Iron Plays a Certain Role in Patterned Hair Loss

Abstract

Role of iron in hair loss is not clear yet. The purpose of this study was to evaluate the relationship between iron and hair loss. Retrospective chart review was conducted on patients with female pattern hair loss (FPHL) and male pattern hair loss (MPHL). All patients underwent screening including serum ferritin, iron, and total iron binding capacity (TIBC), CBC, ESR and thyroid function test. For normal healthy controls, age-sex matched subjects who had visited the hospital for a check-up with no serious disease were selected. A total 210 patients with FPHL (n = 113) and MPHL (n = 97) with 210 healthy controls were analyzed. Serum ferritin concentration (FC) was lower in patients with FPHL (49.27 ± 55.8 µg/L), compared with normal healthy women (77.89 ± 48.32 µg/L) (P < 0.001). Premenopausal FPHL patients turned out to show much lower serum ferritin than age/sex-matched controls (P < 0.001). Among MPHL patients, 22.7% of them showed serum FC lower than 70 µg/L, while no one had serum FC lower 70 µg/L in healthy age matched males. These results suggest that iron may play a certain role especially in premenopausal FPHL. The initial screening of iron status could be of help for hair loss patients.

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Iron Plays a Certain Role in Patterned Hair Loss
Role of iron in hair loss is not clear yet. The purpose of this study was to evaluate the
relationship between iron and hair loss. Retrospective chart review was conducted on
patients with female pattern hair loss (FPHL) and male pattern hair loss (MPHL). All patients
underwent screening including serum ferritin, iron, and total iron binding capacity (TIBC),
CBC, ESR and thyroid function test. For normal healthy controls, age-sex matched subjects
who had visited the hospital for a check-up with no serious disease were selected. A total
210 patients with FPHL (n = 113) and MPHL (n = 97) with 210 healthy controls were
analyzed. Serum ferritin concentration (FC) was lower in patients with FPHL (49.27 ±55.8
µg/L), compared with normal healthy women (77.89 ±48.32 µg/L) (P< 0.001).
Premenopausal FPHL patients turned out to show much lower serum ferritin than age/sex-
matched controls (P< 0.001). Among MPHL patients, 22.7% of them showed serum FC
lower than 70 µg/L, while no one had serum FC lower 70 µg/L in healthy age matched
males. These results suggest that iron may play a certain role especially in premenopausal
FPHL. The initial screening of iron status could be of help for hair loss patients.
Key Words: Ferritin; Iron Deficiency; Alopecia
Song Youn Park,1 Se Young Na,2
Jun Hwan Kim,3 Soyun Cho,4 and
Jong Hee Lee3
1Department of Dermatology, Seoul National
University College of Medicine, Seoul; 2Department
of Dermatology, Seoul National University Bundang
Hospital, Seongnam; 3Department of Dermatology,
Sungkyunkwan University School of Medicine,
Samsung Medical Center, Seoul; 4Department of
Dermatology, Seoul National University Boramae
Hospital, Seoul, Korea
Received: 30 March 2013
Accepted: 8 May 2013
Address for Correspondence:
Jong Hee Lee, MD
Department of Dermatology, Sungkyunkwan University School
of Medicine, Samsung Medical Center, 81 Irwon-ro,
Gangnam-gu, Seoul 135-710, Korea
Tel: +82.2-3410-3549, Fax: +82.2-3410-3659
E-mail: bell711@hanmail.net
http://dx.doi.org/10.3346/ jkms.2013.28.6.934 • J Korean Med Sci 2013; 28: 934-938
ORIGINAL ARTICLE
Dermatology
INTRODUCTION
Loss of scalp hair is not a serious life threatening disorder, but it
can cause psychological distress and aect quality of life adverse-
ly. Hairs are rapidly proliferating organ with much requirement
of blood supply. erefore, the relationship between micronu-
trients and hair loss has been evaluated in several studies since
the 1960s (1). e most widely cited nutritional causes of hair
loss include iron, one of the key micronutrients in metabolism
of our body. From its diverse functions, it is well known that iron
deciency (ID) is associated with a lot of pathological conditions
(2). However, its role in hair loss is not well established yet.
When reviewing articles which have documented the rela-
tionship between ID and hair lossincluding female pattern hair
loss (FPHL), telogen euvium, alopecia areata, alopecia uni-
versalis or totalis, some (3-7) advocated the association between
ID and hair loss and others were against it (8-12). is contro-
versy might be caused by study designs, methodology and clin-
ical condition dening hair loss.
