Abstract
Background: Premature hair graying (PHG) is one of the most prevalent conditions affecting individuals worldwide. It has been recognized as an important cause of low self-esteem, with a significant physical and social impact. This study investigated the factors associated with PHG by comparing medical students and resident physicians to other non-medical majors at Imam Abdulrahman Bin Faisal University (IAU). Methods: This is a comparative cross-sectional study conducted on resident physicians and students from 10 different colleges of IAU, Eastern Province, Saudi Arabia. This study evaluated the characteristics of PHG and its associated risk factors using an online distributed questionnaire. Results: A total of 2644 students and resident physicians were included in this study, with 45.6% coming from medical colleges. The findings show that the premature graying of hair was higher among obese and overweight individuals and those with a combined deficiency of vitamins B12 and vitamin D. Other factors associated with PHG included a family history of PHG, a lack of exercise, smoking, and allergic rhinitis. Gray hair onset before 25 years old was higher among those with high stress levels (95%) than those with moderate (90%) and or mild (86%) stress levels (p = 0.029). Conclusions: In our study, higher stress levels were related to an earlier age of PHG onset, and there was no difference between medical and non-medical students in PHG. Recommendations for future research include randomized clinical trials and larger cohort studies regarding the characteristics of PHG in the Middle East and those with Arabic ethnicity and assessing the medications that induce possible hair repigmentation.
Keywords: premature graying of hair, early canities, Saudi Arabia, perceived stress level
1. Introduction
Premature hair graying (PHG) is one of the most prevalent conditions affecting individuals worldwide, with a prevalence of 27.3% [1]. It has been recognized as an important cause of low self-esteem, having a significant physical–social impact [2]. Although the definition of premature hair graying (PHG) remains consistent, its operationalization in research may vary across racial and ethnic groups, corresponding to differences in the typical age of onset; PHG is generally considered to occur before the age of 20 in white people, before 25 in people from Asia, and before 30 in people from Africa [2,3]. Previous studies among individuals of Saudi descent considered the appearance of gray hair before the age of 30 to be premature [4,5]. The exact pathophysiological mechanism of PHG remains incompletely understood. However, it revolves around the role of antioxidants in the growth of hair follicles and an increase in oxidative stress, which ultimately damages melanocytes and leads to a loss of pigmentation [1,2]. Multiple factors can predispose patients to this increase in oxidative stress, such as emotional stress, vitamin B12 deficiency, thyroid hormone deficiency, smoking, genetic predisposition, or autoimmune conditions such as vitiligo. Moreover, PHG can be inherited in an autosomal dominant inheritance pattern [3,6,7,8].
Multiple cross-sectional studies from 2013 to 2023 in India, Nepal, Pakistan, Turkey, Korea, Indonesia, Saudi Arabia, and Egypt have assessed the prevalence of PHG and its risk factors [1,6,7,8,9,10,11,12,13,14,15]. There has been a variation in the results of these studies owing to the definition of PHG, which relies on ethnicity. In the Middle East, there is little evidence regarding PHG as a reference age group. However, recent studies conducted in Saudi Arabia and Egypt have assessed PHG with a cutoff of 30 years as an inclusion criterion [4,5,9].
The reported prevalence of PHG among medical students ranged from 31.2% to 41.4% [16,17,18,19], compared to 27.3% in the general population [1]. A study conducted among medical students in Indonesia reported a prevalence of 71.2% [20]. The risk factors that were reported to be significantly associated with PHG among the studies were family history, obesity, smoking, educational status, hair loss, and stress [7,12,14]. Hypothyroidism and nutritional deficiencies including ferritin, vitamin B12, vitamin D, and calcium also had a significant association with PHG [7,8,11]. Other factors included a preference for a vegetarian diet, a low body mass index (BMI) (<18.5), a history of atopy, a sedentary lifestyle, the application of oils on the scalp, and coronary artery disease [6,7,8,11,21].
Due to the demanding academic and clinical training that medical students and resident physicians undergo, they are particularly vulnerable to high levels of stress, which may contribute to early aging markers, such as PHG [9]. Hence, in this study, we aimed to investigate the factors associated with PHG by comparing medical students and resident physicians to other non-medical majors at Imam Abdulrahman Bin Faisal University (IAU) in the Eastern Province, Kingdom of Saudi Arabia.
2. Material and Methods
2.1. Study Design, Setting, and Ethics
This comparative cross-sectional study included undergraduate students from ten colleges, as well as resident physicians (postgraduate students), at Imam Abdulrahman Bin Faisal University in Al-Khobar, Eastern Province, Saudi Arabia. The target group consisted of medical students and residents, and the comparative group consisted of students from non-medical field colleges of the same university, including the colleges of science, education, art, computer science, business administration, architecture and planning, engineering, sharia and law, and the college of applied studies and community service. The study obtained ethical approval from the university’s Institutional Review Board (IRB), with an approval date of 10 August 2023 and IRB number IRB-2023-01-315. The study complied with the ethical standards of research ethics involving human subjects (Declaration of Helsinki) [22]. Data collection was performed from August 2023 to December 2023.
