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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 1  |  Page : 221-225

Vitmain D level in female pattern hair loss with normal androgen level


1 Department of Dermatology and Androgy, Faculty of Medicine, Mounifia University, Mounifia, Egypt
2 Department of Medical Biochemistry, Faculty of Medicine, Mounifia University, Mounifia, Egypt
3 Department of Dermatology, Ministry of Health, Mounifia, Egypt

Date of Submission14-Apr-2017
Date of Acceptance11-Jun-2017
Date of Web Publication17-Apr-2019

Correspondence Address:
Rasha A Darwish
Berket El-Sabih, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_236_17

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  Abstract 


Objectives
The aim of this study was to assess serum vitamin D level in women with female pattern hair loss (FPHL) to approve its relation in this disorder.
Background
FPHL is the main cause of diffuse hair loss in adult women and majorly affects patient's personal satisfaction. FPHL is the preferred term for androgenetic alopecia in women as the relation between androgens and this illness is not proved. Androgen excess has not been demonstrated in FPHL. The connection between serum 25-hydroxy vitamin D and FPHL has not been considered altogether.
Patients and methods
In this case–control study, we studied serum vitamin D level concentration among 31 FPHL patients aged 20–40 years in comparison with 31 healthy female controls matched for age, skin phototype, socioeconomic level, and outdoor exposure. Measurements were conducted by enzyme-linked immunosorbent assay. The study was conducted within a 4-month period, from July to October 2016.
Results
The mean serum vitamin D level was significantly lower in FPHL patients (18 ± 7.57 ng/ml) than in controls (35.09 ± 15.39 ng/ml; P < 0.001). This result supports the suggestion that the decreased hair density present in patients with FPHL may possibly be associated with decreased levels of mean serum vitamin D levels. Significant difference was found between the three Ludwig's degrees regarding the mean serum vitamin D level (20.04 ± 7.49, 17.77 ± 6.98, and 8.43 ± 0.75 ng/ml, respectively) between degrees I and III and between degrees II and III.
Conclusion
The lack or inadequacy vitamin D may assume a conceivable part in the pathogenesis of FPHL.

Keywords: 1,25(OH)2D, 25-hydroxy vitamin D, female pattern hair loss, hair loss, vitamin D


How to cite this article:
Hagag MM, El-Shafie M, Darwish RA. Vitmain D level in female pattern hair loss with normal androgen level. Menoufia Med J 2019;32:221-5

How to cite this URL:
Hagag MM, El-Shafie M, Darwish RA. Vitmain D level in female pattern hair loss with normal androgen level. Menoufia Med J [serial online] 2019 [cited 2019 May 27];32:221-5. Available from: http://www.mmj.eg.net/text.asp?2019/32/1/221/256092




  Introduction Top


Female pattern hair loss (FPHL) is the preferred term for androgenetic alopecia in women attributable to the indeterminate connection among androgens and this entity [1].

It is the main cause of diffuse hair loss in adult women and majorly affects patient's personal satisfaction. It evolves from progressive miniaturization of hair follicles that leads to a subsequent decrease of the hair thickness, leading to a nonscarring diffuse alopecia [2].

In FPHL, there is a diminishment in the length of the anagen stage and a scaling down of the dermal papilla (diminishing of the hair). Thick pigmented hairs are slowly replaced by finer hairs. Besides, there is a delay between the end of the telogen stage and the beginning of the new anagen phase [3].

The miniaturization process is because of the diminishing volume of the papillae. As the hair keeps a similar thickness from the tip to the proximal segment, it is known that nothing happens during the anagen stage. The miniaturization process happens now and then between the catagen stage and the arrangement of the new hair [4].

The elements that cause a reduction in volume of the papillae are not known, and more studies should be conducted to elicit these factors [4].

The pathogenesis of FPHL differs from that seen in male pattern hair loss (MPHL). Although the role of androgens in the pathogenesis of MPHL has been unmistakably settled, its role in FPHL is unverifiable. There are a few women with FPHL who do not have high androgen levels, and distinctive components are probably going to be required in the advancement of FPHL [5],[6].

Vitamin D is a fat-soluble prohormone steroid that has endocrine, paracrine, and autocrine functions [7].

