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Prevalence and factors associated with telogen effluvium in adult females at Makkah region, Saudi Arabia: A retrospective study
Available online at www.sciencedirect.com www.jdds.org
ScienceDirect Journal of Dermatology & Dermatologic Surgery 19 (2015) 27–30
Original article
Prevalence and factors associated with telogen effluvium in adult females at Makkah region, Saudi Arabia: A retrospective study M.I. Fatani a,⇑, A.M. Bin mahfoz b, A.H. Mahdi b, K.A. Alafif a, W.A. Hussain a, A.S. Khan a, A.A. Banjar a a b
Hera General Hospital, Makkah, Saudi Arabia Umm AlQura University, Makkah, Saudi Arabia
Received 25 March 2014; accepted 6 April 2014 Available online 13 January 2015
Abstract Background: Data on the epidemiology of telogen effluvium (TE) are limited, and its true incidence is largely unknown. Our aim is to calculate the prevalence of TE and evaluate its comorbidities and its relation to iron-deficiency anemia. Methods: We performed a retrospective review of 279 medical records of the patients with TE seen at Hera Hospital, Makkah, Saudi Arabia, between 2011 and 2013. Results: Of 279 female patients (mean age: 29.82 years), 58.5% of the patients were between the age of 21 and 40. Hypothyroidism was reported in 21.1% of the patients, dermatitis in 11.8%, diabetes mellitus in 5.7%, and bronchial asthma in 3.6%. Low hemoglobin was observed in 94.9% of the patients, low MCH in 99.6%, and low hematocrit in 90.21%. Serum ferritin was at 630 ng/mL in 64% of the patients and 670 ng/mL in 89.1%. The systemic treatment included the following: iron supplementation in 58.8%, folic acid in 51.3%, and zinc in 25.1%. Topical treatments included steroid in 63.1%, minoxidil in 34.8%, hair tonic in 68.8%, and antidandruff in 19.4%. Conclusions: All patients were females, with most of their ages of onset between 21 and 40. It was commonly associated with irondeficiency anemia and hypothyroidism. Ó 2014 Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Keywords: Telogen effluvium; Iron deficiency anemia; Makkah; Serum ferritin
1. Introduction
⇑ Corresponding author. Address: Hera General Hospital, PO Box 5970, Postcode 21955 Makkah, Saudi Arabia. Tel.: +966 555517839. E-mail addresses: [email protected] (M.I. Fatani), [email protected] (A.M. Bin mahfoz), [email protected] (A.H. Mahdi), Kh_alafi[email protected] (K.A. Alafif), hussainwaleed@ hotmail.com (W.A. Hussain), [email protected] (A.S. Khan), [email protected] (A.A. Banjar). Peer review under responsibility of King Saud University.
Production and hosting by Elsevier
Telogen effluvium (TE) is a form of non-scarring alopecia characterized by diffuse hair shedding, often with an acute onset. A chronic form with a more insidious onset and a longer duration also exists (Sinclair, 2005; Whiting, 1996). It is an abnormality in the hair cycle (Harrison and Sinclair, 2002), occurring as a reaction pattern to various physical or mental stressors (Bernstein et al., 1988). The degree of effluvium depends on the severity and duration of exposure rather than the type of agent (Tosti et al., 1994). Data on the epidemiology of TE are limited, and its true incidence or prevalence is largely unknown (Harrison and
http://dx.doi.org/10.1016/j.jdds.2014.04.002 2352-2410/Ó 2014 Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
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M.I. Fatani et al. / Journal of Dermatology & Dermatologic Surgery 19 (2015) 27–30
Sinclair, 2002; Sinclair et al., 1999). The disorder is one of the most common forms of non-scarring hair loss, which patients present for clinical evaluation (Hordinsky, 2006). TE does not appear to have a predilection for particular racial or ethnic groups. TE can be acute (lasting for less than six months), chronic (six months or more), or chronic-repetitive (Bergfeld and Mulinari-Brenner, 2001; McMichael et al., 2008). If a trigger is acute and short-lived, the TE will likely be acute and will be resolved. If the trigger is ongoing, repeated, sequentially occurring, or not reversed, then the telogen hair shedding can be ongoing (McMichael et al., 2008). For reasons that are unclear, chronic telogen effluvium (CTE) seems to affect only women (Whiting, 1996). The aim of this study was to calculate the prevalence of TE and evaluate its comorbidities and its relation to irondeficiency anemia. There is little reported data about this topic in Saudi Arabia. 