Abstract
Background:
Telogen effluvium (TE) is the most common cause of alopecia in women. Treatment should address the etiological factors and may include adjuvant therapies. In practice, physicians may employ modified approaches and utilize various combinations of topical and oral molecules.
Aims:
In this real-life observational study, the aim was to evaluate the response of TE to iron supplementation.
Materials and Methods:
The population consisted of all patients who sought consultation for TE at our dermatology department between March 2021 and February 2022. Eligible participants were women, aged between 18 and 65, having a clinical diagnosis of TE, and intended for treatment with iron supplementation. Exclusion criteria comprised current pregnancy, chronic or active inflammatory disease, newly discovered dysthyroidism, concurrent use of hair supplements, topical minoxidil, or any other medications. The response was assessed based on the patient’s level of satisfaction, a significant indicator, given the substantial psychological impact of TE on women’s daily lives.
Results:
The analysis included 200 women. The average age was 32.9 ± 11.4 years. A recent history of COVID-19 or treated dysthyroidism was present in 18.5% and 8% of patients, respectively, but did not impact their response. Significantly, patients with baseline ferritin ≥50 ng/ml were mostly “very satisfied”, those with baseline ferritin <50 ng/ml were mostly “not satisfied”, and those with unknown levels were mostly “partially satisfied” with iron supplementation. A high dose of elemental iron and a prolonged duration of treatment significantly improved the patients’ level of satisfaction.
Conclusion:
Iron supplementation can improve the patient’s level of satisfaction in TE even if serum ferritin is not low.
Keywords: Ferritin, iron supplementation, quality of life, telogen effluvium
Introduction
Telogen effluvium (TE) is the most common cause of alopecia in women. It can occur at any age and is diagnosed clinically. The psychological impact is significant. Common causes include iron deficiency, dysthyroidism, physical or psychological stress, and medication. Typically, TE resolves spontaneously within 6 to 12 months, but chronicity and relapses are common. Treatment involves addressing the underlying cause and using adjunct therapies. In practice, physicians may employ various combinations of topical and oral treatments. Several studies and expert opinions suggest an association, though not causality, between TE and low serum ferritin levels, leading to oral iron supplementation.[1,2,3,4,5,6] We propose that this supplementation remains beneficial when the serum ferritin baseline level exceeds 50 ng/ml. Consequently, we aimed to assess the response of TE to iron supplementation in a real-life setting.
Materials and Methods
Study setting, objectives, and eligibility criteria
We conducted this real-life observational single-centre cohort study at our tertiary care university hospital to assess the response to iron supplementation in TE and to identify factors that can modify it.
The population consisted of all patients who newly consulted our dermatology department for TE between March 2021 and February 2022. The inclusion criteria were as follows: women, aged between 18 and 65, with a clinical diagnosis of TE, and intended to be treated with iron supplementation. TE was diagnosed when excessive, diffuse, nonscarring hair shedding lasted for less than six months; no diagnostic tests such as the hair wash test, trichogram, phototrichogram, or scalp biopsy were used. The exclusion criteria were as follows: current pregnancy, chronic or active inflammatory disease, a newly discovered dysthyroidism, additional treatment with hair supplements, topical minoxidil, or any other molecules.
The real-life course of the study
The study was conducted without any interference or influence on the dermatologists’ approach and management of TE. Dermatologists were only asked to specify the patients’ level of satisfaction with the treatment at the follow-up visit, and none of them were aware of the study’s details.
Institutional Review Board (IRB) approval
The study received approval from the institution’s IRB committee (Reference Number: Tfem-2022-68) to collect information from patients’ files in our dermatology department. The study protocol adhered to the ethical guidelines of the 1975 Declaration of Helsinki.
Data collection
For data collection, we reviewed the files of eligible patients and gathered the following information: age, history of treated and reversed dysthyroidism, history of recent Covid-19, baseline serum ferritin levels, and the daily dose of elemental iron. After the follow-up visit, we re-examined the files to collect data on the duration of iron supplementation and the patient’s level of satisfaction.
Outcomes
We opted for the 50 ng/ml cut-off value of serum ferritin since it approximates the mean ferritin level in normal women (54.9 ng/ml) described in a large population-based study.[7]
We believed that, regardless of the objective assessment of treatment response in TE, patients’ satisfaction level could serve as the most relevant indicator, given the significant psychological impact of TE on women’s daily lives.
Sample size
The determination of the study size did not rely on prespecified statistical assumptions for the outcomes. Instead, it aimed to be optimal by including all eligible patients while adhering to the inclusion/exclusion criteria.
Statistical methods
Categorical variables were analysed using the Chi-square test or Fisher’s exact test. Age was presented as the mean and standard deviation and analysed with an ANOVA test. Statistical analyses were conducted using XLSTAT software (Addinsoft, Paris, France; version 2021.2.1.1100). A P value less than 0.05 was considered statistically significant.