For detection of ID, serum ferritin level can be used as a very
early marker. It is a main iron-binding protein in nonerythroid
cells reecting total body iron stores. It decreases from very ear-
ly stage of ID as iron reserves go down (2). Because only ID can
cause very low serum ferritin concentration (FC), a FC is very
specic for ID (13). However, it can play a role in inammation
as a reactive protein, patients with active infection and/or in-
flammation should not be included in the analysis when we
consider FC is used for detecting ID. Hormonal status can af-
fect hair loss and it should be considered when interpreting the
clinical condition, too.
is study was designed to nd out evidence about associa-
tion between ID and hair loss. Current studies only concerned
of females, but not male subjects. Although females have more
issues about ID in general, hair loss is common problem in males,
too. erefore, we also analyzed the eect of ID among patients
with male pattern hair loss (MPHL).
MATERIALS AND METHODS
Retrospective chart review on patients with hair loss was con-
ducted. Medical data for patients who had visited our hair clinic
from January 2010 to February 2011 and been diagnosed as
FPHL or MPHL were obtained. Among them, patients who had
more than 6 months of history of hair loss and had not received
any kind of treatments for their hair loss were enrolled in the
analysis. Patients who had visited for their regular check-up of
general health condition and did not suer from hair loss were
selected for a normal control. ey were matched by age and
sex with hair loss patients. e database includes diagnosis, phy-
sical examination findings, laboratory data, medication lists

Park SY, et al. • Iron and Hair Loss
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http://dx.doi.org/10.3346/jkms.2013.28.6.934
and medical history. FPHL was diagnosed as central scalp hair
loss with or without frontal accentuation with hair miniaturiza-
tion and no signs of scarring alopecia (14). MPHL was dened
as non-scarring progressive miniaturization of the hair follicle
with a usually characteristic pattern distribution in genetically
predisposed men (15). MPHL patient was classied according
to basic and specic (BASP) scale for further analysis (16).
All patients in the analysis underwent biochemical investiga-
tion at the rst visit. It included thyroid function tests, complete
blood count with erythrocyte sedimentation rate (ESR), renal
and liver function tests, and iron studies (FC, iron, total iron
binding capacity [TIBC] and hemoglobin). Follow up FC and
complete blood cell count with ESR was checked on patients
who had received iron supplementation. All of these tests were
performed at our institution using the same laboratory system.
e biochemical investigation in age/sex matched normal con-
trol patients were analyzed, too.
Patients or their controls who had evidence of active infection
or inflammation and who were or had been pregnant within
previous 12 months were excluded because those factors can
inuence FC. ose who had abnormal thyroid function results
were also excluded from the analysis. Those currently taking
iron supplements due to other cause were also excluded.
To assess the clinical outcome of iron supplementation, Pa-
tient Global Assessment (PGA) and Patient Satisfaction (PS)
score were recorded several months (at least 6 months) after the
supplementation. PGA was graded into 5 categories, as worse,
unchanged, slightly improved, moderately improved and much
improved. PS was graded into 4 classes as unsatised, slightly
satised, satised and very satised.
Subgroup analysis
Female patients with hair loss were divided into two subgroups
according to their menstrual status. Male patients with MPHL
were classified into M dominant, and F dominant type using
BASP scale to see dierence between two types (16).
Statistics
Basic frequencies and prevalence rates were calculated for de-
mographic data and other parameters. The χ2 test or Fisher’s
exact test was performed to compare observed frequencies. P
values less than 0.05 were considered as a statistical signicance.
To compare patients with normal healthy controls, Student t-
test was conducted. Regression analysis was done to see rela-
tion between age and other parameters.
Ethics statement
e protocol and associated documents were reviewed and ap-
proved by the institutional review board of Seoul National Uni-
versity Boramae Hospital (approval ID: 20111103/06-2011-203-
113). is was a retrospective study and therefore, informed con-
sent was exempted by the board.
RESULTS
There were 210 patients diagnosed as FPHL (113 women) or
MPHL (97 men) who met the inclusion criteria of this study.