2. Materials and methods This study was conducted at the outpatient Department of Dermatology, Hera General Hospital, Makkah, Saudi Arabia. We retrospectively reviewed 279 cases from records of the patients seen at the clinic during 2011–2013. For the diagnosis of telogen hair loss, all patients were evaluated by a dermatologist through history and physical examination. The following data were collected: age, gender, duration, possible associated medical condition, family history, and data related to menstrual cycle. Examination of the hair included scalp examination and a hair-pull test. The following laboratory investigations were recorded: complete blood counts, serum ferritin, free T3, free T4, and thyroid-stimulating hormone. Systemic treatment included iron supplement, folic acid, zinc capsule, priorin capsule, and finasteride. The topical treatment included corticosteroid, minoxidil (2% and 5%), hair tonic solution and ampoule, anti-hair fall shampoo, and antidandruff shampoo. In this study, we used the Statistical Package for the Social Sciences software, version 20, for data entry and analysis. Continuous data are presented as means. Categorical variables are presented as frequencies and percentages. This study was designed around ethical considerations of justice, autonomy, and beneficence. The
research proposal was approved by the Research Ethics Committee of the Hera General Hospital in Makkah, Saudi Arabia. 3. Results In all, 16,014 new female patients were seen in the Dermatology Department of Hera General Hospital, Makkah, Saudi Arabia, from January 2011 to December 2013. Among those patients, 279 had TE; thus, its incidence was 1.74%. All the patients were females. Their ages ranged from 10 to 62 years, with a mean age of 29.82 ± 11.34 years, and median is 27 years. The majority (58.5%) of the patients noticed the onset of TE between the age of 21 and 40, and 20.8% had acute TE, and 79.2% had chronic TE (see Table 1). Only 10.4% of the patients reported that other family members have had TE, and 6.8% related it to their menstrual cycle. For scalp examination, we found that only 1.1% showed erythema, 17% showed seborrheic scalp, and 81.9% showed no changes. A hair-pull test was found to be positive in 61.0% of the patients and negative in 39%. Associated autoimmune/endocrine disorders were present in the majority of the patients. Of these, hypothyroidism was the most common, reported to be in 21.1% of the patients. Diabetes mellitus was reported in 5.7% of the patients, systemic lupus erythematosus in 2.2%, and rheumatoid arthritis in 2.2%. Associated cutaneous diseases noted in this study were dermatitis in 11.8% of the patients, psoriasis in 0.4%, and urticaria in 0.4%. Other comorbidities included hypertension in 2.5% of the patients, bronchial asthma in 3.6%, osteoarthritis in 3.9%, chronic hepatitis B infection in 2.9%, gastritis in 2.2%, migraine in 2.9%, and epilepsy in 1.4%. Among all records, only 14 files documented drugs related to TE, which are as follows: retinoids in 50% of the patients, anticoagulants in 35.7%, and carbamazepine in 14.3%. In this study, we found that 94.9% of the patients showed hemoglobin (g/dL) less than the lower normal range in our laboratory reference (13.5–17.5), 99.6% showed MCH (%) less than the lower normal range (27–33), 31% showed MCV (fL) less than the lower normal range (80–101), 90.2% showed hematocrit (%) less than the lower normal range (40–50), and 48.3% showed RDW (%)
Table 1 Age at onset in relation with the duration of TE. Age-group (in years)
10–20 21–30 31–40 41–50 51–60 61–70 Total
Duration of hair fall
Total (%)
Acute <6 months
Chronic >6 months
13 27 11 6 1 0 58 (20.8%)
44 75 50 33 18 1 221 (79.2%)
57 (20.4%) 102 (36.6%) 61 (21.9%) 39 (14%) 19 (6.8%) 1 (0.36%) 279 (100%)
M.I. Fatani et al. / Journal of Dermatology & Dermatologic Surgery 19 (2015) 27–30
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Table 2 Details of the results of complete blood count (CBC) investigations.
Hemoglobin MCH MCV Hematocrit RDW
Mean
Median
Mode
Std. deviation
Minimum
Maximum
11.4978 26.7014 81.6993 35.2398 15.2242
11.7000 27.4000 82.7000 36.0000 14.5000
11.90 28.50 89.60 36.20 13.30
1.48091 3.18183 7.54551 4.21205 2.87125
7.00 13.50 51.20 20.40 11.50
15.10 35.90 97.50 46.40 41.20
MCH (mean corpuscular hemoglobin), MCV (mean corpuscular volume), RDW (red blood cell distribution width).