2.2. Participants
The inclusion criteria were students enrolled in the university and aged 18–30 years. Participants with a hypopigmentary disorder were excluded. All the medical students were approached at different levels. The comparative non-medical field group was selected through stratified random sampling according to theoretical and practical simple random sampling with proportional allocation. Participants were recruited via student groups on WhatsApp and Telegram, which are widely used instant messaging platforms.
2.3. Data Collection Tool and Processes
Data were collected using a self-administered online questionnaire developed in Arabic by the research team through the QuestionPro platform. A pilot study was conducted to ensure the clarity and appropriateness of the survey items prior to distribution. The final questionnaire comprised three structured sections. The first section collected sociodemographic information, including age, sex, marital status, financial income, educational level, college affiliation, and academic performance. The second section focused on premature hair graying (PHG) and psychological stress, including the self-reported presence and extent of hair graying, age at onset, and the prior use of hair oils or minoxidil. Psychological stress was assessed using the validated Arabic version of the Perceived Stress Scale (PSS-10) with a Cronbach’s alpha of 0.67 [23]. The third section addressed potential PHG-associated factors, including self-reported medical conditions, vitamin and mineral deficiencies, family history of PHG, dietary habits, physical activity (measured by average daily steps), and smoking. For participants with a history of smoking, additional information on lifetime cigarette exposure was obtained. An optional item allowed participants to request follow-up contact via phone or email for psychological support or stress evaluation.
2.4. Variables
This study included a comprehensive set of variables categorized into sociodemographic characteristics, variables related to premature hair graying (PHG) and psychological stress, and potential PHG-associated factors. Sociodemographic variables comprised sex (male, female), age (mean and standard deviation), marital status (married, single, widowed/divorced), financial income (not enough, enough, more than enough), educational level (undergraduate, postgraduate), college affiliation (medicine, science, art, education, computer science, business administration, engineering, architecture and planning, applied studies and community service, and sharia and law), and academic performance, which was categorized based on the participants’ self-reported grade point average (GPA) as good, very good, or excellent. Variables related to PHG and psychological stress included the presence of hair graying (yes/no), the estimated number of gray hairs (<10, 10–100, >100), the age of onset of gray hair (before 25 years, between 25 and <30 years, or 30 years and above), and the use of hair oils or minoxidil prior to the appearance of gray hair (yes/no). Psychological stress was assessed using the validated Arabic version of the Perceived Stress Scale (PSS-10), which consists of 10 items. Each item of the PSS-10 is rated on a 5-point Likert scale (0 = Never, 1 = Almost Never, 2 = Sometimes, 3 = Fairly Often, 4 = Very Often). The total score, ranging from 0 to 40, is obtained by summing all items and is categorized as follows: 0–13 = low stress, 14–26 = moderate stress, and 27–40 = high stress. PHG-associated factors included the presence of specific medical conditions (yes/no), such as depression, hypothyroidism, coronary artery disease, atopic dermatitis, bronchial asthma, and allergic rhinitis. Nutritional deficiencies were assessed based on self-reported serum measurements for vitamin B12, vitamin D, combined vitamin D and B12, calcium, and iron. Participants were asked whether they had been tested for these nutrients and, if so, whether deficiencies had been diagnosed based on their serum measurements (Yes, only a deficiency in [vitamin/mineral]/Yes, a deficiency in both/No deficiency/and Test was not performed.) Additional variables encompassed a family history of PHG and lifestyle-related factors, including the participants’ diet type (vegetarian, mostly meat, or mixed) [7], average number of daily steps (<3000; 3000–6000; 6001–10,000; >10,000) [24], and smoking status (current, past, occasional, second-hand exposure, or non-smoker) [25]. For participants who reported a history of smoking, the lifetime number of cigarettes smoked was categorized as fewer than 100 or more than 100.
2.5. Sample Size and Power Analysis
Sample size was calculated using an online sample size calculator (epi info v5.5.10) [26], assuming that the percentage of gray hair in the general population is 27.3% [27]. At a 95% confidence interval (CI) and 80% statistical power, to detect a significant odds ratio of 1.5, the minimum required sample size was 934, in which 467 participants were equally stratified from the target group and the comparative groups.
2.6. Statistical Analysis
IBM SPSS Statistics for Windows, version 26.0, was used for the data entry and analysis. Statistical significance was set at a p value < 0.05. Bivariate analyses were conducted using premature hair graying (PHG) as a binary variable, defined as the presence of graying before the age of 30. Categorical data were described as frequencies and percentages, while means and standard deviations were used to describe quantitative data. The chi-square test was used to evaluate the association between variables. Logistic regression models were used to identify the independent factors associated with PHG (appeared before the age of 30 years) and to control for confounders.
3. Results
Table 1 presents the characteristics of the study participants. In this study, 2644 students were included, with the majority (95%) being undergraduates. Almost half of the students (45.6%) were from medical colleges. Female participants accounted for 64%. Most patients were single (90.4%). The highest percentage (62.7%) of these students had a sufficient financial status. Almost half of the students’ academic performances were very good.
Table 1.