Vitamin D is necessary for maintenance of the different vital functions in the body. Its role has been demonstrated in different diseases such as breast cancer, prostatic cancer, and cardiovascular diseases, as well as in different skin diseases such as psoriasis. It has been found that topical vitamin D analog in combination with steroids is superior to steroid alone in the management in psoriasis, which reflects the role of vitamin D in skin differentiation and proliferation process [8],[9].

In-vitro studies have supported that vitamin D receptor (VDR) may assume an indispensable part in the postnatal support of the hair follicle. Mesodermal papilla cells and the external root sheath (outer root sheath) epidermal keratinocytes express VDR in varied degrees in correlation with the phases of the hair cycle. In both the late anagen and catagen stages, there is an expansion in VDR, which is related with diminished multiplication and expanded differentiation of the keratinocytes. These progressions are thought to advance the occurrence of the hair cycle [10].

The aim of this study was to assess serum vitamin D level in women with FPHL to approve its relation in this disorder.


  Patients and Methods Top


The study was approved by the ethics committee in Menoufia University. Informed consents were taken from the patients before the beginning of the study.

This case–control study was conducted on 31 female patients with female pattern hair loss aged 20–40 years and 31 solid female controls coordinated for age, skin phototype, financial status, and open air introduction. Patients were chosen from the dermatology outpatient facility, Tala general Hospital. Controls were chosen from sound volunteers. Consent was taken from the studied group. Estimations were directed inside a 4-month time frame (July–October) to limit regular inclination in 25(OH)D levels.

Avoidance criteria included members experiencing other scalp diseases whether primary (e.g., telogen effluvium, alopecia areata, tricotillmania, tinea capitis, and tractionalopecia) or secondary (e.g., seborrheic dermatitis, psoriasis); members with hyperandrogenemia, indicated clinically (e.g hirsutism, menstrual anomalies, and polycystic ovary) or by laboratory examinations (e.g., increased free testosterone, raised serum dehydroepianderosterone sulfate); members taking medications that could change serum vitamin D levels (e.g., systemic corticosteroids, contraceptives, weight-reduction drugs, antiepileptic medications, and cholesterol-lowering medications); and members experiencing malabsorption issue, nutritious inadequacies, or kidney, liver, or bone illnesses.

All patients and controls were subjected to full history taking including age, occupation, term of the illness, past medicines taken, family history of a similar condition (FPHL), financial status, menstrual history of drug intake that could alter the serum vitamin D level. Complete general examination and complete dermatological examination were also performed.

The determination of FPHL depended on clinical findings (the pattern of hair loss: reduction in hair thickness over the crown and enlarging of the central hair line with relative saving of the frontal hair line) and a positive hair-pull test.

Patients were evaluated as stage I, II, or III FPHL by clinical examination of the pattern of hair loss that depended on Ludwig's scale.

Laboratory examinations including a complete blood count, serum ferritin, free testosterone, and dehydroepiandrosterone sulfate were performed to exclude those with hyperandrogenism.

For evaluation of 25(OH)D level, a venous blood sample was taken from patients and quantitative measurement of 25(OH)D was performed using reagents provided by Argentic Dianostika GmbH (Mainz, Germany) by enzyme-linked immunosorbant assay.

The values were interpreted as follows: less than 20 ng/ml, deficient; 21–29 ng/ml, insufficient; more than 30–150 ng/ml, sufficient; more than 150 ng/ml, intoxication.

Data management and statistical analysis

Results were collected, tabulated, and statistically analyzed by an IBM personal computer and statistical package, version 20 (SPSS Inc., Chicago, IL, USA) on an IBM-compatible computer. Two types of statistics were done: descriptive statistics – example, %, mean, and SD and analytic statistics – example, Student's t-test is a test of significance used for comparison between two groups having quantitative variables. χ2-Test was used to study the association between two qualitative variables. Pearson's correlation coefficient measures how variables or rank orders are related. Mann–Whitney test (nonparametric test) is a test of significance used for comparison between two groups of not normally distributed quantitative variables.

A P value less than 0.05 was considered statistically significant.

The correlation coefficient (r) is defined as the strength and the direction of the linear relationship between two variables [Figure 1].
Figure 1: Diagonal segments are produced by ties. ROC, receiver operating characteristic.