above the normal range (11.6–14.4) (see Table 2). In 64% of the patients, serum ferritin was at 630 ng/mL and 670 ng/ mL in 89.1%. Serum ferritin at 670 ng/mL was found in 19.35% of acute TE and in 80.5% of chronic TE, which proved to be statistically significant (P value = 0.035). We found that 30.7% of the patients’ thyroid-stimulating hormone showed a value above the normal range at 0.27–4.2 mIU/L, in which 3.6% of the patients with acute TE and 27% of the patients with chronic TE were statistically not significant (P value = 0.294). The patients received different systemic treatments including the following: iron supplementation in 58.8%, folic acid in 51.3%, zinc in 25.1%, priorin N in 17.6, and finasteride in 1.8%. Topical treatments included steroid in 63.1%, minoxidil (2% and 5%) in 34.8%, hair tonic and ampoule in 68.8%, anti-hair fall shampoo in 47.1%, and antidandruff in 19.4%. 4. Discussion TE is the most common form of hair loss encountered in clinical practice (Hordinsky, 2006). Among new female patients who have been examined in our department, the incidence of TE is 1.74%. Information about the true incidence or prevalence is lacking in the published literature. In the study, the clinical pattern of TE in 279 female patients showed a peak incidence (58.5%) in the 21–40 age-group. The disease usually affects women aged 30–60 years and starts abruptly with or without a recognizable initiating factor (Whiting, 1996). For unknown reasons, chronic TE seems to affect only women (Whiting, 1996), which also applies to this study. The hair-pull test, which is a maneuver performed by the examiner by gently pulling tufts of hair along the scalp, is usually positive in the affected scalp as miniaturization causes shortening of the hair cycle with increased telogen shedding. Associated TE is indicated when the test is positive in all scalp areas. In our study, we found that 61.0% showed positive results, while 39% showed negative results; this is because before hair examination, the patients recently took a shower or were on treatment. For an associated medical condition with TE, both hypothyroidism and hyperthyroidism can cause diffuse telogen hair loss that is usually reversible once the euthyroid state is restored (Sperling, 2001; Jain et al., 2000; Comaisch, 1985). This supports our findings in which 21.1% of the patients had hypothyroidism. The associated
cutaneous diseases noted in this study were dermatitis, seborrheic scalp, psoriasis, and urticaria, which had been reported in other studies (Pie´rard-Franchimont et al., 2006; A pache PG, 1986). Many chronic illnesses seen in these patients such as diabetes mellitus, hypertension, bronchial asthma, osteoarthritis, chronic hepatitis B infection, gastritis, migraine, and epilepsy can cause telogen hair shedding as reported in other studies as chronic systemic disorders (Jain et al., 2000; Kligman, 1961). A few of the patients (2.2%) with systemic lupus erythematosus were presented with TE, which is reported in other studies (Yun et al., 2007; Trueb, 2010), but its mechanism is yet to be determined. Medications including retinoids, anticoagulants, and carbamazine were reported as possible causes of TE in this study; these findings are supported by other studies (Tosti and Pazzaglia, 2007; Berth-Jones et al., 1990). Laboratory studies, such as hemoglobin concentration, hematocrit, and mean corpuscular volume (MCV) serum ferritin concentration, can be used to detect iron deficiency. However, these laboratory studies may vary in other conditions. In 94.9% of the patients, the hemoglobin value was less than the lower normal limit; 90.2% of the patients had a low hematocrit value, 99.6% had low MCH, and 31% had low MCV. These laboratory results may support the evidence that iron-deficiency anemia may be associated with TE in the patients. Only iron deficiency causes very low serum ferritin concentrations. However, normal does not mean optimal. Optimal level for both men and women is 70 ng/mL and above. The lack of lower serum ferritin levels in patients with TE may be due to its multifactorial nature. Medications, fevers, rapid weight loss, and numerous other factors may cause TE (Harrison and Sinclair, 2002; Headington, 1993). In our study, we found that most of the patients’ (89.1%) serum ferritin was at 670 ng/mL and 64% were at 630 ng/mL. These results are comparable with those of a study that concluded that women with serum ferritin at 630 ng/mL had a significant risk of developing telogen hair loss, as 93.3% of the patients with telogen hair loss had this level of serum ferritin (Moeinvaziri et al., 2009). This conclusion is not conclusive because there is a data showing that iron deficiency anemia, vitamin D deficiency and iodine deficiency (in few areas) do exist in Saudi Arabia (Madani and Kumosani, 2001), also with heavy consump-
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M.I. Fatani et al. / Journal of Dermatology & Dermatologic Surgery 19 (2015) 27–30
tion of tea and coffee by adults during the day, especially after meals inhibit the absorption of iron. (Madani and Kumosani, 2001) So further studies need to confirm the direct correlation between iron deficiency anemia and TE. We found that 30% of patients’ had thyroid stimulating hormone above normal range value which shows the effect of hypothyroidism in TE patients which had been mentioned in other study. (Haritha and Kirthi Sampath, 2013). Treatment for TE is primarily reassurance and counseling. We should look for specific causes in order to treat it. Because 17% of the patients have underlying seborrheic dermatitis, they were treated with an antidandruff shampoo and a topical corticosteroid, which has also been reported by other studies as part of the treatment of TE (Bergfeld and Mulinari-Brenner, 2001; Pie´rard-Franchimont et al., 2006). Only 20% of the patients were using topical minoxidil at 2%, and 14% were using minoxidil at 5%. Despite that, topical minoxidil is not proven to promote recovery of hair in TE. This medication has a theoretical benefit and is well tolerated by a few of the patients. Hair tonic and ampoule were used in 68.8% of the patients, and anti-hair fall shampoo in 47.1%, but there is no clear evidence about their effectiveness. But the patients’ experience showed a beneficial effect on their condition. Substitution therapy for catagen promoting deficiencies like those of iron, zinc, estradiol, or proteins can also be initiated (Whiting, 1996; Kantor et al., 2003). This is applied to the following patients: 58.8% receive iron, 51.3% receive folic acid, and 25.1% receive zinc supplementation with multivitamins. However, until this time, there are no proven vitamins or supplements to treat any form of hair loss (McMichael, 2011). If there is a measurable deficiency such as iron-deficiency anemia, then its substitute may help, which is administered to the patients. Controlled studies regarding the efficacy of the replacement of iron or thyroxine on the outcome of TE are also lacking, although some benefits have been claimed (Bernstein et al., 1988; Comaisch, 1985). It has been suggested by some authors that maintaining serum ferritin above 40 ng/dL (Kantor et al., 2003) or 70 ng/dL (Trost et al., 2006) helps to reverse hair loss, so we advise the patients to consider iron replacement as part of their treatment because 89.1% of the patients who used serum ferritin showed results of less than 70 ng/dL. 5. Conclusion We recommend to take an adequate dietary intake of iron and, if required, oral ferrous sulfate as most of the patients showed low serum ferritin, which is a widely accepted and cost-effective initial therapy. Conflict of interest We have no conflict of interest to declare.
