and methods
A total of 40 premenopausal women with TE, and 20 age-matched healthy women were enrolled in this study. Venous blood samples were collected from all and examined for complete blood cell counts, serum iron, serum ferritin, and total iron-binding capacity.
Results
TE patients showed statistically significant decreased hemoglobin concentrations in comparison with controls, and acute TE women had the lowest hemoglobin concentrations. Serum iron showed a statistically highly significant decrease in TE women (both acute and chronic) in comparison with controls. No statistically significant difference could be detected between the studied groups regarding serum ferritin and total iron-binding capacity, but there was a statistically significant number of chronic TE patients with serum ferritin levels below 20 ng/ml.
Conclusion
Iron deficiency may have a possible role in the pathogenesis of TE among premenopausal women. Checking hemoglobin concentrations is particularly important in acute TE, whereas determining serum ferritin levels is particularly important in chronic TE.

Keywords: serum ferritin, serum iron, telogen effluvium, total iron-binding capacity


How to cite this article:
Hodeib AA, El-Hamd Neinaa YM, Mourad HA, Sabry Daba RA. Role of iron in telogen effluvium among premenopausal women. Egypt J Dermatol Venerol 2017;37:56-61

How to cite this URL:
Hodeib AA, El-Hamd Neinaa YM, Mourad HA, Sabry Daba RA. Role of iron in telogen effluvium among premenopausal women. Egypt J Dermatol Venerol [serial online] 2017 [cited 2017 Dec 18];37:56-61. Available from: http://www.ejdv.eg.net/text.asp?2017/37/2/56/212105




  Introduction Top


Women presenting with diffuse hair loss is a very common and challenging problem for dermatologists. Telogen effluvium (TE) is one of the most common causes for diffuse nonscarring hair loss affecting the scalp. It is an abnormality of hair cycling that results in excessive loss of telogen hairs occurring as a reaction pattern to various physical or mental stresses around 3 months after a triggering event [1],[2],[3]. A wide variety of potential triggers have been implicated in initiating TE. If the trigger is acute and short-lived, TE will likely be acute TE (ATE), and recovery is expected to be complete within 6 months. If the trigger is ongoing, repeated, or not reversed, chronic TE (CTE) will develop lasting for 6 months or more [4],[5].

Iron deficiency is one of the most common nutritional deficiencies that is encountered in daily practice. In premenopausal women, the most common causes for iron deficiency are menstrual blood loss and pregnancy [6],[7],[8]. The relationship between iron deficiency and TE is complex and controversial. Low iron stores were first suggested as a possible etiological factor for TE in women in 1963. Subsequently, several studies examined the relationship between iron deficiency and hair loss. Some suggested that iron deficiency may be related to TE, whereas others did not [8],[9],[10],[11],[12]. Therefore, it seemed interesting to study whether there is really an association between iron status and TE.

The aim of this study was to assess the iron profile in TE among premenopausal women to throw light on its possible role in the pathogenesis of this disease.


  Patients and methods Top


The present study included 40 premenopausal women with TE and 20 healthy women matched for age who served as the control group. They were selected from the outpatient clinic of the Dermatology and Venereology Department, Tanta University Hospitals, Tanta, Egypt. Ethics approval was obtained from the Ethics committee before commencement of the study. This study included female patients of childbearing age, presenting with primary idiopathic TE and who did not receive any treatment in the last 3 months. Pregnant, lactating, and postmenopausal women were excluded. In addition, those with secondary TE or any other causes of diffuse hair loss [such as female pattern hair loss (FPHL) or alopecia areata incognito (AAI)], active scalp infection, autoimmune or systemic diseases, or those under any medications were excluded.

All participants were subjected to compete careful history taking to identify the trigger and to rule out conditions that can cause diffuse hair loss (hair care procedures, dietary history, e.g. crash diet or strict vegetarian, psychological stress, fever, infection, childbirth, recent surgery, chronic diseases, autoimmune diseases, thyroid disease, or malignancy).

