The association between iron deficiency (ID) and hair loss is controversial. Currently, there is no standard oral iron supplementation for patients with female pattern hair loss (FPHL) and ID. We investigated the efficacy of oral iron supplementation for treating FPHL patients with ID. The results of our study revealed that oral iron supplementation combined with topical 3% minoxidil was not superior to topical 3% minoxidil alone in treating FPHL and ID.

Chanika Subchookul

Chayanee Likitwattananurak

Daranporn Triwongwaranat

Kanchalit Thanomkitti

Noldtawat Viriyaskultorn

Nuttagarn Jantanapornchai

Rattapon  Thuangtong

Supenya  Varothai

Supisara Wongdama

Siriraj Medical Journal

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Volume 75, No.10: 2023 Siriraj Medical Journalhttps://he02.tci-thaijo.org/index.php/sirirajmedj/index 759Letter to the Editor SMJDaranporn Triwongwaranat, M.D., Kanchalit Thanomkitti, M.D., Supisara Wongdama, M.D., Nuttagarn Jantanapornchai, M.D., Chanika Subchookul, M.D., Chayanee Likitwattananurak, M.D., Noldtawat Viriyaskultorn, M.D., Supenya Varothai, M.D., Rattapon Thuangtong, M.D.Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.Efficacy of Oral Iron Supplementation in Treating Patients with Female Pattern Hair Loss and Low Serum Ferritin: A Pilot StudyCorresponding author: Kanchalit Thanomkitti E-mail: kanchalitt@gmail.comReceived 27 July 2023    Revised 7 September 2023    Accepted 8 September 2023ORCID ID:http://orcid.org/0000-0002-2399-5659https://doi.org/10.33192/smj.v75i10.264385All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.To the Editor: Androgenetic alopecia or pattern hair loss (PHL) is the most common cause of non-scarring alopecia in the general population.  It is characterized by a gradually progressive decline in hair density and diameter in both sexes.1 The association between iron deficiency (ID) and hair loss is controversial.2 Currently, there is no standard oral iron supplementation for patients with Female PHL (FPHL) who have ID. We investigated the efficacy of oral iron supplementation for treating FPHL patients with ID. Patients diagnosed with FPHL and ID (serum ferritin level <70 μg/l) were included in the study.3 The FPHL diagnoses were made by dermatologists based on histories, physical examinations, and dermoscopic findings.4 We excluded patients with other hair diseases (e.g., scarring alopecia, telogen effluvium), scalp inflammatory diseases (e.g., scalp psoriasis, tinea capitis), and systemic diseases that can have an impact on hair loss conditions (e.g., diabetes mellitus, hypo/hyperthyroidism). Patients who had received any other type of hair-thinning treatment in the prior 24 weeks were also excluded. We performed a 24-week, randomized, open comparative study at a dermatology clinic, Siriraj Hospital, Mahidol University. Twenty individuals were recruited and assigned to two groups of 10 by using block randomization. The treatment group was given 200 mg ferrous sulfate (65 mg elemental iron; Inpac Pharma Co. Ltd., Bangkok, Thailand) orally three times daily after meals, as well as 3% topical minoxidil solution (made by the Department of Pharmacy, Faculty of Medicine Siriraj Hospital, Mahidol University). 