Sociodemographic characteristics of students at Imam Abdulrahman Bin Faisal University (IAU), Eastern province, Saudi Arabia, 2023.
| No. (n = 2644) |
% | ||
|---|---|---|---|
| College | Medicine | 1127 | 42.6 |
| Non-medical | 1517 | 57.4 | |
| Age | Min–max Mean ± SD |
17–35 21 ± 3.1 |
|
| Educational level | Undergraduate | 2514 | 95.1 |
| Postgraduate | 130 | 4.9 | |
| Sex | Male | 951 | 36.0 |
| Female | 1693 | 64.0 | |
| Marital status | Married | 235 | 8.9 |
| Single | 2391 | 90.4 | |
| Divorced or Widowed | 18 | 0.7 | |
| Financial status | Not enough | 640 | 24.2 |
| Enough | 1658 | 62.7 | |
| More than enough | 346 | 13.1 | |
| Academic performance (GPA) | (<3.5) Good | 371 | 14.8 |
| (3.5–4.49) Very Good | 1282 | 51.0 | |
| (>4.49) Excellent | 861 | 34.2 | |
Table 2 shows the characteristics of PHG among university students from the medical and non-medical fields. This shows that 39.1% observed the graying of hair. Almost 70% of them noticed less than 10 gray hairs, and 6.7% noticed more than 100 gray hairs. Regarding the onset of gray hair, 90% of them had it before the age of 25 and 5.9% of them had it between the ages of 25 and 30. Almost 30% of them mentioned the use of hair oils and 13% mentioned the use of minoxidil prior to the onset of hair graying. Among those who had graying hair, the level of stress was moderate in 65.3% (95% CI = [62.4, 68.3]) and high in 20% (95% CI = [17.6, 22.6]), which is higher than that previously reported (12.7%) among Saudi university students [27].
Table 2.
Characteristics of premature hair graying (PHG) in students at IAU, Saudi Arabia, 2023.
| No. (n = 2644) |
% | ||
|---|---|---|---|
| Noticed graying of hair | Yes | 1035 | 39.1 |
| No | 1609 | 60.9 | |
| PHG (n = 1035) | |||
| Number of gray hairs | <10 | 720 | 69.6 |
| 10–100 | 246 | 23.8 | |
| >100 | 69 | 6.7 | |
| Age of noticing graying of hair (years) | Before 25 | 933 | 90.1 |
| 25–<30 | 61 | 5.9 | |
| 30+ | 41 | 4.0 | |
| Use of hair oils before the onset of hair graying | No | 728 | 70.5 |
| Yes | 305 | 29.5 | |
| Use of minoxidil before the onset of hair graying | Yes | 134 | 13.0 |
| No | 899 | 87.0 | |
| Perceived Stress Scale | Low | 152 | 14.7 |
| Moderate | 677 | 65.3 | |
| High | 207 | 20.0 | |
Figure 1 shows that the onset of gray hair before 25 years old was higher among those with high stress levels (95%) than those with moderate (90%) or mild (86%) stress levels (p = 0.029). However, no association was found between the number of gray hairs and stress level.
Figure 1.
Association between stress levels and age at onset of grey hair.
Participants’ characteristics were compared between students with and without PHG, as illustrated in Table 3. PHG was higher among obese and overweight individuals and those with a combined deficiency of vitamin B12 and vitamin D. Among the triad of atopy, allergic rhinitis demonstrated a statistically significant association with PHG (p = 0.018); other factors associated with PHG included a family history of PHG, a lack of exercise represented by a low number of daily steps, smoking, and smoking a high number of cigarettes. Sex, marital status, diet type, financial status, and calcium and iron deficiencies were not significantly associated with PHG. All the values are listed in Table 3.
Table 3.
Factors associated with premature hair graying (PHG) among IAU students.
