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Efficacy of Oral Vitamin D3 Therapy in Patients Suffering from Diffuse Hair Loss (Telogen Effluvium)

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Abstract

The aim of the present study was to estimate the prevalence of telogen effluvium (TE) and to evaluate the efficacy of vitamin D in the treatment of this problem in women belonging to various cities of south Punjab, Pakistan. In the present study, 40 adult women suffering from the problem of TE were included. Each woman was treated with oral vitamin D3 (200,000 IU) therapy fortnightly and a total of 6 doses were given to each patient. After 15 d of the last dose, the condition of patients was assessed clinically. The mean age of female patients was 32.2±1.5 y, 42.5% of the patients between 21-30 y of age were found to be more frequently affected with TE compared to 35% females of 31-40 y of age. Results showed significant improvement in hair growth in young (r=0.457 p<0.003) women and in those, which do not use sunscreen (r=-0.331 p<0.037) but commonly utilize milk or milk protein (r=-0.311 p<0.051). Vitamin D3 therapy resulted in the improvement of the condition in 82.5% (p<0.001) patients of TE. The use of oral vitamin D3 (200,000 IU, fortnightly) for 3 mo resulted in significant improvement in hair regrowth in the patient of TE. Results showed improvement in hair growth in young women those do not use sunscreen but commonly utilize milk or milk protein.
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J Nutr Sci Vitaminol, 67, 68–71, 2021
Note
Effi cacy of Oral Vitamin D3 Therapy in Patients Suffering from
Diffuse Hair Loss (Telogen Effl uvium)
Farah SATTAR 1, Uzma ALMAS2, Nihal Abdalla IBRAHIM3, Aliya AKHTAR1,
Muhammad Khuram SHAZAD4, Shamshad AKRAM1,
Muhammad Shahid Nawaz KHAN5 and Ghulam MURTAZA6,*
1 Department of Dermatology, Nishtar Medical University Multan, Punjab, Pakistan
2 Department of Dermatology, Bahawal-Victoria Hospital/Quaid-e-Azam Medical College,
Bahawalpur, Punjab, Pakistan
3 Department of Clinical Sciences, Ajman University, Ajman 346, UAE
4 Sheikh Zayed Medical College and Hospital Rahim Yar Khan, Pakistan
5 Department of Medicine, Nishtar Medical University Multan, Punjab, Pakistan
6 Department of Pharmacy, COMSATS University Islamabad, Lahore Campus 54000, Pakistan
(Received September 17, 2020)
Summary The aim of the present study was to estimate the prevalence of telogen effl u-
vium (TE) and to evaluate the effi cacy of vitamin D in the treatment of this problem in
women belonging to various cities of south Punjab, Pakistan. In the present study, 40 adult
women suffering from the problem of TE were included. Each woman was treated with oral
vitamin D3 (200,000 IU) therapy fortnightly and a total of 6 doses were given to each
patient. After 15 d of the last dose, the condition of patients was assessed clinically. The
mean age of female patients was 32.21.5 y, 42.5% of the patients between 21–30 y of
age were found to be more frequently affected with TE compared to 35% females of 31–40 y
of age. Results showed signifi cant improvement in hair growth in young (r0.457 p
0.003) women and in those, which do not use sunscreen (r0.331 p 0.037) but com-
monly utilize milk or milk protein (r0.311 p0.051). Vitamin D3 therapy resulted in
the improvement of the condition in 82.5% (p0.001) patients of TE. The use of oral vita-
min D3 (200,000 IU, fortnightly) for 3 mo resulted in signifi cant improvement in hair
regrowth in the patient of TE. Results showed improvement in hair growth in young women
those do not use sunscreen but commonly utilize milk or milk protein.
Key Words vitamin D3, hair growth, diffused hair loss, prevalence, telogen effl uvium
Telogen Effl uvium (TE) is a common clinical problem,
defi ned as loss of hairs at telogen phase of the hair
cycling (1). It is a non-scarring alopecia and becomes
acute when occurs at 2–3 mo after the triggering event
like fever, starvation, surgical trauma, haemorrhage, or
postoperative telogen gravidae (2).
Micronutrients, including vitamins, play a very im-
portant role in cellular multiplication and development
in the matrix cells in hair follicle bulb. Hair loss has
signifi cant impact on patient’s quality of life and can be
treated with supplementation of vitamins and minerals
(3). In human body, skin is the only site where the
action of UV-B radiation on 7-dehydrocholesterol pres-
ent in the epidermal keratinocytes results in endoge-
nous synthesis of 1,25(OH)2D3 or cholecalciferol (vita-
min D3) (4).