Age-sex matched healthy 210 controls (113 women and 97 men)
were compared. Age of enrolled patients was 42.9 ± 13.0, and
32.5 ± 9.6 yr old for FPHL and MPHL group respectively, show-
ing later onset of FPHL (P< 0.001) (Table 1). Hemoglobin levels
were normal in all groups. FC was 49.27 ± 55.8 and 77.89 ± 48.32
µg/L in FPHL patients and its age/sex-matched controls respec-
tively. MPHL patients showed 132.3 ± 72.1 µg/L of FC, while
210.92 ± 53.22 µg/L of FC was observed in its age/sex-matched
controls. Iron concentration was 90.89 ± 43.50 µg/dL and 88.49 ±
38.23 µg/dL for FPHL and its controls. Patients with MPHL show-
ed 115.13 ± 40.94 µg/dL of iron concentration while healthy
men without hair loss showed 122.33 ± 59.84 µg/dL. TIBC was
346.30 ± 57.4 µg/dL and 319.85 ± 49.6 µg/dL for FPHL and MP-
HL, respectively (Table 1).
FPHL group was classied according to menstrual state. FC
in patients with FPHL before menopause was 30.67 μg/L on the
Table 1. Average value of participants’ age, laboratory value and iron deficiency rate
Parameters FPHL Female healthy controls MPHL Male healthy controls
Participant n = 113 n = 113 n = 97 n = 97
Age 42.9 ±13.0 40.1 ±12.5 32.5 ±9.6 33.4 ±8.6
Hb (g/dL) 13.0 ±1.1 12.7 ±1.8 15.4 ±1.0 15.7 ±1.3
Ferritin (μg/L) 49.27 ±55.8* 77.89 ±48.32 132.31 ±72.1* 210.92 ±53.22
Iron (Fe) (µg/dL) 90.89 ±43.5 88.49 ±38.23 115.13 ±40.94 122.33 ±59.84
TIBC (µg/dL) 346.30 ±57.40 330.24 ±27.40 319.85 ±49.60 308.23 ±39.52
ID by FC (μg/L) < 10.00
< 15.00
< 30.00
< 41.00
< 70.00
14.20%*
20.40%*
46.90%*
58.40%*
82.30%*
0.00%
0.00%
0.00%
2.81%
15.23%
0.00%
0.00%
3.10%*
8.20%*
22.70%*
0.00%
0.00%
0.00%
0.00%
0.00%
*P< 0.001 FPHL vs its age-sex matched controls and MPHL vs its age-sex matched controls. M, male; F, female; Hb, hemoglobin; TIBC, total iron binding capacity; ID, iron defi-
ciency; FC, ferritin concentration; FPHL, female pattern hair loss; MPHL, male pattern hair loss; % in ID by FC means the designated value of patient had ID in the disease group
they belong.

Park SY, et al. • Iron and Hair Loss
936 http://jkms.org http://dx.doi.org/10.3346/jkms.2013.28.6.934
average while patients after menopause showed mean FC of
83.22 μg/L (P< 0.001).For healthy controls before menopause,
higher FC level was detected (69.32 ± 33.92 μg/L). However,
postmenopausal healthy control showed almost same FC com-
pared with patients with hair loss (83.22 ± 76.92 μg/L vs 85.38
± 21.22 μg/L) (Table 2).
MPHL group was subdivided into M or F type by BASP clas-
sication. ere were 58 M type, 7 F type and 31 miscellaneous
patients. Mean hemoglobin, FC, iron, TIBC was 15.3 ± 1.0 g/dL,
133.55 ± 60 µg/L, 120.58 ± 53.9, 315.27 ± 50.8 µg/dL for M type
patients and 15.3 ± 1.6 g/dL, 123.00 ± 63.8 µg/L, 112.60 ± 48.7,
314.50 ± 43.0 µg/dL respectively for F type patients. F type show-
ed slight lower values compared to M group. However we did
not find any significant differences among three groups. Pa-
tients with FC < 70 μg/L were more frequently noticed in M
group (17.2%) than F group (7.35%),which was not statistically
dierent. ere was no correlation between onset age and FC
in MPHL patient (r = 0.12) (Table 3).
Patient whose FC was less than 70 µg/L, had been put on oral
iron supplementation for several months. PGA of iron supple-
mentation group and other treatment group was not much dif-
ferent (P= 0.10). PS of iron supplement group was 2.11, which
was lower than that of non-supplement group (2.23) but not
statistically signicant (P= 0.29). PGA was 3.05 vs 2.91 (P= 0.46)
in iron supplementation group of FPHL vs non supplementa-
tion group of FPHL which was slightly higher in supplementa-
tion group but not signicantly dierent. However, patients with
MPHL rated lower PGA and PS when they had been on oral iron
supplementation (Table 4).