Results
Initially, there were 304 eligible patients. We excluded 104 patients, of which 8 were pregnant, 5 had connective tissue diseases or multiple sclerosis, 2 were diagnosed with hyperthyroidism, and 89 received combined treatments. Ultimately, we analysed data from 200 women. The average age was 32.9 ± 11.4 years, with a range of 18–62 years. A recent history of COVID-19 was present in 37 patients (18.5%). Additionally, we found diagnosed and reversed dysthyroidism in 16 patients (8%).
Effect of age, history of COVID-19, or dysthyroidism
Neither age (as determined by the ANOVA test) nor a recent history of COVID-19 or dysthyroidism (as determined by Fisher’s exact test) exhibited a significant influence on patients’ satisfaction levels with iron supplementation (data not shown).
Effect of serum ferritin baseline level [Table 1]
Table 1.
Patients’ level of satisfaction according to serum ferritin baseline level, the daily dose of elemental iron, and the duration of iron supplementation
| Variable | Number of patients, n (%) | Very satisfied patients, n (%) | Partially satisfied patients, n (%) | Not satisfied patients, n (%) | P |
|---|---|---|---|---|---|
| Ferritin level in serum before treatment | |||||
| <50 ng/ml | 40 | 4 (10) | 15 (37.5) | 21 (52.5) | <0.0001 |
| >50 ng/ml | 35 | 25 (71.4) | 7 (20) | 3 (8.6) | <0.0001 |
| Unknown | 125 | 38 (30.4) | 62 (49.6) | 25 (20) | 0.016 |
| Daily dose of elemental iron | |||||
| ≤100 mg | 83 | 17 (20.5) | 26 (31.3) | 40 (48.2) | <0.01 |
| >100 mg | 117 | 59 (50.4) | 42 (35.9) | 16 (13.7) | <0.01 |
| Duration of iron supplementation | |||||
| 1 month | 17 | 3 (17.6) | 1 (5.9) | 13 (76.5) | <0.0001 |
| 2 months | 104 | 32 (30.8) | 48 (46.1) | 24 (23.1) | 0.46 |
| 3 months | 72 | 30 (41.7) | 31 (43.1) | 11 (15.3) | 0.046 |
The P is computed using the Chi-square test
Significantly, patients with a baseline ferritin level of ≥50 ng/ml were more frequently “very satisfied”, while those with a baseline ferritin level of <50 ng/ml were more frequently “not satisfied”. Patients with unknown levels were mostly “partially satisfied” with iron supplementation.
Effect of the daily dose of iron [Table 1]
Significantly, most patients were “very satisfied” when the daily dose of elemental iron exceeded 100 mg, whereas they were “not satisfied” when the dose was ≤100 mg.
Effect of iron supplementation duration [Table 1]
When the treatment was prescribed or taken for one month, significantly more patients were “not satisfied”. However, when the treatment lasted for 3 months, significantly more patients were “very or partially satisfied”.
Discussion
Our results suggest that in the treatment of TE, oral iron supplementation remains beneficial if the serum ferritin baseline level is not low or not known. Additionally, a high dose of elemental iron and a prolonged duration of treatment significantly improve the patient’s level of satisfaction. Neither the patient’s age nor a history of treated dysthyroidism or recent COVID-19 has affected the patient’s response, even though COVID-19 was suspected to be a significant trigger of TE.[8]
Counterintuitively, patients with a higher baseline level of serum ferritin were more satisfied with iron supplementation than those with a lower level. We can speculate that the closer the ferritin number is to the optimum for hair well-being, the faster the response to supplementation and the patients’ satisfaction will be. Another explanation could relate, in patients with low ferritin levels, to inadequate intestinal absorption of iron, whether provided with food or as a supplement, or to chronic and consistent loss through menses.
The real-life setting of the study does not have the same level of evidence as randomized trials but can provide plausible arguments for daily practice and additional studies. Several limitations need to be considered when interpreting our results. First, the study duration was short. Also, TE can have a self-limited course irrespective of the given treatment. In addition, we assessed patients only at the follow-up visit; the date was decided by the treating dermatologist. If done at monthly intervals, the assessment could have unmasked whether early nonresponders would benefit from prolonged supplementation. Furthermore, we did not make an objective evaluation of the response. Finally, we did not measure the degree of compliance with the treatment nor analyse certain confounding factors such as psychological stress and heavy periods.
The correlation between TE and iron deficiency is not fully elucidated. Iron is a cofactor of the enzyme ribonucleotide reductase that determines the speed of DNA synthesis; thus, the highly proliferative stem cells of the hair follicle would be highly sensitive to the bioavailability of iron.[9] However, some studies found no higher prevalence of iron deficiency in women with hair loss.[10,11]
The reference limits of serum ferritin are still debatable, particularly in cases of TE without anaemia.[12] This fact can expose any data to different interpretations.
In conclusion, iron supplementation can improve the patient’s level of satisfaction in TE even if serum ferritin is not low. A higher daily dose and a more prolonged treatment may increase the number of satisfied patients. Future research with a larger sample will validate or not such observations, considering other variables that play a role in the response, such as the patient’s characteristics, genetic background, and compliance with treatment.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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