References A Pache PG, 1986. Eczematous dermatitis of the scalp. In: Zviak, C. (Ed.), The Science of Hair Care. Marcel Dekker, New York, NY, pp. 513– 521. Bergfeld, W.F., Mulinari-Brenner, F., 2001. Shedding: how to manage a common cause of hair loss. Cleve. Clin. J. Med. 68, 256–261. Bernstein, G.M., Crollick, J.S., Hassett, J.M., 1988. Post-febrile telogen effluvium in critically ill patients. Crit. Care Med. 16, 98–99. Berth-Jones, J., Shuttleworth, D., Hutchinson, P.E., 1990. A study of etretinate alopecia. Br. J. Dermatol. 122 (6), 751–755. Comaisch, S., 1985. The thyroid and hair growth. Semin. Dermatol. 4, 4– 8. Haritha, S., Kirthi Sampath, K., 2013. Skin manifestations of hypothyroidism – a clinical study. OSR-JDMS 7, 58–60. Harrison, S., Sinclair, R., 2002. Telogen effluvium. Clin. Exp. Dermatol. 27, 389-5. Headington, J.T., 1993. Telogen effluvium: new concepts and review. Arch. Dermatol. 129, 356–363. Hordinsky, M.K., 2006. Medical treatment of noncicatricial alopecia. Semin. Cutan. Med. Surg. 25 (1), 51–55. Jain, V.K., Kataria, U., Dayal, S., 2000. Study of diffuse alopecia in females. Indian J. Dermatol. Venereol. Leprol. 66 (2), 65–68. Kantor, J., Kessler, L.J., Brooks, D.G., Cotsarelis, G., 2003. Decreased serum ferritin is associated with alopecia in women. J. Invest. Dermatol. 121, 985–988. Kligman, A.M., 1961. Pathologic dynamics of human hair loss. I. Telogen effluvium. Arch. Dermatol. 83, 175–198. Madani, K., Kumosani, T., 2001. Micronutrients status in Saudi Arabia. Bahrain Med. Bull. 23 (3), 135–139. McMichael, A., 2011. Approach to office visits for hair loss in women. Cutis 87, 8–9. McMichael, J., Hordin, M.K., Bergfeld, W.F., 2008. Telogen effluvium. In: McMichael, J., Hordin, M.K. (Eds.), Hair and Scalp Diseases: Medical, Surgical, and Cosmetic Treatments. Informa Health Care, London, UK, pp. 119–135 (chapter 9). Moeinvaziri, M., Mansoori, P., Holakooee, K., Safaee Naraghi, Z., Abbasi, A., 2009. Iron status in diffuse telogen hair loss among women. Acta Dermatovenerol. Croat. 17 (4), 279–284. Pie´rard-Franchimont, C., Xhauflaire-Uhoda, E., Pie´rard, G.E., 2006. Revisiting dandruff. Int. J. Cosmet. Sci. 28 (5), 311–318. Sinclair, R., 2005. Chronic telogen effluvium: a study of 5 patients over 7 years. J. Am. Acad. Dermatol. 52 (2 Suppl. 1), 12–16. Sinclair, R.D., Banfield, C.C., Dawber, R.P., 1999. Diffuse hair loss. In: Sinclair, R.D., Banfield, C.C., Dawber, R.P. (Eds.), Handbook of Diseases of the Hair and Scalp. Blackwell Science Ltd, UK, pp. 64–74. Sperling, L.C., 2001. Hair and systemic disease. Dermatol. Clin. 19, 711– 726. Tosti, A., Pazzaglia, M., 2007. Drug reactions affecting hair: diagnosis. Dermatol. Clin. 25, 223–231. Tosti, A., Misciali, C., Piraccini, B.M., Peluso, A.M., Bardazzi, F., 1994. Drug induced hair loss and hair growth. Drug Saf. 10, 310–317. Trost, L.B., Bergfeld, W.F., Calogeras, E., 2006. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J. Am. Acad. Dermatol. 54, 824–844. Trueb, R.M., 2010. Involvement of scalp and nails in lupus erythematosus. Lupus 19, 1078–1086. Whiting, D.A., 1996. Chronic telogen effluvium: increased scalp hair shedding in middle-aged women. J. Am. Acad. Dermatol. 35 (6), 899– 906. Whiting, D.A., 1996. Chronic telogen effluvium. Dermatol. Clin. 14, 723– 731. Yun, S.J., Lee, J.W., Yoon, H.J., et al., 2007. Cross-sectional study of hair loss patterns in 122 Korean systemic lupus erythematosus patients: a frequent finding of non-scarring patch alopecia. J. Dermatol. 34, 451– 455.