Patients who had received oral iron supplementation had
follow-up laboratory test for FC and hemoglobin. In general, FC
doubled after 6 months of supplementation (325 mg of ferrous
sulfate twice a day: elemental iron content 65 mg) (35.8 ± 25.5
µg/L to 62.5 ± 37.9µg/L) (P< 0.001) but hemoglobin level did
not alter after iron supplementation. (13.1 ± 1.5 to 13.1 ± 1.8 g/
dL, P= 0.5).
DISCUSSION
e association between ID and hair loss is still a debating is-
sue. Kantor et al. (5) reported that alopecia areata, FPHL and
telogen euvium patients under 40 yr old showed lower serum
ferritin concentration than controls without hair loss. Rushton
et al. (7) also demonstrated that there was signicant decrease
of hair loss and increase of FC in patients with telogen euvi-
um who received oral iron therapy. ese results are supported
Table 2. Average value of participants’ age, laboratory value and iron deficiency rate according to menopause status
Variables Premenopausal status Postmenopausal status
FPHL Controls FPHL Controls
Hb (g/dL) 12.94 ±1.2 11.95 ±1.9 13.06 ±0.9 13.59 ±1.1
Ferritin (µg/L) 30.67 ±25.5* 69.32 ±33.92 83.22 ±76.9 85.38 ±21.22
Iron (Fe) (µg/dL) 90.55 ±48.5 93.22 ±35.89 91.5 ±34.0 90.34 ±38.52
TIBC (µg/dL) 359.54 ±68.2 322.00 ±78.49 330.4 ±36.5 325.39 ±69.22
*P< 0.001 FPHL vs its controls. Hb, hemoglobin; TIBC, total iron binding capacity; FC, ferritin concentration; TE, telogen effluvium; FPHL , female pattern hair loss.
Table 3. Average value of participants’ age, laboratory value and iron deficiency rate in MPHL group
Variables Participants P value among groups P value of M vs F
M (n = 58) F (n = 7) Others (n = 31)
Frequency (%) 60.4 7.3 32.3
Age (yr) 32.1 ±10.0 32.0 ±4.4 33.0 ±10.1 0.95 0.91
Hb (g/dL) 15.3 ±1.0 15.3 ±1.6 15.5 ±0.9 0.68 0.99
Ferritin (µg/L) 133.55 ±60.1 123.00 ±63.8 127.96 ±91.4 0.90 0.66
Iron (Fe) (µg/dL) 120.58 ±53.9 112.60 ±48.7 103.35 ±9.2 0.40 0.75
TIBC (µg/dL) 315.27 ±50.8 314.50 ±43.0 331.13 ±10.0 0.44 0.98
ID by FC < 70.00 µg/L (%) 17.20 9.10 32.30 0.21 0.60
M, M type baldness by BASP classification; F, F type baldness by BASP classification; Hb, hemoglobin; TIBC, total iron binding capacity; ID, iron deficiency; FC, ferritin concen-
tration.
Table 4. Treatment response according to iron supplementation
Response FPHL MPHL All
IS Non-IS P value IS Non-IS P value IS Non-IS P value
PGA 3.05 ±0.9 2.91 ±0.9 0.46 2.61 ±0.8 3.14 ±1.0 0.03 2.98 2.98 0.10
PS 2.19 ±0.9 2.16 ±1.0 0.87 1.83 ±0.7 2.35 ±1.0 0.04 2.11 2.23 0.29
IS, iron supplement, PGA, patient global assessment; PS, patient satisfaction; FPHL, female pattern hair loss; MPHL, male pattern hair loss.

Park SY, et al. • Iron and Hair Loss
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http://dx.doi.org/10.3346/jkms.2013.28.6.934
by Moeinvaziri et al. (3) who suggested that serum FC and trans-
ferrin saturation is lower in patients with telogen euvium bas-
ed on the case control study design. In contrast, Sinclair (12) re-
ported that response rates to iron supplementation were not
dierent between low ferritin (< 20 ng/mL) and normal group
(≥ 20 ng/mL) in FPHL patients. Olsen et al. (8) also showed no
differences in prevalence of ID between female patients with
(285 FPHL patients and 96 telogen euvium patients) or with-
out hair loss (a total of 76 Caucasian women older than 18 yr
old). Rushton et al. (17) criticized study of Olsen et al. (8) in that
it appears to have some confounding issues and contradictions
such as no-standardized evaluation in blood sampling and no
quantitative hair evaluation in control group.