| PGH (<30 years) | ||||||
|---|---|---|---|---|---|---|
| Yes (n = 994, 37.6%) | No (n = 1650, 62.4%) | p Value | ||||
| No. | % | No. | % | |||
| College | Medicine (n = 1127) | 422 | 37.4 | 705 | 62.6 | 0.891 |
| Non-medical (n = 1517) | 572 | 37.7 | 945 | 62.3 | ||
| Sex | Male (n = 951) | 366 | 38.5 | 585 | 61.5 | 0.478 |
| Female (n = 1693) | 628 | 37.1 | 1065 | 62.9 | ||
| Marital status | Married (n = 235) | 91 | 38.7 | 144 | 61.3 | 0.175 |
| Single (n = 2391) | 900 | 37.6 | 1491 | 62.4 | ||
| Widowed or divorced (n = 18) | 3 | 16.7 | 15 | 83.3 | ||
| Body mass index (BMI) |
Underweight (n = 414) | 136 | 32.9 | 278 | 67.1 | <0.001 |
| Normal (n = 1401) | 484 | 34.5 | 917 | 65.5 | ||
| Overweight (n = 541) | 245 | 45.3 | 296 | 54.7 | ||
| Obese (n = 288) | 129 | 44.8 | 159 | 55.2 | ||
| Financial Status | Not enough (n = 640) | 242 | 37.8 | 398 | 62.2 | 0.833 |
| Enough (n = 1658) | 627 | 37.8 | 1031 | 62.2 | ||
| More than enough (n = 346) | 125 | 36.1 | 221 | 63.9 | ||
| Vitamin deficiency | B12 (n = 67) | 18 | 26.9 | 49 | 73.1 | 0.002 |
| D (n = 523) | 207 | 39.6 | 316 | 60.4 | ||
| B12 and D (n = 278) | 122 | 43.9 | 156 | 56.1 | ||
| No (n = 400) | 126 | 31.5 | 274 | 68.5 | ||
| Iron deficiency | Yes (n = 737) | 287 | 38.9 | 450 | 61.1 | 0.376 |
| No (n = 808) | 297 | 36.8 | 511 | 63.2 | ||
| Calcium deficiency | Yes (n = 209) | 74 | 35.4 | 135 | 64.6 | 0.918 |
| No (n = 883) | 316 | 35.8 | 567 | 64.2 | ||
| Depression | Yes (n = 211) | 91 | 43.1 | 120 | 56.9 | 0.083 |
| No (n = 2428) | 901 | 37.1 | 1527 | 62.9 | ||
| Allergic rhinitis | Yes (n = 316) | 138 | 43.7 | 178 | 56.3 | 0.017 |
| No (n = 2323) | 854 | 36.8 | 1469 | 63.2 | ||
| Atopic dermatitis | Yes (n = 208) | 75 | 36.1 | 133 | 63.9 | 0.635 |
| No (n = 2431) | 917 | 37.7 | 1514 | 62.3 | ||
| Bronchial asthma | Yes (n = 179) | 60 | 33.5 | 119 | 66.5 | 0.244 |
| No (n = 2460) | 932 | 37.9 | 1528 | 62.1 | ||
| Coronary artery disease | Yes (n = 7) | 3 | 42.9 | 4 | 57.1 | 0.773 |
| No (n = 2632) | 989 | 37.6 | 1643 | 62.4 | ||
| Hypothyroidism | Yes (n = 52) | 20 | 38.5 | 32 | 61.5 | 0.896 |
| No (n = 2587) | 972 | 37.6 | 1615 | 62.4 | ||
| Family history of PHG (before the age of 25) | Yes (n = 718) | 443 | 61.7 | 275 | 38.3 | <0.001 |
| No (n = 1925) | 550 | 28.6 | 1375 | 71.4 | ||
| Number of daily steps | <3000 steps (Lack) (n = 799) | 333 | 41.7 | 466 | 58.3 | <0.001 |
| 3000–6000 steps (Low) (n = 1069) | 425 | 39.8 | 644 | 60.2 | ||
| 6001–10,000 (Moderate) (n = 1069) | 195 | 30.9 | 437 | 69.1 | ||
| >10,000 steps (Recommended) (n = 632) | 40 | 28.2 | 102 | 71.8 | ||
| Diet | Vegetarian (n = 80) | 24 | 30.0 | 56 | 70.0 | 0.119 |
| Mostly meat (n = 713) | 286 | 40.1 | 427 | 59.9 | ||
| Mixed meat and vegetables (n = 1850) | 683 | 36.9 | 1167 | 63.1 | ||
| Smoking | Current smoker (n = 178) | 86 | 48.3 | 92 | 51.7 | 0.037 |
| Past smoker (n = 54) | 22 | 40.7 | 32 | 59.3 | ||
| Secondhand smoker (n = 261) | 97 | 37.2 | 164 | 62.8 | ||
| Occasional smoker (n = 119) | 47 | 39.5 | 72 | 60.5 | ||
| Non-smoker (n = 2031) | 741 | 36.5 | 1290 | 63.5 | ||
| Number of cigarettes ever smoked | 100 + (n = 177) | 92 | 52.0 | 85 | 48.0 | 0.003 |
| <100 (n = 170) | 61 | 35.9 | 109 | 64.1 | ||
After entering the studied variables into a logistic regression model, the independent factors associated with PHG included a family history of PHG, a lack of or low exercise, smoking, overweight, and obesity. All the values are listed in Table 4.
Table 4.
Logistic regression for independent factors associated with PGH.