ScienceDirect Journal of Dermatology & Dermatologic Surgery 19 (2015) 27–30
Original article
Prevalence and factors associated with telogen effluvium in adult females at Makkah region, Saudi Arabia: A retrospective study M.I. Fatani a,⇑, A.M. Bin mahfoz b, A.H. Mahdi b, K.A. Alafif a, W.A. Hussain a, A.S. Khan a, A.A. Banjar a a b
Hera General Hospital, Makkah, Saudi Arabia Umm AlQura University, Makkah, Saudi Arabia
Received 25 March 2014; accepted 6 April 2014 Available online 13 January 2015
Abstract Background: Data on the epidemiology of telogen effluvium (TE) are limited, and its true incidence is largely unknown. Our aim is to calculate the prevalence of TE and evaluate its comorbidities and its relation to iron-deficiency anemia. Methods: We performed a retrospective review of 279 medical records of the patients with TE seen at Hera Hospital, Makkah, Saudi Arabia, between 2011 and 2013. Results: Of 279 female patients (mean age: 29.82 years), 58.5% of the patients were between the age of 21 and 40. Hypothyroidism was reported in 21.1% of the patients, dermatitis in 11.8%, diabetes mellitus in 5.7%, and bronchial asthma in 3.6%. Low hemoglobin was observed in 94.9% of the patients, low MCH in 99.6%, and low hematocrit in 90.21%. Serum ferritin was at 630 ng/mL in 64% of the patients and 670 ng/mL in 89.1%. The systemic treatment included the following: iron supplementation in 58.8%, folic acid in 51.3%, and zinc in 25.1%. Topical treatments included steroid in 63.1%, minoxidil in 34.8%, hair tonic in 68.8%, and antidandruff in 19.4%. Conclusions: All patients were females, with most of their ages of onset between 21 and 40. It was commonly associated with irondeficiency anemia and hypothyroidism. Ó 2014 Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Keywords: Telogen effluvium; Iron deficiency anemia; Makkah; Serum ferritin
1. Introduction
⇑ Corresponding author. Address: Hera General Hospital, PO Box 5970, Postcode 21955 Makkah, Saudi Arabia. Tel.: +966 555517839. E-mail addresses: [email protected] (M.I. Fatani), [email protected] (A.M. Bin mahfoz), [email protected] (A.H. Mahdi), Kh_alafi[email protected] (K.A. Alafif), hussainwaleed@ hotmail.com (W.A. Hussain), [email protected] (A.S. Khan), [email protected] (A.A. Banjar). Peer review under responsibility of King Saud University.
Production and hosting by Elsevier
Telogen effluvium (TE) is a form of non-scarring alopecia characterized by diffuse hair shedding, often with an acute onset. A chronic form with a more insidious onset and a longer duration also exists (Sinclair, 2005; Whiting, 1996). It is an abnormality in the hair cycle (Harrison and Sinclair, 2002), occurring as a reaction pattern to various physical or mental stressors (Bernstein et al., 1988). The degree of effluvium depends on the severity and duration of exposure rather than the type of agent (Tosti et al., 1994). Data on the epidemiology of TE are limited, and its true incidence or prevalence is largely unknown (Harrison and
http://dx.doi.org/10.1016/j.jdds.2014.04.002 2352-2410/Ó 2014 Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
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M.I. Fatani et al. / Journal of Dermatology & Dermatologic Surgery 19 (2015) 27–30
Sinclair, 2002; Sinclair et al., 1999). The disorder is one of the most common forms of non-scarring hair loss, which patients present for clinical evaluation (Hordinsky, 2006). TE does not appear to have a predilection for particular racial or ethnic groups. TE can be acute (lasting for less than six months), chronic (six months or more), or chronic-repetitive (Bergfeld and Mulinari-Brenner, 2001; McMichael et al., 2008). If a trigger is acute and short-lived, the TE will likely be acute and will be resolved. If the trigger is ongoing, repeated, sequentially occurring, or not reversed, then the telogen hair shedding can be ongoing (McMichael et al., 2008). For reasons that are unclear, chronic telogen effluvium (CTE) seems to affect only women (Whiting, 1996). The aim of this study was to calculate the prevalence of TE and evaluate its comorbidities and its relation to irondeficiency anemia. There is little reported data about this topic in Saudi Arabia. 