Thorough general and dermatological examinations were performed with detailed examination of the scalp, including the hair-pull test. Hair shampooing was not allowed for 24 h before the test, and then roughly about 60 hairs were grasped between the thumb and fingers and pulled gently but firmly from root to tip. The test was repeated in all four quadrants of the scalp and bi-temporal areas. If six or less hairs were obtained, the test was considered negative, indicating normal shedding, whereas if more than six hairs were obtained the test was considered positive, indicating active hair shedding [13]. Trichoscopic examination of the scalp was carried out to rule out other possible causes of diffuse nonscarring hair loss (FPHL or AAI). On trichoscopy, TE is a diagnosis of exclusion [14],[15].

After obtaining written informed consent, 10-ml venous blood samples were collected from each participant and divided as follows:
  1. A volume of 3 ml was transferred to an EDTA-containing tube for complete blood cell count (CBC) analysis, including hemoglobin (Hb) concentration, red blood cell count, hematocrit (HCT) values, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) using a completely automatic hematology analyzer.
  2. A volume of 7 ml was transferred to a plain tube, centrifuged, and separated. Serum samples were obtained and used for analysing the following:
    1. Serum iron was estimated by an autoanalyzer, using a commercially available kit (normal values 50–160 μg/dl).
    2. Serum ferritin level was determined by an Automated Chemiluminescence System (Roche, Germany) using quantitative enzyme-linked immunosorbent assay. This is a two-sided sandwich immunoassay that utilizes one rabbit antiferritin antibody for solid-phase (microtiter wells) immobilization and a mouse monoclonal antiferritin antibody in the antibody–enzyme (horseradish peroxidase) conjugate solution [12] (normal range: 20–150 ng/ml). The analysis was carried out using a serum ferritin cut-off point of 20 ng/ml as the most acceptable lower limit of normal [16].
    3. Total iron-binding capacity (TIBC) is the sum of plasma iron and unsaturated iron-binding capacity, calculated from the level of transferrin in blood, which was estimated using a commercially available kit (normal range: 145–399 μg/dl).


Statistical analysis

Data were fed to a computer, and analyzed using IBM SPSS software package, version 20.0 (IBM Corp., Armonk, New York, USA). Quantitative data were described using ranges (minimum and maximum) and mean±SD. Student’s t-tests were then used to compare the means different groups. A significant difference was considered at P of 0.05 or less, and a highly significant difference was considered at P of 0.001 or less.


  Results Top


Clinical results

The present study included 40 premenopausal women with TE. Their ages ranged from 18 to 44 years with a mean age of 28.10±4.65 years. The control group included 20 healthy, age-matched women. Their ages ranged from 18 to 42 years with a mean age of 27.45±6.41 years. The duration of TE ranged from 3 to 12 months with a mean of 7.50±1.99 months. Regarding the clinical type of TE, seven (17.5%) patients had ATE and 33 (82.5%) patients had CTE. In all TE patients, the hair-pull test was positive all over the scalp (including frontal, parietal, and occipital regions). Trichoscopic examination of TE patients ([Figure 1]) detected decreased hair density all over the scalp with no site predilection, one follicular hair unit dominance, and variation in the diameter of the hair shafts was below 20%. There was no significant difference between the findings in the frontal area and those in the occipital area, thus excluding FPHL. No black or yellow dots or exclamation mark hair could be detected, thus excluding AAI.
Figure 1 Trichoscopy of the frontal scalp area of a telogen effluvium patient, showing decreased hair density, one follicular hair unit dominance, and variation in the diameter of hair shafts below 20% (20-fold magnification).