Reviewing previous studies (3-6, 8-12), the role of iron in hair
loss appears untangled until now. erefore, we conducted this
study in order to find out the relationship between body iron
status and various conditions with hair loss. In order to over-
come the limitation of retrospective study, we carefully selected
patients diagnosed with FPHL and MPHL who had visited our
clinic between January 2010 and February 2011 and underwent
the screening test at their rst visit. We excluded patients with
abnormal thyroid function or any medical history which can
aect body iron status (18). For the better comparison, age-sex
matched healthy controls without complaint of hair loss were
selected who had visited the hospital for a check-up which in-
cludes all blood tests of initial screening test.
ID is a continuum of various status of iron deposition in the
body. Iron depletion is the mildest form of ID followed by iron-
deficient erythropoiesis andiron deficient anemia being the
most severe form (2). Body iron stores can be assessed by se-
rum FC (13) but there is no consensus which ferritin level is the
right one to dene ID in practice. Although many laboratories
use FC of 10 to 15 µg/L as the lower limits of normal based on
reference sample groups, this only gives a sensitivity of 59% and
a specicity of 99% for diagnosing iron deciency (19). In wom-
en of childbearing age, using a cuto of 10 to 15 µg/L yields a
sensitivity of 75% and specicity of 98% in diagnosis of ID (2). A
cuto of 30 µg/L yields a sensitivity of 92% and a specicity of
98%, while a cuto of 41 µg/L yields a sensitivity of 98% and a
specicity of 98%. It might have contributed to the controversy
that there is no guideline to define ID. From this study, over
80% of FPHL showed serum FC lower than 70 µg/L, while only
less than 20% of age matched healthy female controls showed
it. No female healthy controls showed serum FC lower than 30
µg/L in this study. erefore, serum FC lower than 30 µg/L might
be a clinically significant indicator for ID especially in female
hair loss patients considering their menstrual status.
In this study, patients with MPHL show relatively early onset
age, which means they appear to visit the clinic earlier than
those with FPHL. Patients with FPHL show denitely lower se-
rum FC compared with age/sex-matched normal controls. Fe-
male patients with FPHL were divided into two groups based
on their menstrual status. Premenopausal patients with FPHL
demonstrate much lower serum FC than postmenopausal FPHL
patients. When compared with normal age/sex matched con-
trols, statistically signicant low serum FC is observed in FPHL
premenopausal patients, while it is not significantly different
between FPHL patients and normal controls after menopause.
is result implicates that ID plays a certain role in premeno-
pausal female patients with FPHL. However, weak association
of ID with FPHL in postmenopausal patients could be addressed
from this study.
Patients with MPHL show considerably lower serum FC on
the average than age-sex matched healthy controls, although
the serum level of FC is within normal range. We failed to prove
the correlation between onset age and serum FC in MPHL pa-
tient, either (r = 0.12). However, approximately 20% of MPHL
show serum FC lower than 70 µg/L and their age matched con-
trols do not show that low serum FC. is result implicates that
screening of iron status in even male patients with hair loss might
provide clinical benets.
Clinical manifestations of F type of MPHL looks like those of
FPHL in female patients (16). erefore, we looked into patients
with MPHL according to types (M type, F type and others based
on BASP classication), which turns out there was no strong re-
lationship between subtype of MPHL and ID.
Patients showing low FC level < 70 µg/L had been on oral fer-
rous sulfate (130 mg of elemental iron/day) and serum level of FC
doubled after 6 months of supplementation. Clinical response to
iron supplementation proves not to be much higher than expect-
ed. Especially patients with MPHL patients rated lower PGA and
PS when they were on oral iron supplementation. Oral 5 alpha
reductase inhibitor is the first line treatment to MPHL patients
(20) and if MPHL patients showed lower FC, iron supplementa-
tion was rst given to patients during almost 6 months until FC
became higher than 70 μg/L. Therefore, iron supplementation
group did not receive any kind of oral 5 alpha reductase inhibitor,
which might cause signicantly lower PGA and PS.
is study owns its value because it demonstrates the rst di-
rect comparison between hair loss patients and same number
of healthy controls matched by age and sex. It strongly supports
the previous studies that ID can be a certain factor of develop-
ing or worsening FPHL especially in premenopausal female
patients. Its role in MPHL is hard to conclude from this study.
However, screening for ID as the rst evaluation of hair loss in
even male patients might be worthwhile in the clinical eld.
DISCLOSURE
All of the authors have no conict of interest to disclosure.

Park SY, et al. • Iron and Hair Loss
938 http://jkms.org http://dx.doi.org/10.3346/jkms.2013.28.6.934
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