| B | S.E. | Wald | Df | Sig. | Exp (B) | 95% C.I. for Exp (B) |
||
|---|---|---|---|---|---|---|---|---|
| Lower | Upper | |||||||
| Medical college | 0.006 | 0.087 | 0.005 | 1 | 0.946 | 1.006 | 0.848 | 1.194 |
| Family history of PGH | 1.434 | 0.094 | 231.163 | 1 | 0.000 | 4.197 | 3.489 | 5.050 |
| Number of daily steps [24] (>10,000 steps) | 22.800 | 3 | 0.000 | |||||
| <3000 steps (Lack) | 0.593 | 0.213 | 7.794 | 1 | 0.005 | 1.810 | 1.193 | 2.745 |
| 3000–6000 steps (Low) | 0.538 | 0.209 | 6.605 | 1 | 0.010 | 1.712 | 1.136 | 2.580 |
| 6001–10,000 (Moderate) | 0.124 | 0.218 | 0.325 | 1 | 0.569 | 1.132 | 0.738 | 1.737 |
| Atopic dermatitis | 0.261 | 0.164 | 2.545 | 1 | 0.111 | 0.770 | 0.559 | 1.061 |
| Bronchial asthma | 0.389 | 0.179 | 4.710 | 1 | 0.030 | 0.678 | 0.477 | 0.963 |
| Allergic rhinitis | 0.243 | 0.132 | 3.394 | 1 | 0.065 | 1.275 | 0.985 | 1.652 |
| Depression | 0.128 | 0.157 | 0.664 | 1 | 0.415 | 1.136 | 0.836 | 1.546 |
| Coronary artery disease | 0.104 | 0.802 | 0.017 | 1 | 0.897 | 1.110 | 0.231 | 5.338 |
| Hypothyroidism | 0.121 | 0.313 | 0.150 | 1 | 0.698 | 0.886 | 0.480 | 1.635 |
| Non-smoker | 13.644 | 4 | 0.009 | |||||
| Current smoker | 0.602 | 0.168 | 12.900 | 1 | 0.000 | 1.826 | 1.315 | 2.537 |
| Past smoker | 0.280 | 0.302 | 0.858 | 1 | 0.354 | 1.323 | 0.732 | 2.389 |
| Secondhand smoker | 0.092 | 0.146 | 0.400 | 1 | 0.527 | 1.096 | 0.824 | 1.458 |
| Occasional smoker | 0.155 | 0.207 | 0.566 | 1 | 0.452 | 1.168 | 0.779 | 1.752 |
| Underweight | 32.903 | 3 | 0.000 | |||||
| Normal | 0.082 | 0.126 | 0.421 | 1 | 0.516 | 1.085 | 0.847 | 1.390 |
| Overweight | 0.604 | 0.145 | 17.333 | 1 | 0.000 | 1.829 | 1.377 | 2.431 |
| Obese | 0.552 | 0.168 | 10.747 | 1 | 0.001 | 1.737 | 1.249 | 2.416 |
| Mixed meat and vegetables [8] | 4.240 | 2 | 0.120 | |||||
| Vegetarian | 0.320 | 0.266 | 1.445 | 1 | 0.229 | 0.726 | 0.431 | 1.223 |
| Mostly meat | 0.151 | 0.098 | 2.379 | 1 | 0.123 | 1.163 | 0.960 | 1.410 |
| Constant | 1.654 | 0.230 | 51.669 | 1 | 0.000 | 0.191 | ||
Furthermore, by creating a model for only those who were known to have vitamin deficiencies (diagnosed by previous laboratory results) and controlling for the above factors, both vitamin D and B12 were a positive factor associated with PHG, with an adjusted odds ratio = 1.48 (95%CI [1.06, 2.09]), and also those diagnosed with depression (OR = 1.5, 95%CI [1.03, 2.2]).
4. Discussion
PHG is the presence of gray hair before the age of 20–30 years, depending on ethnicity [1,3]. In Saudi Arabia, where our study was conducted, the age of PHG was considered to be 30 years and below, according to previous studies conducted in Saudi Arabia [4,5].
The mechanism of action of PHG remains uncertain, but it is likely caused by oxidative stress in the growing hair follicle, which leads to melanocyte damage and a loss of pigment within the hair follicle [2,10]. The multiple factors mentioned earlier contribute to an increased risk of PHG. Of these, stress is a significant contributing factor [12].
Our study was conducted to investigate the factors associated with PHG by comparing medical students and resident physicians below the age of 30 to other non-medical majors at IAU.
We found that the percentage of students with PHG was 39.1% among students at IAU, which was higher than the 28.2% found in a previous study reported by Kansal et al. on university students at a university in Mysuru [28], and close to another study conducted by Rehab Almutairi in Saudi Arabia at another university in Al-Hassa, which found that 42.5% of students had PHG [4]. Moreover, no difference was observed between medical and non-medical specialties (p = 0.891) or between males and females (p = 0.478).
In our study, the age at PHG onset was associated with higher stress levels. Gray hair onset before 25 years of age was higher among those with high stress levels than among those with moderate and mild stress levels (p = 0.029). Recently, Zhang et al. reported how stress may cause PHG. They found that stress induces noradrenaline release from sympathetic nerves, which in turn depletes the melanocyte stem cell niche that provides pigments to hair follicles [29]. It was found that external factors such as psychological stress can also contribute to oxidative stress outside the melanocytes of hair follicles, further challenging the antioxidant capacity of melanocytes and leading to increased damage in aging hair follicles [3]. However, there was no association between the level of stress and the severity of PGH, as illustrated by the number of gray hairs.
Interestingly, the higher the BMI, the higher the prevalence of hair graying before the age of 30 years. In our study, 45.3% of overweight students had PHG and 44.8% of obese students had PHG, as opposed to 32.9% of underweight students and 34.5% of students with a normal BMI and PHG. This result supports previous data reported by Kansal et al. in a study conducted in Mysuru [28], which confirmed the proportional relationship between BMI and PHG. These results support the idea that obesity may reduce melanin production due to the common occurrence of leptin resistance in obese individuals, which in turn increases the levels of substances that counteract melanocyte-stimulating hormone [14,30].