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Laboratory results

The mean values of different parameters included in the CBC count are illustrated in [Table 1]. There was a statistically highly significant decrease in Hb concentrations in TE patients when compared with the control group (P<0.001) ([Table 1]). TE patients were evaluated for anemia, defined as Hb concentrations less than 12 g/dl. There was a statistically highly significant number of TE patients with Hb concentrations below 12 g/dl (P=0.001), and ATE patients had the lowest Hb concentrations ([Figure 2]). In addition, there were statistically highly significant decreases in HCT, MCV, MCH, and MCHC in TE patients in comparison with healthy controls (P<0.001) ([Table 1]). However, no statistically significant difference could be detected regarding red blood cell count between TE patients and healthy controls (P=1.000) ([Table 1]).
Table 1 Comparison between telogen effluvium patients and controls with regard to complete blood cell count

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Figure 2 Comparison between acute and chronic telogen effluvium patients and controls with regard to hemoglobin concentration at a cut-off point of 12 g/dl.

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The mean values of the different parameters of the iron profile in TE patients in comparison with healthy controls are illustrated in [Table 2]. Serum iron levels showed a statistically significant decrease in ATE patients and a statistically highly significant decrease in CTE patients in comparison with healthy controls (P=0023 and <0.001, respectively) ([Table 2]).
Table 2 Comparison between telogen effluvium patients and controls with regard to serum iron profile

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Serum ferritin levels showed no statistically significant differences between TE patients (both ATE and CTE) and healthy controls (P=0.434, 0.138, respectively) ([Table 2]). Further analyses were carried out using a serum ferritin cut-off point of 20 ng/ml as the most acceptable lower limit of normal [16]. It was found that 25 (62.5%) TE patients had serum ferritin levels below 20 ng/ml, whereas in the control group only six (30%) women had serum ferritin levels below 20 ng/ml, and this difference was proved to be statistically significant with a P-value of 0.018. Furthermore, a statistically significant number of CTE patients (66.7%) had serum ferritin levels less than 20 ng/ml with a P value of 0.010 ([Figure 3]).
Figure 3 Comparison between acute and chronic telogen effluvium patients and controls with regard to serum ferritin at a cut-off point of 20 ng/ml.

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Regarding TIBC, there was no statistically significant difference between TE patients (both ATE and CTE) and healthy controls (P=0.0.144) ([Table 2]).


  Discussion Top


The present study evaluated the important parameters of the iron profile in TE patients, and analyzed them in both clinical types of TE (ATE and CTE).

Regarding CBC count, the mean values of Hb, HCT, MCV, MCH, and MCHC were significantly lower in TE women in comparison with control women. Our finding that Hb concentration was statistically significantly lower in TE patients was in agreement with Chisti et al. [16] and Fatani et al. [17] but in contrast to other studies by Moeinvaziri et al. [11], Ibrahem et al. [18], and Elethawi and Jabbar[19], who found that the mean value of Hb showed no statistically significant difference between TE patients and controls.

In this study, further analysis was performed using Hb concentrations of 12 g/dl as the cut-off point, and there was a statistically significant number of TE patients with Hb concentrations less than 12 g/dl, with the lowest Hb levels seen in ATE patients. These results are in agreement with Moeinvaziri et al. [11], who stated that eight out of nine patients with iron-deficiency anemia had telogen hair loss.

Serum iron is a measure of circulating iron that is bound to transferrin, which is a major serum iron-transport protein. In the present study, there was statistically highly significant decrease in serum iron levels in TE women compared with control women. This finding was in agreement with Hamad et al. [12] but in contrast to Moeinvaziri et al. [11]. Further analysis of serum iron was performed in our study, according to the clinical type of TE, and we found a statistically significant decrease in serum iron levels in ATE and a highly significant decrease in CTE patients in comparison with the control group.

The deleterious effects of iron deficiency are partly due to impaired oxygen delivery to the rapidly proliferating hair follicle matrix cells. Another mechanism for the possible effect of iron on hair growth stem cells, is its requirement as a cofactor for ribonucleotide reductase enzyme, which is involved in DNA synthesis. Iron depletion could prevent proper function of this enzyme, resulting in inhibition of proliferation [11].