The problem of TE is being treated by the various
modalities like zinc supplements, multivitamins and
iron therapy, topical minoxidil along with removal of
the causative factors, if known. However, existing liter-
ature suggest that cause of TE may be established after
elicitation of patient history and proper laboratory in-
vestigations to exclude the possibility of endocrine, nu-
tritional and autoimmune diseases (5). Recently, Ruiz-
Tagle et al. reported association of TE with defi ciencies
of iron, zinc, and vitamin D and recommended supple-
mentation of vitamin D at a dose rate of 50,000 IU/wk
and 800 to 2,000 IU/wk as maintenance dose to avoid
recurrence of CTE (6). Suad and Modawe reported suc-
cessful decrease of hair loss in a woman treated with
vitamin D3 50,000 IU/wk and 1,000 IU/wk as mainte-
nance dose (7).
Based on these facts this study was conducted to see
the benefi cial effect of vitamin D3 supplements in indi-
viduals after excluding the secondary causes of diffuse
hair loss. However, there is relatively little information
regarding demographical prevalence of TE in south
Punjab, Pakistan. Therefore, the present study was
planned to estimate the prevalence of TE among women
living in south Punjab, Pakistan and to evaluate the effi -
cacy of vitamin D in relieving the problem in patients
suffering from this condition.
* To whom correspondence should be addressed.
E-mail: gmdogar356@gmail.com
Application of Vitamin D 69
Materials and Methods
Target area. This study was approved (GHU/98/
BVH/2018) by Institutional Review Board of Bahawal
Victoria Hospital and executed according to the Helsin-
ki’s declaration about human use in research. A total of
40 adult women, suffering with TE were included in the
present study. These women belonged to various locali-
ties of the South Punjab, Pakistan, including Multan
(n24), Khanewal-Kabir wala (n3), Muzaffar-Ghar,
Jatoi, Ghazi Ghat, Kot Addu, Ali Pur (n5), DG Khan-
Taunsa Sharif, Choti (n3), Layyah-Chowk Azam (n
1), DI Khan (n3) and Sadiqabad (n1).
Clinical diagnosis. The presence of TE in the females
was confi rmed clinically by the loss of hair between
50–100/d for about 3 mo (1). The exclusion criteria
were presence of secondary causes of the disease, like
anemia, hypo and hyper thyroid function, mal-nutri-
tion, acro-dermatitis, entero-pathica (3), squamous
lupus erythema, chronic illness, telogen gravidum,
androgenic alopecia, alopecia areata, pregnancy and
lactation. The inclusion criteria were non-use of drugs
like hormones, corticosteroids, immune-suppressive
and contraceptives for more than 3 mo (1). Type of skin
was recorded and assigned the score of 1–5 according
Table 1. Cross tabulation of age, marital status, socio-economic status, type of skin, exposure to sunlight, use of sun-
screen and use of milk/milk protein in respect of improvement in the hair growth in patients of telogen effl uvium after
vitamin D3 therapy.
Parameter
Improvement in TE Patient
(No.)
Patients
(%)
Not satisfi ed Satisfi ed Highly satisfi ed
Age 20–50 y
20 00225
21–30 0 11 6 17 43
31–40 2 7 5 14 35
41–50 4 2 1 7 18
Total 6 20 14 40
Marital status
Un-married 0 2 5 7 18
Married 6 18 9 33 83
Total 6 20 14 40
Socio-economic status
Poor 3 9 6 18 45
Low middle class 0 0 1 1 3
Middle class 3 10 7 20 50
Upper class 0 1013
Total 6 20 14 40
Skin types
IV 6 15103178
V 0 54923
Total 6 20 14 40
Exposure to sunlight
No 3 11102460
Yes 3 9 4 16 40
Total 6 20 14 40
Use sun-screen
No 4 16143485
Yes 2 4 0 6 1 5
Total 6 20 14 40
Using milk and milk protein
No 3 5 0 8 20
Occasional (7 d a week) 0 0338
Frequent (7 d a week) 3 15 11 29 73
Total 6 20 14 40
Overall improvement 34/40(85%)
SATTA R F et al.
70
to the criterion established by Fitzpatrick (9).
