Review Article of International Journal of Food and Nutrition Research
Controversy on the role of iron and a clinical trial with intermittent iron and nutritional supplements in hair loss management
Dr Rajendrasingh J Rajput,
M.S., M.Ch., Hair Transplant Surgeon,Member ISHRS, IAT, & AHRS India.
Background: Reports dating 1932, (86 years prior) emphasise the role of iron deficiency in hair loss. However, blood tests sometimes show normal iron levels in these patients. Should we still include iron in our treatment or conclude that iron has no role in hair loss management? In an attempt to review the dilemma we have come across studies recommending intermittent iron therapy, which as a low dose supplement, can be utilized even in the absence of overt deficiencies. A clinical comparison of hair loss patients having normal haemoglobin is presented with standard 2% minoxidil treatment versus intermittent iron therapy once in three days and comprehensive iron therapy along with intermittent once in three days, inclusion of other hair nutrients, antioxidants, vitamins, calcium, aminoacids and omega 3.
Objective: Review the role of iron in hair loss management. Understand why hair loss patients sometimes present with normal iron reports. Evaluate if intermittent iron therapy can help in hair loss management. Evaluate if by the same analogy, inclusion of other intermittent hair nutrients along with iron therapy can deliver better hair growth in addition to controlling hair loss.
Method: Sixty women volunteers having hair loss despite normal haemoglobin, were enlisted for this prospective study. Three groups of twenty women each were created. Treatment group I, received standard hair loss treatment with 2% minoxidil. Iron therapy group II, received intermittent iron therapy and the nutrition group III, received intermittent iron with intermittent inclusion of antioxidants, vitamins, calcium, aminoacids and omega 3 which are known to benefit hair loss management. Results were evaluated with global photography, trichoscopy counts for hair density and hair calibre.
Observations: Minoxidil 2% group I had reduction in hair fall after 10 weeks. This group at the end of 6 months had 9% improvement in density, with 17% non responders and 3% worsening of the condition. The intermittent iron therapy group II, had reduction of hair fall after 8 weeks and 16% improvement in density over 6 months. The group III, with Intermittent iron plus intermittent antioxidants, vitamins, calcium, aminoacids and omega 3 had the best benefit showing reduction in hair fall after 4 weeks and 21% improvement in density over 6 months. This group also showed 12% improvement in hair calibre over 6 months. There were no non responders or worsening of condition in group II & III.
Conclusion: Iron is an integral part of hair loss management program. Compensation of low iron levels by autophagy or arrest of hair growth make iron available to maintain normal levels in circulation which may mislead to us believe that there is no iron deficiency. Other nutrients antioxidants, vitamins, calcium, aminoacids and omega 3 are required to ensure complete utilization of iron and also support active hair growth. We present clinical evidence that intermittent iron therapy once in three days along with comprehensive inclusion of other nutrients once in three days consistently results in control of hair loss along with new hair growth. The comprehensive intermittent therapy, can be a considered for management of hair loss without waiting for the evidence of detecting low nutrient levels through laboratory tests.
How to cite this article:
Rajendrasingh J Rajput. Controversy on the role of iron and a clinical trial with intermittent iron and nutritional supplements in hair loss management. International Journal of Food and Nutrition Research, 2018; 2:11. DOI: 10.28933/ijfnr-2018-07-1202.
1. Sinclair R. There is no clear association between low serum ferritin and chronic diffuse telogen hair loss. Br J Dermatol. 2002;147:982–984.
2. Bregy A, Trueb RM. No association between serum ferritin levels >10 microg/l and hair loss activity in women. Dermatology. 2008;217:1–6.
3. Olsen EA, Reed KB, Cacchio PB, Caudill L. Iron deficiency in female pattern hair loss, chronic telogen effluvium, and control groups. J Am Acad Dermatol. 2010;63:991–999.
4. Rajput RJ. Controlled clinical trial for evaluation of hair growth with low dose cyclical nutrition therapy in men and women without the use of finasteride. Plast Aesthet Res 2017;4:161-73.
5. Rajput RJ. Cyclical Medicine for Hair loss Management and Improving Results in Hair Transplant. Published in the Hair Transplant Forum International, Vol. 18 pg 208 Nov 2008. available from: https://www.researchgate.net/publication/295859340_Cyclical_medicine_for_hair_loss_management_and_improved_results_in_hair_transplantation.