Ferritin is a protein that plays a key role in iron metabolism and allows storage of iron. Its serum level is used to evaluate iron reserves, and thus help in early detection of iron deficiency. In the present study, we found no statistically significant difference in serum ferritin levels between TE women and control women. As serum ferritin levels accurately reflect body iron stores, our study clearly demonstrated no association between low iron stores and telogen hair loss. This result was in agreement with Chisti et al. [16] and Ibrahem et al. [18]. They concluded that there was no closely linked relationship between iron metabolism and TE.

In contrast to our results, Moeinvaziri et al. [11], Elethawi and Jabbar [19], Rasheed et al. [20], and Fatani et al. [17] showed that serum ferritin levels in TE patients were significantly lower compared with the control group, and concluded that there was a significant association between low serum ferritin and TE.

In the present study, further analysis was carried out using serum ferritin levels of 20 ng/ml as the cut-off point (the most acceptable lower normal limit), and a statistically significant number of patients with CTE (66.7%) had serum ferritin levels below 20 ng/ml. Accordingly, we could suggest that decreased serum ferritin levels might be considered as a potential risk factor for developing CTE.

Our results were in agreement with Moeinvaziri et al. [11], who used serum ferritin levels of 30 ng/ml as the cut-off point, and Sarkar et al. [21], who used serum ferritin levels of 20 ng/ml as the cut-off point. Both of them concluded that women with lower serum ferritin levels than the proposed cut-off point had a significant risk of developing telogen hair loss. In addition, Fatani et al. [17] found that serum ferritin levels in 61.25% of TE patients were less than 30 ng/ml, which proved to be statistically significant. Furthermore, Chisti et al. [16] found a statistically significant number of CTE patients with serum ferritin levels less than 20 ng/ml when compared with those of controls.

The results of the present study regarding serum ferritin could be explained on the basis of the ‘threshold hypothesis’, as proposed by Kantor et al. [22] who stated that the decreased iron stores lower the threshold for developing different types of alopecia in those individuals. They proposed that in patients with a genetic predisposition to develop alopecia, or with the presence of other triggering factors, it is possible that low iron stores may lower their threshold to the point where they develop alopecia. Theoretically, it will be this subgroup of patients who are best candidates for iron therapy. However, in individuals without a hereditary predisposition or without other triggering factors, low iron stores would not cause alopecia [22].

Total iron-binding capacity is the sum of plasma iron and unsaturated iron-binding capacity, which is calculated from the level of transferrin in blood. In this study, serum TIBC showed no statistically significant difference between TE patients (neither ATE nor CTE) and healthy controls. This finding was in contrast to Moeinvaziri et al. [11] who found that serum TIBC was statistically significantly higher in TE patients than in controls.

From the present study, we conclude that evaluation of iron status must be taken into consideration in assessing premenopausal women presenting with TE. There was a strong association between Hb concentrations and serum iron levels (circulating iron) and diffuse telogen hair loss. However, there was no association between serum ferritin levels (reflecting iron stores) or TIBC and TE. Premenopausal women with Hb concentrations of less than 12 g/dl were at a significant risk of developing ATE, whereas those with serum ferritin levels of less than 20 ng/ml were at a significant risk of developing CTE.

We recommend additional laboratory and population-based studies to confirm our findings. Appropriately powered randomized, placebo-controlled trials would be helpful in leading us toward a better understanding of the role of iron in telogen hair loss.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Fatani MI, Bin mahfoz AM, Mahdi AH, Alafif KA, Hussain WA, Khan AS et al. Prevalence and factors associated with telogen effluvium in adult females at Makkah region, Saudi Arabia: a retrospective study. J Dermatol Dermatol Surg 2015; 19:27–30.  Back to cited text no. 17
    
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    Tables

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