Therapeutic intervention. Each patient was given oral
Vitamin D3 (200,000 IU) therapy fortnightly for 3 mo
(in total 6 treatments per woman). After 15 d of the last
therapeutic dose, patients were examined clinically and
level of satisfaction to treatment was recorded (9). Hair
growth was quantifi ed by hair pull test. In this approach,
20–60 hairs are fi rmly grasped between thumb and
fore-fi nger from base of hair near scalp, but not force-
fully tugged away from scalp. If 6 or more than 6 hairs
are pulled away, it constitutes positive pull test that
implies active hair shedding. No adverse signs were
reported by any patient during and after the therapy.
Statistical analysis. Frequencies for age, marital and
socio-economic status, skin types; exposure to sun light,
use of sunscreen, using milk or milk protein by the TE
affected patients and improvement of hair growth after
oral vitamin D3 therapy were determined by descriptive
analysis using computer software (SPSS-17), and
results are presented in cross-tabulations. Correlations
of improvement in hair growth with various variables
were computed, Chi-square test was applied to draw the
inference. If hair loss is less than 10% in hair-pull test,
it suggests that there is improvement in hair growth.
Results and Discussion
Frequency distribution in respect of age, marital and
socio-economic status, skin types, exposure to sun light,
use of sunscreen, using milk or milk protein and im-
provement of hair growth after oral vitamin D3 therapy
in TE affected patients are presented in Table 1. Results
of statistical analysis showed that females aged 21–30 y
were found to be more frequently (42.5%) suffered with
the TE compared to females of aged 31–40 y (35%).
Similarly, females aged 20 y and 41–50 y showed
lower frequency being suffered with TE compared to
above two age groups (5.0 and 17.5%, respectively). A
previous study conducted on Pakistani females has
already reported severe defi ciency (vitamin D level
10 ng/mL), mild to moderate defi ciency (vitamin D
level 10–25 ng/mL), and normal level of vitamin D (vi-
tamin D level 25 ng/mL) in 24%, 44%, and 30% of
the respondents, respectively (10). On the other hand,
mean age of the patients included in the study was
32.21.5 y. According to the data 82.5% females were
married and 17.5% were un-married. Results showed
that higher number of middle class (n20) and lower
class (n18) females complained about the problem of
TE compared to females belonging to upper and low-
middle-classes status. These results are in line with the
ndings that TE was more commonly recorded in
women aged 21 to 40 y (mean age 29.8 y), and most of
the patient were in their productive state (4). Previous
studies have shown that during the age of 20 to 40 y,
females are mostly in their active menstruating and
productive state, when they suffer with vitamin D and
iron defi ciency (1). TE is a multifactorial disease and
about 78% of women having diffuse hair loss suffer
with acute or chronic form, however, supplementation
of vitamin D3 is needed during treatment of TE (5).
There may be multiple factors such as personality com-
plex, which are responsible for high frequency of TE af-
fected women of the middle class and lower class. The
psychosocial impact of life in women is greater than
that in men, which may have negative impact on qual-
ity of their life. Women between 20 to 50 y old are more
concerned about their hair changes. They also feel
changes in their personality due to their social or job
status (8).
Results showed that 77.5% patients bare skin type IV
(light brown skin), while 22.5% were of skin type V
(brown skin). Most of the patients (60%) avoid exposure
to sunlight and 85% patients did not use sunscreen.
Majority of patients 72% were using milk and milk pro-
teins and among them 89.7% (26 out of 29) showed
satisfactory response, 20% were not using any milk or
milk proteins in their diet out of which 62.5% (5 out of
8) were satisfi ed with the results and only 8% occasion-
ally used milk and milk proteins and they showed 100%
(3 out of 3) response. During the present trial, vitamin
D3 therapy resulted in signifi cant (p0.001) improve-
ment (72.5%) in TE affected patients those were using
milk and milk protein (Table 1), which might be due to
the defi ciency of vitamin D in TE affected females with
other reported defi ciencies of ferritin (45.2%), followed
by vitamin D (33.9%) and zinc (9.6%) in large popula-
Table 2. Correlation between improvement in hair growth with age, economic status, marital status, type of skin, expo-
sure to sun, use of sunscreen, use milk in the patients suffering with telogen effl uvium.
Parameter
Improvement in hair growth
Pearson correlation Signifi cance Chi-square value Signifi cance
Age 0.46** 0.01 16.80** 0.01
Economic status 0.01 0.97 2.91 0.82
Marital status 0.35* 0.01 5.27 0.05
Skin type 0.19 0.23 2.11 0.35
Exposure to sun 0.17 0.31 1.22 0.54
Use sunscreen 0.33* 0.04 4.44 0.11
Use milk 0.31* 0.05 11.83* 0.02
* Signifi cant (p0.05), ** signifi cant (p0.01).