2. Materials and methods This study was conducted at the outpatient Department of Dermatology, Hera General Hospital, Makkah, Saudi Arabia. We retrospectively reviewed 279 cases from records of the patients seen at the clinic during 2011–2013. For the diagnosis of telogen hair loss, all patients were evaluated by a dermatologist through history and physical examination. The following data were collected: age, gender, duration, possible associated medical condition, family history, and data related to menstrual cycle. Examination of the hair included scalp examination and a hair-pull test. The following laboratory investigations were recorded: complete blood counts, serum ferritin, free T3, free T4, and thyroid-stimulating hormone. Systemic treatment included iron supplement, folic acid, zinc capsule, priorin capsule, and finasteride. The topical treatment included corticosteroid, minoxidil (2% and 5%), hair tonic solution and ampoule, anti-hair fall shampoo, and antidandruff shampoo. In this study, we used the Statistical Package for the Social Sciences software, version 20, for data entry and analysis. Continuous data are presented as means. Categorical variables are presented as frequencies and percentages. This study was designed around ethical considerations of justice, autonomy, and beneficence. The
research proposal was approved by the Research Ethics Committee of the Hera General Hospital in Makkah, Saudi Arabia. 3. Results In all, 16,014 new female patients were seen in the Dermatology Department of Hera General Hospital, Makkah, Saudi Arabia, from January 2011 to December 2013. Among those patients, 279 had TE; thus, its incidence was 1.74%. All the patients were females. Their ages ranged from 10 to 62 years, with a mean age of 29.82 ± 11.34 years, and median is 27 years. The majority (58.5%) of the patients noticed the onset of TE between the age of 21 and 40, and 20.8% had acute TE, and 79.2% had chronic TE (see Table 1). Only 10.4% of the patients reported that other family members have had TE, and 6.8% related it to their menstrual cycle. For scalp examination, we found that only 1.1% showed erythema, 17% showed seborrheic scalp, and 81.9% showed no changes. A hair-pull test was found to be positive in 61.0% of the patients and negative in 39%. Associated autoimmune/endocrine disorders were present in the majority of the patients. Of these, hypothyroidism was the most common, reported to be in 21.1% of the patients. Diabetes mellitus was reported in 5.7% of the patients, systemic lupus erythematosus in 2.2%, and rheumatoid arthritis in 2.2%. Associated cutaneous diseases noted in this study were dermatitis in 11.8% of the patients, psoriasis in 0.4%, and urticaria in 0.4%. Other comorbidities included hypertension in 2.5% of the patients, bronchial asthma in 3.6%, osteoarthritis in 3.9%, chronic hepatitis B infection in 2.9%, gastritis in 2.2%, migraine in 2.9%, and epilepsy in 1.4%. Among all records, only 14 files documented drugs related to TE, which are as follows: retinoids in 50% of the patients, anticoagulants in 35.7%, and carbamazepine in 14.3%. In this study, we found that 94.9% of the patients showed hemoglobin (g/dL) less than the lower normal range in our laboratory reference (13.5–17.5), 99.6% showed MCH (%) less than the lower normal range (27–33), 31% showed MCV (fL) less than the lower normal range (80–101), 90.2% showed hematocrit (%) less than the lower normal range (40–50), and 48.3% showed RDW (%)
Table 1 Age at onset in relation with the duration of TE. Age-group (in years)
10–20 21–30 31–40 41–50 51–60 61–70 Total
Duration of hair fall
Total (%)
Acute <6 months
Chronic >6 months
13 27 11 6 1 0 58 (20.8%)
44 75 50 33 18 1 221 (79.2%)
57 (20.4%) 102 (36.6%) 61 (21.9%) 39 (14%) 19 (6.8%) 1 (0.36%) 279 (100%)
M.I. Fatani et al. / Journal of Dermatology & Dermatologic Surgery 19 (2015) 27–30
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Table 2 Details of the results of complete blood count (CBC) investigations.
Hemoglobin MCH MCV Hematocrit RDW
Mean
Median
Mode
Std. deviation
Minimum
Maximum
11.4978 26.7014 81.6993 35.2398 15.2242
11.7000 27.4000 82.7000 36.0000 14.5000
11.90 28.50 89.60 36.20 13.30
1.48091 3.18183 7.54551 4.21205 2.87125
7.00 13.50 51.20 20.40 11.50
15.10 35.90 97.50 46.40 41.20
MCH (mean corpuscular hemoglobin), MCV (mean corpuscular volume), RDW (red blood cell distribution width).