6. Levy LL, Emer JJ. Female pattern alopecia: current perspectives. International Journal of Women’s Health. 2013;5:541-556. doi:10.2147/IJWH.S49337.
7. Whiting DA, Jacobson C. Treatment of female androgenetic alopecia with minoxidil 2%. Int J Dermatol. 1992;31(11):800–804.
8. Jacobs JP, Szpunar CA, Warner ML. Use of topical minoxidil therapy for androgenetic alopecia in women. Int J Dermatol. 1993;32(10): 758–762.
9. Alleyne M, Horne MK, Miller JL. Individualized treatment for iron deficiency anemia in adults. The American journal of medicine. 2008;121(11):943-948. doi:10.1016/j.amjmed.2008.07.012.
10. Cook JD. Iron-deficiency anemia. Baillieres Clin Haematol 1994;7:787–804.
11. Massey A. Microcytic Anemia. Differential diagnosis and management of iron deficiency anemia. The Medical Clinics of North America 1992;76:549–565.
12. Rimon E, Kagansky N, Kagansky M, et al. Are we giving too much iron? Low-dose iron therapy is effective in octogenarians. Am J Med 2005;118:1142–1147.
13. Bonnar J, Goldberg A, Smith JA. Do pregnant women take their iron? Lancet 1969;1:457–458.
14. Cunningham IJ 1932. The influence of dietary iron on hair and wool groMh. NZ J Agric 1999; 4: 335—7.
15. Hård S. Non-anemic iron deficiency as an etiological factor in diffuse loss of hair of the scalp in women. Acta Derm Venereo. 1963;43:562-9.
16. Rushton DH. Nutritional factors and hair loss. Clin Exp Dermatol. 2002;27:396–404.
17. Rushton DH, Norris M}, Dover R, Busuttil N. Causes of hair loss and the developments in hair rejuvenation. Int J Cos- met Sci 2002; 24: 1 7—2 3.
18. Kantor J, Jay K, Brooks D, Cotsarelis G. Decreased serum ferritin is associated with alopecia in women: a case con- trolled study. J Invest Dermotol 2001; 117 (2): 435.
19. Trost LB1, Bergfeld WF, Calogeras E. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J Am Acad Dermatol. 2006 May;54(5):824-44.
20. Abdel Aziz AM, Sh Hamed S, Gaballah MA. Possible relationship between chronic telogen effluvium and changes in lead, cadmium, zinc, and iron total blood levels in females: A case-control study. Int J Trichol 2015;7:100-6.
21. Rushton DH, Dover R, Sainsbury AW, Norris MJ, Gilkes JJ, Ramsay ID. Iron deficiency is neglected in women’s health. BMJ 2002;325:1176.
22. Ohyama M. Management of hair loss diseases. Dermatol Sin 2010;28:139‑45.
23. Rebora A, Guarrera M. Kenogen. A new phase of hair cycle. Dermatology 2002; 205 (2): 108-10
24. Guarrera M, Rebora A. Kenogen in female androgenetic alopecia. A longitudinal study. Dermatology 2005;210:18-20.
25. Yoshimori, T. Autophagy: A regulated bulk degradation process inside cells. Biochem. Biophys. Res. Commun. 2004, 313: 453–458.
26. Guimaraes, C. & Linden, R. Programmed cell death, apoptosis and alternate death styles. Eur. J. Biochem. 2004,271:1638–1650.
27. Glick, D., Barth, S., & Macleod, K. F. (2010). Autophagy: cellular and molecular mechanisms. The Journal of Pathology, 221(1), 3–12. http://doi.org/10.1002/path.2697
28. Parodi C, Hardman JA, Allavena G, Marotta R, Catelani T, Bertolini M, et al. (2018) Autophagy is essential for maintaining the growth of a human (mini-)organ: Evidence from scalp hair follicle organ culture. PLoS Biol 16(3): e2002864. https://doi.org/10.1371/journal.pbio.2002864
29. Deshwali S, Kare PK, Agrawal BK, Alex A. Study of serum zinc, copper and ferritin levels in alopecia patients. Int. J. Adv. Res. Biol. Sci. 2(7): (2015): 94–96.
30. Park SY, Na SY, Kim JH, Cho S, Lee JH. Iron Plays a Certain Role in Patterned Hair Loss. Journal of Korean Medical Science. 2013;28(6):934-938.