It was found that almost 30% of the students with PHG mentioned the use of hair oils and 13% mentioned the use of minoxidil prior to the onset of hair graying. Further studies are required to investigate the association between their use and PHG levels.
In our study, we also found that students with combined vitamin D and B12 deficiency, confirmed by a history of serum measurement, had a higher prevalence of PHG (43.9%) than those with either vitamin D or B12 deficiency. A study by Chakrabaty et al. in Bengaluru found that serum levels of vitamin B12 were significantly lower in people with PHG than in controls, with no association between vitamin D3 levels and PHG [31]. Hair follicle cells are known for their rapid division. However, the growth of these cells relies on DNA synthesis, which in turn requires an adequate supply of vitamin B12 [32]. Vitamin B12 helps stabilize the initial growth phase of hair follicles [33].
Studying the association between PHG and family history, we found that there is a significant relation between them, where 61.7% of patients with PHG have a family history of PHG. This study confirms the previously reported association, as in studies conducted in India and Indonesia [17,20,28,34].
Our study also revealed that approximately half of the students (48.3%) who were current smokers had PHG, and those who smoked a higher number of cigarettes per day had a higher percentage of PHG. Smoking is a major contributor to oxidative stress and plays an important role in the development of PHG. This finding was confirmed in many studies, such as those conducted by Shin et al., Kansal et al., Bhramaramba et al., and Zayed et al. [14,28,34,35].
Interestingly, allergic rhinitis is also a risk factor for PHG, as individuals with allergic rhinitis were found to have a higher prevalence of PHG (43.7%). The relationship between atopy and PHG remains unclear, but a study by Acer et al. confirmed this association [7]. Further studies are warranted.
A sedentary lifestyle not only affects the coronary arteries, but also affects PHG. This accelerates the aging process in all aspects. We found that people with daily steps of < 3000 had a higher prevalence of PHG at around 40%, whereas those who walked more than 10,000 steps per day had a prevalence of PHG of 28.2%. Chakrabaty et al. confirmed this association [31].
From the factors studied, it was found that sex, marital status, type of diet, financial status, calcium deficiency, and iron deficiency were not statistically significantly associated with PHG.
This study had some limitations. This was survey-based research, and the serum levels of vitamins and iron were not measured. Moreover, it was lacking a clinical examination to evaluate PHG severity.
5. Conclusions
In our study, PHG was noticed in almost 37% of students, with no difference between medical and non-medical students. Higher stress levels were related to earlier PHG onset. Recommendations for future research include randomized clinical trials and larger cohort studies on the characteristics of PHG in the Middle East region and among individuals of Arabic ethnicity, as well as assessments of medications that may induce hair repigmentation. Furthermore, additional research is needed to clarify the relationship between PHG and allergic rhinitis.
Acknowledgments
The authors would like to thank the following data collectors: Nawaf Radi Alaswad, Mohammed Yousef Alhammrani, Lara Hasan Al Massloom, Sadiq Fuad Alherz, Wesam Adel Almuslim, Ibrahim Abdullah Alsinan, Hassan Ghassan Alahsaie, Razan Mohammed Alawadh, Daniah Naif Alotaibi, Noura Essam Alkadi, Nora Ahmed Aljarri, Reema Abdullah Alruwais, Hassan Tahir Alwail, and Alanoud Rashed Alsubaie. Additionally, we extend our gratitude to all the students and resident physicians who participated in this study.
Abbreviations
| PHG | Premature hair graying |
| IAU | Imam Abdulrahman Bin Faisal University |
| PSS | Perceived stress scale |
| BMI | Body mass index |
| IRB | Institutional review board |
Author Contributions
Conceptualization, I.B.A. and N.J.A.; Formal Analysis, I.B.A. and S.M.A.; Methodology, I.B.A., H.A.A., N.J.A. and M.M.A.W.; Software, I.B.A. and S.M.A.; Supervision, N.J.A. and S.A.A.; Validation, I.B.A., N.J.A. and H.A.A.; Writing—Original Draft, I.B.A. and S.M.A.; Writing—Review and Editing, I.B.A., N.J.A., S.A.A. and M.M.A.W.; Project Administration, S.A.A. and H.A.A. All authors have read and agreed to the published version of the manuscript.
Institutional Review Board Statement
Ethical approval was obtained from the Institutional Review Board of Imam Abdulrahman Bin Faisal University under number IRB-2023-01-315 on 10 August 2023.
Informed Consent Statement
The questionnaire included a cover letter stating that participation in the study is voluntary, along with a checkbox for participants to give their consent prior to participation.
Data Availability Statement
Data supporting the findings and conclusions are available upon request from the corresponding author.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding Statement
This research received no external funding.
Footnotes
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.