50% ethyl alcohol, 25% propylene glycol, and 25% filtered water were used as solution vehicles. Patients were instructed to apply 1 ml of minoxidil twice daily to affected areas of the scalp. The control group was administered 3% minoxidil solution alone, with the same instructions and treatment period. The primary outcome was a change in terminal hair density (hairs/cm2) of the target area on the scalp vertex was evaluated from baseline to week 24. Secondary outcomes were global photographic assessments (by two blinded dermatologists), patient satisfaction, and change in serum ferritin and CBC. Seventeen patients completed the study. Dropouts were unrelated to treatment side effects. Their mean age was 35.2 years, and most (70.6%) had Ludwig grade II. There were no significant differences in the profiles of the two groups, except baseline serum ferritin (Table 1). Consequently, the serum ferritin level was adjusted using multiple linear regression to diminish the baseline difference. The changes in hair densities of the groups were not significant (P = 0.118). At week 24, there were no significant differences in physician assessment and patient satisfaction between the groups (Table 2). Side effects reported from iron supplements were dark stools (35.3%), diarrhea (17.6%), nausea (11.8%), gastrointestinal irritation (11.8%), and constipation (11.8%). Serum ferritin, a main iron-binding protein in nonerythroid cells that decreases in the very early stage of ID, is considered the most effective screening tool for ID.5 Park and colleagues administered an oral iron Volume 75, No.10: 2023 Siriraj Medical Journal https://he02.tci-thaijo.org/index.php/sirirajmedj/index760TABLE 1. Demographic data, baseline clinical characteristics, and laboratory results of patients with female pattern hair loss and iron deficiency. Total Ferrous sulfate and 3% minoxidil (N = 17) 3% minoxidil solution solution P value  (N = 9) (N = 8) Age (years), mean ± SD 35.2 ± 7.4 34.1 ± 6.5 36.5 ± 8.7 0.527Duration of hair loss (months),  12.0 (2.0, 120.0) 12.0 (4.0, 84.0) 12.0 (2.0, 120.0) 0.618  median (min, max) Comorbidities, n (%)        Allergic rhinitis 2 (11.8) 0 2 (25.0) 0.206    GERD 1 (5.9) 0 1 (12.5) 0.471Family history of hair loss, n (%) 9 (52.9) 5 (55.6) 4 (50.0) 1.000Physical examination    Ludwig classification, n (%)        Grade I 4 (23.5) 1 (11.1) 3 (37.5) 0.424    Grade II 12 (70.6) 7 (77.8) 5 (62.5)     Grade III 1 (5.9) 1 (11.1) 0 Signs of hyperandrogenism, n (%) 6 (35.3) 3 (33.3) 3 (37.5) 1.000    Hirsutism 2 (11.8) 1 (11.1) 1 (12.5) 1.000    Acne vulgaris 4 (23.5) 2 (22.2) 2 (25.0) 1.000    Oily skin 3 (17.6) 2 (22.2) 1 (12.5) 1.000    Irregular menstruation 2 (11.8) 1 (11.1) 1 (12.5) 1.000Hair density, mean ± SD 98.9 ± 36.8 114.8 ± 40.9 81.1 ± 22.4 0.057Laboratory investigations    Serum ferritin (μg/l), mean ± SD 39.2 ± 19.6 23.9 ± 11.8 56.4 ± 8.9 < 0.001*Hemoglobin (g/dl), mean ± SD 12.8 ± 0.7 12.7 ± 0.8 12.9 ± 0.7 0.578Hematocrit (%), mean ± SD 38.9 ± 2.3 39.1 ± 2.6 38.9 ± 2.0 0.959ESR (mm/h), median (min, max) 11.0 (7.0,42.0) 9.0 (7.0,25.0) 15.5 (7.0,42.0)  0.09125-hydroxyvitamin D2 (ng/ml),  23.9 ± 5.1 24.6 ± 4.5 23.3 ± 5.8 0.728  mean ± SD*, P value < 0.050Abbreviations: ESR, erythrocyte sedimentation rate; GERD, gastroesophageal reflux disease; SD, standard deviationTriwongwaranat et al.Volume 75, No.10: 2023 Siriraj Medical Journalhttps://he02.tci-thaijo.org/index.php/sirirajmedj/index 761Letter to the Editor SMJTABLE 2. Clinical evaluations and laboratory results of patients with female pattern hair loss and iron deficiency after treatment.  Mean ± SD or n (%)   Ferrous sulfate and 3% 3% minoxidil   minoxidil solution solution P value  (N = 9) (N = 8) Clinical evaluations    Change in terminal hair  Difference 20.6 ± 16.7 20.6 ± 24.1 0.995 density (hairs/cm2),  (baseline VS mean ± SD week 24) Physician assessment  At week 24       Improvement  4 (44.4) 6 (75.0) 1.000    No improvement  5 (55.6) 2 (25.0) Patient satisfaction At week 24       Satisfied  8 (88.9) 7 (87.5) 1.000    Not satisfied  1 (11.1) 1 (12.5) Laboratory investigations    Serum ferritin (μg/l),  Difference 94.5 ± 59.5 4.7 ± 13.2 0.003* mean ± SD (baseline VS  week 24) Hemoglobin (g/dl),  Difference 0.09 ± 0.52 0.09 ± 0.41 0.995 mean ± SD (baseline VS  week 24) Hematocrit (%),     Difference  0.13 ± 1.84 0.30 ± 1.55 0.844    mean ± SD (baseline VS  week 24) *, P value < 0.050Abbreviation: SD, standard deviationsupplement (325 mg of ferrous sulfate twice daily; 65 mg elemental iron) for 6 months to FPHL patients with serum ferritin <70 μg/l. There was no significant difference in the patient-assessed treatment responses of the supplementation and non-supplementation groups.6 Moreover, Sinclair reported that four of seven FPHL patients with serum ferritin <20 μg/l responded to oral spironolactone and iron replacement, with a similar response rate to FPHL patients with normal ferritin treated with oral spironolactone alone.2 Although the total elemental iron prescribed in our study was higher than those in previous studies, treatment responses (terminal hair density, physician assessment, and patient satisfaction) were not statistically significant compared with topical 3% minoxidil treatment alone.2,6 In conclusion, topical 3% minoxidil combined with oral iron supplementation was not superior to topical 3% minoxidil alone in treating FPHL with ID. However, no serious side effect was documented from that supplement. Further studies with larger samples are needed to determine the efficacy of oral iron supplementation for FPHL with ID.ACKNOWLEDGEMENTSFunding This study was supported by a grant from the Siriraj Research Fund of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (R015932035)Authorship All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.Volume 75, No.10: 2023 Siriraj Medical Journal https://he02.tci-thaijo.org/index.php/sirirajmedj/index762Author Contributions  DT, NJ, CS and CL conceptualized this study, generated population and conducted the field trials with assistance from KT, RT and SV. DT and SW performed the data analysis with advice from KT, RT and SV. DT, KT, SW and NV wrote the manuscript. All authors revised the manuscript.Disclosures  All named authors have nothing to disclose.Compliance with Ethics Guidelines  This study is approved by the Siriraj Institutional Review Board with Certificate of Approval No. Si 500/2015Data Availability  Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.Open Access  This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/.Conflict-of-interest declaration All authors declare that there are no conflicts of interest related to any aspect of this research.REFERENCES1. Pattanaprichakul P, Thuangtong R, Thanomkitti K, Varothai  S, Triwongwaranat D, Sitthinamsuwan P, et al. Evaluation  of Hair Follicle Counts of Occipital Scalp Biopsies from Male  Hair Transplant Patients in Thailand. Siriraj Med J. 2023;75:  132-7.2. Sinclair R. There is no clear association between low serum ferritin  and chronic diffuse telogen hair loss. Br J Dermatol. 2002;147(5):  982-4.3. Schrier SL. Causes and diagnosis of anemia due to iron deficiency.  Available from: www.UpToDate.com. Accessed January 24,  2022; last updated November 6, 2003.4. Bhat YJ, Saqib NU, Latif I, Hassan I. Female Pattern Hair  Loss-An Update. Indian Dermatol Online J. 2020;11(4):493-  501.5. Trost LB, Bergfeld WF, Calogeras E. The diagnosis and treatment  of iron deficiency and its potential relationship to hair loss. J  Am Acad Dermatol. 2006;54(5):824-44.6. Park SY, Na SY, Kim JH, Cho S, Lee JH. Iron plays a certain  role in patterned hair loss. J Korean Med Sci. 2013;28(6):934-8.Triwongwaranat et al.

Efficacy of Oral Iron Supplementation in Treating Patients with Female Pattern Hair Loss and Low Serum Ferritin: A Pilot Study

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Efficacy of Oral Iron Supplementation in Treating Patients with Female Pattern Hair Loss and Low Serum Ferritin: A Pilot Study

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