31. Moeinvaziri M, Mansoori P, Holakooee K, Safaee Naraghi Z, Abbasi A. Iron status in diffuse telogen hair loss among women. Acta Dermatovenerol Croat. 2009;17:279–284
32. Kantor J, Kessler LJ, Brooks DG, Cotsarelis G. Decreased serum ferritin is associated with alopecia in women. J Invest Dermatol. 2003;121:985–988.
33. Deloche C, Bastien P, Chadoutaud S, Galan P, Bertrais S, Hercberg S, de Lacharrière O. Low iron stores: a risk factor for excessive hair loss in non-menopausal women. Eur J Dermatol. 2007;17:507–512.
34. Sinclair R. There is no clear association between low serum ferritin and chronic diffuse telogen hair loss. Br J Dermatol. 2002;147:982–984.
35. Bregy A, Trueb RM. No association between serum ferritin levels >10 microg/l and hair loss activity in women. Dermatology. 2008;217:1–6.
36. Olsen EA, Reed KB, Cacchio PB, Caudill L. Iron deficiency in female pattern hair loss, chronic telogen effluvium, and control groups. J Am Acad Dermatol. 2010;63:991–999.
37. Rushton DH, Bergfeld WF, Gilkes JJ, Van Neste D. Iron deficiency and hair loss: nothing new? J Am Acad Dermatol. 2011;65:203–204.
38. Kelkitli E, Ozturk N, Aslan NA, et al. Serum zinc levels in patients with iron deficiency anemia and its association with symptoms of iron deficiency anemia. Ann Hematol. 2016;95(5):751-756.
39. Semba RD, Bloem MW. The anemia of vitamin A deficiency: epidemiology and pathogenesis. Eur J Clin Nutr. 2002 Apr;56(4):271-81.
40. Suharno D., West C.E., Muhilal, Karyadi D., Hautvast J.G. Supplementation with vitamin A and iron for nutritional anaemia in pregnant women in West Java, Indonesia. Lancet. 1993;342:1325–1328.
41. Mejia, L. A. & Chew, V. (1988) Hematological effect of supplementing iron with results of Mejia (1986), who demonstrated interactions be- vitamin A alone and in combination with iron. Am. J. Clin. Nutr. 48: 595–600.
42. García-Casal M.N., Layrisse M, Solano L, et al. Vitamin A b -carotene can improve nonheme iron absorption from rice wheat and corn by humans. J Nutr 1998;28:646-650.
43. Thankachan P, Walczyk T, Muthayya S, Kurpad AV, Hurrell RF. Iron absorption in young Indian women: the interaction of iron status with the influence of tea and ascorbic acid. Am J Clin Nutr April 2008, vol. 87 no. 4 881-886
44. DiazM,Rosado JL, Allen LH, Abrams S, Garcia OP. The efficacy of a local ascorbic acid-rich food in improving iron absorption from Mexican diets: a field study using stable isotopes. Am J Clin Nutr 2003;78:436–40.
45. Lynch SR. Interaction of iron with other nutrients. Nutr Rev. 1997;55(4):102-110.
46. McCance RA, Widdowson EM The absorption and excretion of iron following oral and intravenous administration. J. Physiol. 94: 148, 1938
47. Granick S.: Iron Metabolism. Bull. New York Acad. Mad. 34: 1381, 1954.
48. Conrad ME Jr, Crosby WH. Intestinal mucosal mechanisms controlling iron absorption. Blood 1963, 22:406-415;
49. Hahn PF, Bale WF, Ross JF, Belfour WM, and Whipple GH. Radioactive iron absorption by the gastrointestinal tract. Influence of anemia, anoxia and antecedent feeding distribution in growing dogs. J. Exper. Med. 78: 169, 1943
50. Du X, She E, Gelbart T, et al. The serine protease TMPRSS6 is required to sense iron deficiency. Science (New York, NY). 2008;320(5879):1088-1092. doi:10.1126/science.1157121.
51. van Hoek R, Conrad ME,: Iron absorption: Measurement of ingested iron59 by a human whole body scintillation counter. J. Clin. Invest. 40: 1153, 1961.
52. Brown EG, Dubach R, Moore CV. Studies on iron transportation and metabolism. IX. Critical analysis of mucosal block by large doses of iron in human subjects. J Lab Clin Med 1958;52:335-55.