above the normal range (11.6–14.4) (see Table 2). In 64% of the patients, serum ferritin was at 630 ng/mL and 670 ng/ mL in 89.1%. Serum ferritin at 670 ng/mL was found in 19.35% of acute TE and in 80.5% of chronic TE, which proved to be statistically significant (P value = 0.035). We found that 30.7% of the patients’ thyroid-stimulating hormone showed a value above the normal range at 0.27–4.2 mIU/L, in which 3.6% of the patients with acute TE and 27% of the patients with chronic TE were statistically not significant (P value = 0.294). The patients received different systemic treatments including the following: iron supplementation in 58.8%, folic acid in 51.3%, zinc in 25.1%, priorin N in 17.6, and finasteride in 1.8%. Topical treatments included steroid in 63.1%, minoxidil (2% and 5%) in 34.8%, hair tonic and ampoule in 68.8%, anti-hair fall shampoo in 47.1%, and antidandruff in 19.4%. 4. Discussion TE is the most common form of hair loss encountered in clinical practice (Hordinsky, 2006). Among new female patients who have been examined in our department, the incidence of TE is 1.74%. Information about the true incidence or prevalence is lacking in the published literature. In the study, the clinical pattern of TE in 279 female patients showed a peak incidence (58.5%) in the 21–40 age-group. The disease usually affects women aged 30–60 years and starts abruptly with or without a recognizable initiating factor (Whiting, 1996). For unknown reasons, chronic TE seems to affect only women (Whiting, 1996), which also applies to this study. The hair-pull test, which is a maneuver performed by the examiner by gently pulling tufts of hair along the scalp, is usually positive in the affected scalp as miniaturization causes shortening of the hair cycle with increased telogen shedding. Associated TE is indicated when the test is positive in all scalp areas. In our study, we found that 61.0% showed positive results, while 39% showed negative results; this is because before hair examination, the patients recently took a shower or were on treatment. For an associated medical condition with TE, both hypothyroidism and hyperthyroidism can cause diffuse telogen hair loss that is usually reversible once the euthyroid state is restored (Sperling, 2001; Jain et al., 2000; Comaisch, 1985). This supports our findings in which 21.1% of the patients had hypothyroidism. The associated
cutaneous diseases noted in this study were dermatitis, seborrheic scalp, psoriasis, and urticaria, which had been reported in other studies (Pie´rard-Franchimont et al., 2006; A pache PG, 1986). Many chronic illnesses seen in these patients such as diabetes mellitus, hypertension, bronchial asthma, osteoarthritis, chronic hepatitis B infection, gastritis, migraine, and epilepsy can cause telogen hair shedding as reported in other studies as chronic systemic disorders (Jain et al., 2000; Kligman, 1961). A few of the patients (2.2%) with systemic lupus erythematosus were presented with TE, which is reported in other studies (Yun et al., 2007; Trueb, 2010), but its mechanism is yet to be determined. Medications including retinoids, anticoagulants, and carbamazine were reported as possible causes of TE in this study; these findings are supported by other studies (Tosti and Pazzaglia, 2007; Berth-Jones et al., 1990). Laboratory studies, such as hemoglobin concentration, hematocrit, and mean corpuscular volume (MCV) serum ferritin concentration, can be used to detect iron deficiency. However, these laboratory studies may vary in other conditions. In 94.9% of the patients, the hemoglobin value was less than the lower normal limit; 90.2% of the patients had a low hematocrit value, 99.6% had low MCH, and 31% had low MCV. These laboratory results may support the evidence that iron-deficiency anemia may be associated with TE in the patients. Only iron deficiency causes very low serum ferritin concentrations. However, normal does not mean optimal. Optimal level for both men and women is 70 ng/mL and above. The lack of lower serum ferritin levels in patients with TE may be due to its multifactorial nature. Medications, fevers, rapid weight loss, and numerous other factors may cause TE (Harrison and Sinclair, 2002; Headington, 1993). In our study, we found that most of the patients’ (89.1%) serum ferritin was at 670 ng/mL and 64% were at 630 ng/mL. These results are comparable with those of a study that concluded that women with serum ferritin at 630 ng/mL had a significant risk of developing telogen hair loss, as 93.3% of the patients with telogen hair loss had this level of serum ferritin (Moeinvaziri et al., 2009). This conclusion is not conclusive because there is a data showing that iron deficiency anemia, vitamin D deficiency and iodine deficiency (in few areas) do exist in Saudi Arabia (Madani and Kumosani, 2001), also with heavy consump-
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tion of tea and coffee by adults during the day, especially after meals inhibit the absorption of iron. (Madani and Kumosani, 2001) So further studies need to confirm the direct correlation between iron deficiency anemia and TE. We found that 30% of patients’ had thyroid stimulating hormone above normal range value which shows the effect of hypothyroidism in TE patients which had been mentioned in other study. (Haritha and Kirthi Sampath, 2013). Treatment for TE is primarily reassurance and counseling. We should look for specific causes in order to treat it. Because 17% of the patients have underlying seborrheic dermatitis, they were treated with an antidandruff shampoo and a topical corticosteroid, which has also been reported by other studies as part of the treatment of TE (Bergfeld and Mulinari-Brenner, 2001; Pie´rard-Franchimont et al., 2006). Only 20% of the patients were using topical minoxidil at 2%, and 14% were using minoxidil at 5%. Despite that, topical minoxidil is not proven to promote recovery of hair in TE. This medication has a theoretical benefit and is well tolerated by a few of the patients. Hair tonic and ampoule were used in 68.8% of the patients, and anti-hair fall shampoo in 47.1%, but there is no clear evidence about their effectiveness. But the patients’ experience showed a beneficial effect on their condition. Substitution therapy for catagen promoting deficiencies like those of iron, zinc, estradiol, or proteins can also be initiated (Whiting, 1996; Kantor et al., 2003). This is applied to the following patients: 58.8% receive iron, 51.3% receive folic acid, and 25.1% receive zinc supplementation with multivitamins. However, until this time, there are no proven vitamins or supplements to treat any form of hair loss (McMichael, 2011). If there is a measurable deficiency such as iron-deficiency anemia, then its substitute may help, which is administered to the patients. Controlled studies regarding the efficacy of the replacement of iron or thyroxine on the outcome of TE are also lacking, although some benefits have been claimed (Bernstein et al., 1988; Comaisch, 1985). It has been suggested by some authors that maintaining serum ferritin above 40 ng/dL (Kantor et al., 2003) or 70 ng/dL (Trost et al., 2006) helps to reverse hair loss, so we advise the patients to consider iron replacement as part of their treatment because 89.1% of the patients who used serum ferritin showed results of less than 70 ng/dL. 5. Conclusion We recommend to take an adequate dietary intake of iron and, if required, oral ferrous sulfate as most of the patients showed low serum ferritin, which is a widely accepted and cost-effective initial therapy. Conflict of interest We have no conflict of interest to declare.
