A One Year Cross-Sectional Study To Observe Correlation Of Serum Ferritin Levels, In Female Patients With Chronic Diffuse Hair Loss, Attending Dermatology Clinic Of Kles Dr Prabhakar Kore Hospital And Medical Research Centre, Belagavi

Abstract

Background: Hair forms the most important part of facial aesthetics. An average normal scalp has 1,00,000 hairs, with approximately 86% being in anagen, 1% in catagen, and 13% in telogen. With Telogen Effluvium (TE), the ratio shifts to 70% anagen and 30% telogen, with daily shedding of up to 300 hairs. Iron deficiency and thyroid disorders are common conditions often associated with diffuse hair loss, apart from other etiological causes. Iron is involved in many critical physiological processes within the hair follicle, suggesting that iron deficiency could disrupt hair synthesis. Iron-dependent genes in the hair follicle bulge region may be affected by iron deficiency. Serum ferritin is directly related to intracellular ferritin and thus to the total body iron stores. Hence low ferritin concentration is very specific for iron deficiency. The relationship between body iron status and different types of hair loss has been investigated in a number of studies, however with relatively discrepant findings. There has been controversy over the cut-off level of serum ferritin, below which it can be defined as nutritional deficiency, triggering hair loss. Therefore this study was undertaken to establish the truth regarding the correlation of serum ferritin levels, in patients with chronic diffuse hair loss. Diffuse hair loss affecting the entire scalp, for which no obvious cause can be found, indicates Chronic Telogen Effluvium (CTE), while gradual diffuse hair loss with thinning of central scalp/widening of central parting line/ frontotemporal recession indicates Female Pattern Hair Loss (FPHL). Aim: To evaluate whether chronic telogen effluvium and female pattern hair loss in patients, were associated with decreased tissue iron stores, as measured by serum ferritin and hemoglobin levels. Materials and methods: All the female patients aged between 15 to 45 years, having CTE and FPHL were recruited in the study as per the inclusion and exclusion criteria. The inclusion criteria were, all consenting female subjects of age group 15-45 years, with chronic diffuse and patterned hair loss. The exclusion criteria were, the subjects who were on iron therapy, undergone GI/scalp surgeries, suffering from trichotillomania, hormonal abnormalities and subjects who were on regular medications for other systemic disorders. The sample size was 40 subjects with chronic diffuse hair loss. A detailed history along with systemic and dermatological examination was carried out. Diagnosis of CTE and FPHL was made by clinical examination, by performing hair pull test. Subjects of FPHL were graded as per Ludwig’s grading scale. Serum ferritin and hemoglobin were estimated by standard tests. All the results were tabulated; analysis of results were made by using mean ± SD and Pearson’s correlation coefficient, one sample‘t’ test was used wherever applicable. The results were expressed as percentage and significance. Results: In this study, the total sample size was 40 and number of subjects having CTE was more (35) as compared to the FPHL (5). Hair pull test was positive in all subjects having CTE and negative in subjects with FPHL. Severity of hair loss was assessed in all subjects of FPHL by Ludwig’s scale (Type II grade: 80%, Type III grade: 20% subjects). Mean age of all participants was 25.18 years; CTE was prevalent in the younger age group as compared to FPHL. Mean duration of hair loss was 20.28 months (range 6-60 months), which was less in CTE (18.37 months), as compared to FPHL (33.60 months). Mean Hemoglobin (Hb) levels of all participants was 11.5gms/dL (range: 6.9-13.9 gms/dL), 45% of participants had hemoglobin less than 12 gms/dL (Normal range: 12-15gms/dL).Hb levels were less in subjects having CTE (11.33 gms/dL) as compared to the subjects with FPHL(12.94 gms/dL). In CTE the percentage of subjects with Hb less than 12 gms/dL, was 51.42%.There was negative correlation between duration of hair loss and Hb. Mean serum ferritin levels of all subjects was 18.6µg/L (range: 0-85.6 µg/L). 57.5% of the subjects had serum ferritin levels less than 12 µg/L indicating iron deficiency, 15% of the participants had serum ferritin levels ranging from 13-20 µg/L indicating iron depletion. 25% of the participants had serum ferritin levels ranging from 21-70 µg/L, indicating serum ferritin levels were lower than required for normal hair cycle. Only one participant had serum ferritin level more than 71 µg/L, indicating serum ferritin levels were within the normal range. 42.5% of the participants had serum ferritin levels less than 6 µg/L, which was definitely below the normal range as per specification of the test. Mean serum ferritin levels were low in subjects with CTE (16 µg/L), as compared to FPHL (36.64 µg/L) and the difference was statistically significant (‘p’=0.0389*). As the range of serum ferritin is very wide, cut off levels of serum ferritin (≤ 15 µg/L, ≤ 40 µg/L and ≤ 70 µg/L) were adopted in this study. Majority of the subjects of this study had Iron Deficiency (ID), when cut off level of serum ferritin was used as ≤ 70 µg/L (FPHL=80% and CTE=100% of the subjects). When cut off level of serum ferritin was used as≤ 40 µg/L, 60% of the subjects in FPHL and 85.71% of the subjects in CTE, showed ID. Even when cut off level of serum ferritin was used as ≤ 20 µg/L, 60% of the subjects in FPHL and 74.28% of the subjects in CTE, showed ID. There was positive correlation between Hb and ferritin levels and negative correlation between duration of hair loss and serum ferritin levels. In the subjects with presence of stress (47.5%),the mean Hb was significantly low (10.76 gms/dL) and the mean serum ferritin in those subjects with stress was 11.34 µg/L, which was significantly less, when cut off level of serum ferritin was taken as 41µg/L. Different etiological factors of hair loss like history of hair loss in the family was present in 7.5% of the subjects, 20% of the subjects were having seborrheic capitis/ dandruff, 62.5% of the subjects gave history of exposure to high external environmental changes and only 27.5% the subjects were using headscarf / helmet. Conclusion: In this study, hemoglobin concentration was used to screen for iron deficiency and serum ferritin concentration was used to confirm iron deficiency. Subjects of this study had low serum ferritin levels at different definitions of ID and CTE, FPHL were associated with decreased iron stores. Hence this study confirms that chronic telogen effluvium and female pattern hair loss in patients are definitely associated with decreased tissue iron stores. As ferritin levels accurately reflect body iron stores, this study clearly demonstrated the association between low iron stores and chronic diffuse hair loss.