References
- 1.Nath B., Gupta V., Kumari R. A community based study to estimate prevalence and determine correlates of premature graying of hair among young adults in Srinagar, Uttarakhand, India. Int. J. Trichology. 2020;12:206–212. doi: 10.4103/ijt.ijt_28_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Pandhi D., Khanna D. Premature graying of hair. Indian J. Dermatol. Venereol. Leprol. 2013;79:641–653. doi: 10.4103/0378-6323.116733. [DOI] [PubMed] [Google Scholar]
- 3.Tobin D.J., Paus R. Graying: Gerontobiology of the hair follicle pigmentary unit. Exp. Gerontol. 2001;36:29–54. doi: 10.1016/S0531-5565(00)00210-2. [DOI] [PubMed] [Google Scholar]
- 4.Almutairi R.T., Dhafiri M.A. Premature greying of hair among the population of King Faisal University in Al-Ahasa, Saudi Arabia: An epidemiological study. Int. J. Med. Dev. Ctries. 2019;3:542–548. doi: 10.24911/IJMDC.51-1549226311. [DOI] [Google Scholar]
- 5.Almudimeegh A.M., AlObaid S.O., Albinhar T.H., Alwadany M.M., Alajlan A.H., Alhedaithi N.A., Alawadh R.M., Kadasa A.N., Alobaid A.S., Alshathry Y.H., et al. Prevalence and Predictors of Premature Graying of Hair Before the Age of 30: A Cross-Sectional Study in Saudi Arabia. J. Cosmet. Dermatol. 2024;23:16627. doi: 10.1111/jocd.16627. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.El-Husseiny R., Alrgig N.T., Abdel Fattah N.S.A. Epidemiological and biochemical factors (serum ferritin and vitamin D) associated with premature hair graying in Egyptian population. J. Cosmet. Dermatol. 2021;20:1860–1866. doi: 10.1111/jocd.13747. [DOI] [PubMed] [Google Scholar]
- 7.Acer E., Kaya Erdoğan H., İğrek A., Parlak H., Saraçoğlu Z.N., Bilgin M. Relationship between diet, atopy, family history, and premature hair graying. J. Cosmet. Dermatol. 2019;18:665–670. doi: 10.1111/jocd.12840. [DOI] [PubMed] [Google Scholar]
- 8.Sonthalia S., Priya A., Tobin D.J. Demographic characteristics and association of serum vitamin B12, ferritin and thyroid function with premature canities in Indian patients from an Urban Skin Clinic of North India: A retrospective analysis of 71 cases. Indian J. Dermatol. 2017;62:304–308. doi: 10.4103/ijd.IJD_221_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Alkahtani A.R., Alfadhli R.F., Aldakhilallah M.M., Almutlaq M., Alzamil F. Relationship between premature hair graying and psychological stress: A cross-sectional study on young Saudis in Riyadh, Saudi Arabia. Int. J. Med. Dev. Ctries. 2022;6:574–578. doi: 10.24911/IJMDC.51-1634660336. [DOI] [Google Scholar]
- 10.Kumar A.B., Shamim H., Nagaraju U. Premature graying of hair: Review with updates. Int. J. Trichology. 2018;10:198–203. doi: 10.4103/ijt.ijt_47_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Bhat R.M., Sharma R., Pinto A.C., Dandekeri S., Martis J. Epidemiological and investigative study of premature graying of hair in higher secondary and pre-university school children. Int. J. Trichology. 2013;5:17–21. doi: 10.4103/0974-7753.114706. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Akin Belli A., Etgu F., Ozbas Gok S., Kara B., Dogan G. Risk factors for premature hair graying in young Turkish adults. Pediatr. Dermatol. 2016;33:438–442. doi: 10.1111/pde.12881. [DOI] [PubMed] [Google Scholar]
- 13.Anggraini D.R., Feriyawati L., Hidayat H., Wahyuni A.S. Risk factors associated with premature hair greying of young adult. Open Access Maced. J. Med. Sci. 2019;7:3762–3764. doi: 10.3889/oamjms.2019.498. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Shin H., Ryu H.H., Yoon J., Jo S.J., Jang S., Choi M., Kwon O., Jo S.J. Association of premature hair graying with family history, smoking, and obesity: A cross-sectional study. J. Am. Acad. Dermatol. 2015;72:321–327. doi: 10.1016/j.jaad.2014.11.008. [DOI] [PubMed] [Google Scholar]
- 15.Thompson K.G., Marchitto M.C., Ly B.C.K., Chien A.L. Evaluation of physiological, psychological, and lifestyle factors associated with premature hair graying. Int. J. Trichology. 2019;11:153–158. doi: 10.1016/j.jid.2019.03.948. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Saad M., Babar N.F., Majeed R., Aftab S., Khaliq S., Qamar A., Naseer R., Malik S., Abbas M., Azam A. Impact of premature greying of hair on socio-cultural adjustment and self-esteem among medical undergraduates in Foundation University, Islamabad. Cureus. 2019;11:e5083. doi: 10.7759/cureus.5083. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Padmavathi P., Sathiyapriya V., Jos P., Sudha V. Prevalence of premature canities among college students studying in a private medical college, Chennai: A cross sectional study. Int. J. Health Sci. 2022;6:6576–6582. doi: 10.53730/ijhs.v6nS6.11182. [DOI] [Google Scholar]