Application of Vitamin D 71
tion of patients suffering with TE (3).
Analysis of data revealed improvement in hair
growth was signifi cantly and negatively correlated with
age, marital status and use of sunscreen (r 0.457,
0.349, 0.330, respectively), while it was positively
correlated with use of milk (r0.311) (Table 2). Chi-
square test revealed highly signifi cant effect of age and
use of milk or milk proteins on the improvement of hair
growth after vitamin D3 therapy (Table 2). Results
showed that improvement in hair growth was (p
0.003) better than of later age. Similarly, non-use of
sunscreen resulted in signifi cantly higher improvement
in hair growth after vitamin D therapy in TE patients.
The non-use of sunscreen results in absorption of UV
light, resulting in increased synthesis of vitamin D in
the skin, which might improve hair growth (2). The
results also indicated that patients having skin type IV
and V showed high tolerance against exposure to sun
burns and availed the opportunity for the synthesis of
vitamin D by their skin.
Conclusion
The females of middle and poor socio-economic sta-
tus (50 and 45%, respectively) and those aged 21–40 y
showed high prevalence of TE. The overall response to
oral vitamin D3 therapy was satisfactory (85%) in terms
of hair regrow. Results showed improvement in hair
growth in young women those do not use sunscreen
but commonly utilize milk or milk protein. Large dou-
ble-blind placebo-controlled studies are required to
determine the role of vitamin D supplementation and
its relation-ship with micronutrients necessary to avoid
occurrence of TE.
Authorship
Research conception and design: FS, UA, AA, and
GM; experiments: FS, UA, and AA; statistical analysis of
the data: MKS, SA, and MSNK; interpretation of the
data: FS, UA, AA, MKS, and SA; writing of the manu-
script: FS, NAI, MSNK, and GM.
Disclosure of state of COI
No confl icts of interest to be declared.
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... 25 An additional survey on TE and treatment using search string 3 identified 11 papers ( Table 1). [28][29][30][31][32][33][34][35][36][37][38] Currently, no established treatments or guidelines on TE treatment are available. 23 Various studies on treatment have been conducted. ...
... 23 Various studies on treatment have been conducted. [28][29][30][31][32][33][34][35][36][37][38] The most common treatment was oral minoxidil ( Table 3). 28 can inhibit shortening of the anagen phase induced by androgens in AGA and promote the shift from the telogen to early anagen phase ( Figure 3). ...
... Minoxidil has also been reported to be efficacious for treatment of AA. 35 Exacerbation of AA has been implicated in the mechanisms of HLASCI, 4,12 and topical minoxidil would be beneficial in this scenario, especially when primary inflammatory change is reduced. ...
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... Vitamin D plays an important dermatological and dermatotherapeutic role in affecting the hair cycle due to its anti-inflammatory and immunomodulatory properties, and regulation of keratinocyte differentiation and proliferation (33). Recently, the benefit of oral vitamin D 3 (200,000 IU) therapy in patients suffering from diffuse hair loss (telogen effluvium) has been demonstrated (34). However, conclusive studies regarding the presumed benefit of vitamin D in hair loss are lacking. ...
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Non-scarring hair loss is a common problem that affects both male and female patients. Since any disturbances in the hair follicle cycle may lead to hair shedding, or alopecia, it is not surprising that the possible role of vitamin D in alopecia was investigated in many studies. Vitamin D has been shown to have many important functions. A growing body of evidence shows that vitamin D and its receptor are responsible for maintaining not only calcium homeostasis but also skin homeostasis. Moreover, vitamin D could also regulate cutaneous innate and adaptive immunity. This paper presents a review of current literature considering the role of vitamin D in alopecia areata, telogen effluvium, and female pattern hair loss. The majority of studies revealed decreased serum 25-hydroxyvitamin D levels in patients with different types of non-scarring alopecia, which could suggest its potential role in the pathogenesis of hair loss. According to the authors, vitamin D supplementation could be a therapeutic option for patients with alopecia areata, female pattern hair loss, or telogen effluvium. However, further studies on a larger group of patients are required.
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Telogen effluvium was first described by Kligman in 1961. It is a most common cause of diffuse hair loss. Women with telogen effluvium more frequently present to dermatologist. A wide variety of potential triggers have been implicated in the pathogenesis of telogen effluvium. Diffuse shedding of telogen hair are seen after 3-4 months of triggering event. The observation of increased telogen hair shedding does not infer a cause. Establishing aetiology of telogen effluvium requires elicitation of relevant history and appropriate laboratory investigations to exclude endocrine, nutritional and autoimmune disorders.