References A Pache PG, 1986. Eczematous dermatitis of the scalp. In: Zviak, C. (Ed.), The Science of Hair Care. Marcel Dekker, New York, NY, pp. 513– 521. Bergfeld, W.F., Mulinari-Brenner, F., 2001. Shedding: how to manage a common cause of hair loss. Cleve. Clin. J. Med. 68, 256–261. Bernstein, G.M., Crollick, J.S., Hassett, J.M., 1988. Post-febrile telogen effluvium in critically ill patients. Crit. Care Med. 16, 98–99. Berth-Jones, J., Shuttleworth, D., Hutchinson, P.E., 1990. A study of etretinate alopecia. Br. J. Dermatol. 122 (6), 751–755. Comaisch, S., 1985. The thyroid and hair growth. Semin. Dermatol. 4, 4– 8. Haritha, S., Kirthi Sampath, K., 2013. Skin manifestations of hypothyroidism – a clinical study. OSR-JDMS 7, 58–60. Harrison, S., Sinclair, R., 2002. Telogen effluvium. Clin. Exp. Dermatol. 27, 389-5. Headington, J.T., 1993. Telogen effluvium: new concepts and review. Arch. Dermatol. 129, 356–363. Hordinsky, M.K., 2006. Medical treatment of noncicatricial alopecia. Semin. Cutan. Med. Surg. 25 (1), 51–55. Jain, V.K., Kataria, U., Dayal, S., 2000. Study of diffuse alopecia in females. Indian J. Dermatol. Venereol. Leprol. 66 (2), 65–68. Kantor, J., Kessler, L.J., Brooks, D.G., Cotsarelis, G., 2003. Decreased serum ferritin is associated with alopecia in women. J. Invest. Dermatol. 121, 985–988. Kligman, A.M., 1961. Pathologic dynamics of human hair loss. I. Telogen effluvium. Arch. Dermatol. 83, 175–198. Madani, K., Kumosani, T., 2001. Micronutrients status in Saudi Arabia. Bahrain Med. Bull. 23 (3), 135–139. McMichael, A., 2011. Approach to office visits for hair loss in women. Cutis 87, 8–9. McMichael, J., Hordin, M.K., Bergfeld, W.F., 2008. Telogen effluvium. In: McMichael, J., Hordin, M.K. (Eds.), Hair and Scalp Diseases: Medical, Surgical, and Cosmetic Treatments. Informa Health Care, London, UK, pp. 119–135 (chapter 9). Moeinvaziri, M., Mansoori, P., Holakooee, K., Safaee Naraghi, Z., Abbasi, A., 2009. Iron status in diffuse telogen hair loss among women. Acta Dermatovenerol. Croat. 17 (4), 279–284. Pie´rard-Franchimont, C., Xhauflaire-Uhoda, E., Pie´rard, G.E., 2006. Revisiting dandruff. Int. J. Cosmet. Sci. 28 (5), 311–318. Sinclair, R., 2005. Chronic telogen effluvium: a study of 5 patients over 7 years. J. Am. Acad. Dermatol. 52 (2 Suppl. 1), 12–16. Sinclair, R.D., Banfield, C.C., Dawber, R.P., 1999. Diffuse hair loss. In: Sinclair, R.D., Banfield, C.C., Dawber, R.P. (Eds.), Handbook of Diseases of the Hair and Scalp. Blackwell Science Ltd, UK, pp. 64–74. Sperling, L.C., 2001. Hair and systemic disease. Dermatol. Clin. 19, 711– 726. Tosti, A., Pazzaglia, M., 2007. Drug reactions affecting hair: diagnosis. Dermatol. Clin. 25, 223–231. Tosti, A., Misciali, C., Piraccini, B.M., Peluso, A.M., Bardazzi, F., 1994. Drug induced hair loss and hair growth. Drug Saf. 10, 310–317. Trost, L.B., Bergfeld, W.F., Calogeras, E., 2006. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J. Am. Acad. Dermatol. 54, 824–844. Trueb, R.M., 2010. Involvement of scalp and nails in lupus erythematosus. Lupus 19, 1078–1086. Whiting, D.A., 1996. Chronic telogen effluvium: increased scalp hair shedding in middle-aged women. J. Am. Acad. Dermatol. 35 (6), 899– 906. Whiting, D.A., 1996. Chronic telogen effluvium. Dermatol. Clin. 14, 723– 731. Yun, S.J., Lee, J.W., Yoon, H.J., et al., 2007. Cross-sectional study of hair loss patterns in 122 Korean systemic lupus erythematosus patients: a frequent finding of non-scarring patch alopecia. J. Dermatol. 34, 451– 455.