- 18.Chaudhary S., Mahotra N.B. Early canities among undergraduate medical students of a medical college: A descriptive cross-sectional study. JNMA J. Nepal Med. Assoc. 2023;61:220–223. doi: 10.31729/jnma.7961. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Parihar S., Verma M., Sharma S., Meena R. Prevalence of premature hair greying, its associated factors and impact on quality of life in medical students from Rajasthan, India. J. Med. Evid. 2023;4:213–219. doi: 10.4103/JME.JME_126_22. [DOI] [Google Scholar]
- 20.Lubis E.Z., Jusuf N.K. Risk factors analysis of premature canities in medical students of universitas Sumatera utara class 2016-2018. Sumat. Med. J. 2020;3:48–58. doi: 10.32734/sumej.v3i1.3543. [DOI] [Google Scholar]
- 21.Kocaman S.A., Çetin M., Durakoğlugil M.E., Yılmaz M., Çiçek G., Erdoğan T., Kılıç M., Akbulut M., İrkin H., Özdemir M. The degree of premature hair graying as an independent risk marker for coronary artery disease: A predictor of biological age rather than chronological age. Anadolu Kardiyol. Derg. 2012;12:457–463. doi: 10.5152/akd.2012.150. [DOI] [PubMed] [Google Scholar]
- 22.World Medical Association World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA. 2013;310:2191–2194. doi: 10.1001/jama.2013.281053. [DOI] [PubMed] [Google Scholar]
- 23.Ali A.M., Hendawy A.O., Ahmad O., Al Sabbah H., Smail L., Kunugi H. The Arabic Version of the Cohen Perceived Stress Scale: Factorial Validity and Measurement Invariance. Brain Sci. 2021;11:419. doi: 10.3390/brainsci11040419. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Piotrowska K., Pabianek Ł. Physical activity–classification, characteristics, and health benefits. Qual. Sport. 2019;5:7–14. doi: 10.12775/QS.2019.007. [DOI] [Google Scholar]
- 25.National Health Interview Survey (NHIS) Adult Tobacco Use—Glossary [Internet] [(accessed on 13 July 2024)];2019 Available online: https://archive.cdc.gov/www_cdc_gov/nchs/nhis/tobacco/tobacco_glossary.htm.
- 26.Epi Info [Computer Program], Version 5. Centers for Disease Control and Prevention; Atlanta, GA, USA: 1990. [Google Scholar]
- 27.Alsaleem M.A., Alsaleem S.A., Al Shehri S., Awadalla N.J., Mirdad T.M., Abbag F.I., Mahfouz A.A. Prevalence and correlates of university students’ perceived stress in south-western Saudi Arabia. Medicine. 2021;100:e27295. doi: 10.1097/MD.0000000000027295. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Kansal S., Bilimale A.S., Gopi A., Bv S. Premature Hair Greying—Magnitude and Associated Factors: A cross-sectional study in a university in Mysuru. Indian J. Community Health. 2021;33:462–465. doi: 10.47203/IJCH.2021.v33i03.010. [DOI] [Google Scholar]
- 29.Zhang B., Ma S., Rachmin I., He M., Baral P., Choi S., Gonçalves W.A., Shwartz Y., Fast E.M., Su Y., et al. Hyperactivation of sympathetic nerves drives depletion of melanocyte stem cells. Nature. 2020;577:676–681. doi: 10.1038/s41586-020-1935-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Morpurgo G., Fioretti B., Catacuzzeno L. The increased incidence of malignant melanoma in obese individuals is due to impaired melanogenesis and melanocyte DNA repair. Med. Hypotheses. 2012;78:533–535. doi: 10.1016/j.mehy.2012.01.028. [DOI] [PubMed] [Google Scholar]
- 31.Chakrabarty S., Krishnappa P.G., Gowda D.G., Hiremath J. Factors associated with premature hair graying in a young Indian population. Int. J. Trichology. 2016;8:11–14. doi: 10.4103/0974-7753.179384. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Volkov I., Press Y., Rudoy I. Vitamin B12 could be a “master key” in the regulation of multiple pathological processes. J. Nippon Med. Sch. 2006;73:65–69. doi: 10.1272/jnms.73.65. [DOI] [PubMed] [Google Scholar]
- 33.Krugluger W., Stiefsohn K., Laciak K., Moser K., Moser C. Vitamin B12 Activates the Wnt-Pathway in Human Hair Follicle Cells by Induction of Beta-Catenin and Inhibition of Glycogen Synthase Kinase-3 Transcription. J. Cosmet. Dermatol. Sci. Appl. 2011;1:25–29. doi: 10.4236/jcdsa.2011.12004. [DOI] [Google Scholar]
- 34.Bhramaramba T.S., Sathyanarayana B.D., Swaroop M.R., Devaraj Y., Raghavendra J.C., Dukkipati M. A clinicoepidemiological study of premature canities of degree college students in the rural area. Int. J. Adv. Case Rep. 2016;3:489–493. [Google Scholar]
- 35.Zayed A.A., Shahait A.D., Ayoub M.N., Yousef A.M. Smokers’ hair: Does smoking cause premature hair graying? Indian Dermatol. Online J. 2013;4:90–92. doi: 10.4103/2229-5178.110586. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data supporting the findings and conclusions are available upon request from the corresponding author.