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Aim: Telogen effluvium (TE) is an abnormality of hair cycling. Vitamin D promotes hair follicle differentiation. The importance of vitamin D in hair growth is evident in patients with hereditary vitamin D receptor deficiency. The role of vitamin D in the pathogenesis of TE has not been investigated before. We investigated the role of vitamin D, ferritin, and zinc in the pathogenesis of TE. Materials and methods: We measured serum hemoglobin, ferritin, zinc, calcium, phosphate, parathormone, magnesium, 25 and 1,25-hydroxyvitamin D3, and bone alkaline phosphatase and thyroid stimulating hormone levels in 63 female patients and 50 control subjects. Twenty-nine of the TE patients were classified in the acute TE group and 34 were classified in the chronic TE groups. Results: Ferritin (acute TE; 17.0 +/- 12.8, chronic TE; 19.6 +/- 15.2, control; 35.5 +/- 31.8, P < 0.001) and hemoglobin (acute TE; 12.7 +/- 1.7, chronic TE; 13.3 +/- 1.0, control; 14.2 +/- 1.2, P < 0.0001) levels were significantly lower in the TE group than in the control group. However, 25-hydroxyvitamin D3 levels were significantly higher in the TE group than in the control group (acute TE; 18.5 +/- 9.2, chronic TE; 24.4 +/- 11.2, control; 15.6 +/- 15.8, P < 0.01). Vitamin D levels increased gradually from control groups to acute and chronic TE groups. However, active D vitamin levels (1,25-hydroxyvitamin D3) were similar. Conclusion: Iron deficiency anemia seems to be the main triggering factor for the development of TE and the increase in serum 25-hydroxyvitamin D3 levels may be related to increased exposure to UV light due to TE.
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Telogen effluvium (TE) is one of the most common causes of diffuse nonscarring hair loss. In its acute form, it generates a lot of anxiety in the patient, which can be significantly allayed with a confident diagnosis. In its more chronic form, however, the hair loss may go unnoticed for long periods of time. Here in, the dermatologist's role in differentiating it from the more common patterned hair loss is significant. Differentiating TE from other causes of diffuse nonscarring hair loss can indeed be a daunting task and TE is often used as a waste basket diagnosis. A number of factors have been implicated in the causation of TE, however, clear evidence in their support is lacking. The role of stress as a causative factor as well as the result of hair loss needs to be adequately understood. This review aims at summarizing our current level of knowledge with respect to this very common cause of hair loss. An attempt is made to help the readers reliably differentiate TE from other causes of diffuse nonscarring hair loss. The possible causative factors, pathogenetic mechanisms, clinical presentation, and possible treatment options are discussed.
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Telogen effluvium (TE) is the most common cause of diffuse hair loss in adult females. TE, along with female pattern hair loss (FPHL) and chronic telogen effluvium (CTE), accounts for the majority of diffuse alopecia cases. Abrupt, rapid, generalized shedding of normal club hairs, 2-3 months after a triggering event like parturition, high fever, major surgery, etc. indicates TE, while gradual diffuse hair loss with thinning of central scalp/widening of central parting line/frontotemporal recession indicates FPHL. Excessive, alarming diffuse shedding coming from a normal looking head with plenty of hairs and without an obvious cause is the hallmark of CTE, which is a distinct entity different from TE and FPHL. Apart from complete blood count and routine urine examination, levels of serum ferritin and T3, T4, and TSH should be checked in all cases of diffuse hair loss without a discernable cause, as iron deficiency and thyroid hormone disorders are the two common conditions often associated with diffuse hair loss, and most of the time, there are no apparent clinical features to suggest them. CTE is often confused with FPHL and can be reliably differentiated from it through biopsy which shows a normal histology in CTE and miniaturization with significant reduction of terminal to vellus hair ratio (T:V < 4:1) in FPHL. Repeated assurance, support, and explanation that the condition represents excessive shedding and not the actual loss of hairs, and it does not lead to baldness, are the guiding principles toward management of TE as well as CTE. TE is self limited and resolves in 3-6 months if the trigger is removed or treated, while the prognosis of CTE is less certain and may take 3-10 years for spontaneous resolution. Topical minoxidil 2% with or without antiandrogens, finestride, hair prosthesis, hair cosmetics, and hair surgery are the therapeutically available options for FPHL management.