53. Morgan EH1, Oates PS. Mechanisms and regulation of intestinal iron absorption. Blood Cells Mol Dis. 2002 Nov-Dec;29(3):384-99.
54. Frazer DM, Wilkins SJ, Becker EM, Murphy TL, Vulpe CD, McKie AT, et al. A rapid decrease in the expression of DMT1 and Dcytb but not Ireg1 or hephaestin explains the mucosal block phenomenon of iron absorption. Gut. 2003;52:340–6.
55. Schultink W, Gross R, Gliwitzki M, et al. Effect of daily vs twice weekly iron supplementation in Indonesian pre-school children with low iron status. Am J Clin Nutr 1995;61:111-5.
56. Viteri FE. Effective iron supplementation does not happen in isolation. Am J Clin Nutr 1997;65:889-90.
57. Singh K, Fong YF, Kuperan P. A comparison between intravenous iron polymaltose complex and oral ferrous fumarate in the treatment of iron deficiency anemia in pregnancy. Eur J Haematol 1998;60:119–24.
58. Chew F., Torun,B and Viteri,FE .Comparison of weekly and daily iron supplementation to pregnant women in Gutemala (supervised and unsupervised). FASEB.J.1996; 10: A4221.
59. Institute of Medicine, Food and Nutrition Board. Iron deficiency anemia: recommended guidelines for the prevention, detection, and management among US children and women of child bearing age. Washington, DC: National Academy Press, 1993. (Appendix C.)
60. Centers for Disease Control and Prevention. CDC report: recommendations to prevent and control iron deficiency in the United States. MMWR Morb Mortal Wkly Rep 1998;47:1–
61. Thomas C, Mackey MM, Diaz AA, Cox DP. Hydroxyl radical is produced via the Fenton reaction in submitochondrial particles under oxidative stress: implications for diseases associated with iron accumulation. Redox Rep. 2009;14(3):102-8. doi: 10.1179/135100009X392566.
62. Gutteridge, John MC. Iron and free radicals. In: Iron nutrition in health and disease. London: John Libbey and Co,1996:239-46.
63. Halliwell B: The antioxidant paradox. Lancet 355:1179–1180, 2000.
64. Salganik R I, The Benefits and Hazards of Antioxidants: Controlling Apoptosis and Other Protective Mechanisms in Cancer Patients and the Human Population. Journal of the American College of Nutrition, Vol. 20, No. 5, 464S–472S (2001).
65. Gregory JF III. Case study: folate bioavailability. J Nutr 2001;131:1376S–82S.
66. Rutkowski M and Grzegorczyk K. Adverse effects of antioxidative vitamins. International Journal of Occupational Medicine and Environmental Health 2012;25(2):105–121
67. Meydani M. Antioxidants in the prevention of chronic diseases. Nutr Clin Care. 2002 Mar-Apr;5(2):47-9. Higher doses of Vitamin C do not result in higher plasma levels.
68. WooJJ. Adverse event monitoring and multivitamin-multi mineral dietary supplements. AmJ Clin Nutr2oo7;85:323S-4S.
69. Stang, J.; Story, M., editors. Guidelines for Adolescent Nutrition Services. 2005.
70. Rajput R. Understanding Hair Loss due to Air Pollution & the Approach to Management. Hair Therapy & Transplant. March 2015.
71. Rajput RS. Benefit From Vitamin Therapy in Smoker’s Hair. Hair Ther Transplant 6:141.2016. doi: 10.4172/2167-0951.1000141.
72. Rajput R Improvement in Hair Loss and Better Hair Quality with Vitamin Therapy in Monilethrix. J Cosmo Trichol 2: 113. 2016. doi: 10.4172/2471-9323.1000113.
73. Rajput R. Hair Loss due to Electromagnetic Radiation from Overuse of Cell Phone. J Cosmo Trichol 2: 114. 2016. doi:10.4172/2471-9323.1000114
74. Rajput RJ. Controlled clinical trial for evaluation of hair growth with low dose cyclical nutrition therapy in men and women without the use of finasteride. Plast Aesthet Res 2017;4:161-73. DOI: 10.20517/2347-9264.2017.57
75. Rajendrasingh Rajput (2018) A Scientific Hypothesis on the Role of Nutritional Supplements for Effective Management of Hair Loss and Promoting Hair Regrowth. J Nutrition Health Food Sci 6(3):1-11 DOI: 10.15226/jnhfs.2018.001132