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  Results Top


The mean serum vitamin D level among patients was 18.04 ± 7.57 ng/ml, whereas that of the control group was 35.09 ± 15.39. A highly statistically significant difference was found between patients and controls regarding the mean serum vitamin D level. The mean serum vitamin D level was significantly lower in FPHL patients than in controls (P < 0.001). There is a significant increase of vitamin D level in the control group when compared with the patient group [Table 1].
Table 1: Difference between the two groups regarding serum level of vitamin D and differential levels (n=62)

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There is a highly statistically significant difference between number and percentage of cases and controls regarding differential serum vitamin D levels with the highest percentage of the cases among the insufficient vitamin D level, whereas the highest percentage of the control is among the sufficient vitmain D levels [Table 1].

There is no statistically significant difference between grades I and II FPHL patients, whereas there is a statistically significant difference between grades I and III and between grades II and III FPHL patients as regards serum vitamin D level [Table 2].
Table 2: Statistical comparison between the three grades of female pattern hair loss regarding serum level of vitamin D and differential levels

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There is no statistically significant difference between grades I and II FPHL patients, whereas there is a statistically significant difference between grades I and III and between grades II and III FPHL patients regarding differential serum vitamin D level [Table 2].

There is a significant negative correlation between differential serum level of vitamin D and grade of hair loss, meaning that with an increase in serum level of vitamin D there is a decline in grade of hair loss [Table 3].
Table 3: Correlation between differential serum level of vitamin D and grade of female pattern hair loss

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The best cutoff point is 20.95; this means that below this point the hair loss begins [Table 4].
Table 4: Receiver operating characteristic curve and cutoff point of vitamin D level between the studied groups

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  Discussion Top


The consequences of the present study bolster that the serum vitamin D levels may have a conceivable role in the pathogenesis of FPHL. This is dependent on finding an exceedingly measurable noteworthy contrast among patients and controls with respect to the mean serum vitamin D level. These discoveries in all probability show the critical effect of inadequate or deficient serum vitamin D levels in FPHL patients.

These outcomes concur with the study conducted by Rasheed et al. [11]; they found that mean serum vitamin D levels in women with FPHL were fundamentally lower than those in controls, proposing that the lessened hair thickness seen in FPHL patients may conceivably be related to low serum levels of vitamin D.

Our outcomes also concur with the study conducted by Moneib et al. [12]. They found that the mean serum vitamin D levels in 60 female patients (14.2 ± 7.31 ng/ml) was significantly lower than that of the control patients (45.90 ± 18.83 ng/ml).

Differential serum vitamin D level evaluation showed statistically significant difference between patients and controls: insufficiency (20–29 ng/ml) rather than deficiency (<20 ng/ml) was highest among patients [17 (54.8%) patients], whereas sufficient levels (29–150 ng/ml) were more frequent among controls [28 (90.3%) controls]; this emphatically recommends the conceivable role of vitamin D deficiency as one of the imperative hazard components to create FPHL.

Our outcomes concur with the study conducted by Rasheed et al. [11], which showed 13 (34.2%) patients with FPHL demonstrating inadequate vitamin D levels and 25 (65.8%) patients with FPHL indicating vitamin D deficiency.

Our results concur also with the study conducted by Siah et al. [2] on 152 patients with FPHL for whom the research facility assessment of the mean serum vitamin D levels was 70.17 ± 35.84 nmol/l. Only 38% of patients were found to have ordinary vitamin D levels.

As indicated by Ludwig degrees, 16 patients were degree I, 12 patients were degree II, and three patients were degree III. The mean vitamin D level was 20.04 ± 7.49 ng/ml among Ludwig's degree I patients, 17.77 ± 6.98 ng/ml among Ludwig's degree II patients, and 8.43 ± 0.75 ng/ml among Ludwig's degree III patients. There was no measurable noteworthy contrast between degree I patients and degree II patients with respect to mean serum vitamin D levels; however, there is a factual critical distinction between degree I patients and degree III patients in regard to mean serum vitamin D levels and between degree II and III. This means that higher the level of balding, the more lacking serum vitamin D levels.

Our outcomes concur with another review by Rasheed et al. [11]; the review uncovered that the serum vitamin D level was most minimal in the extreme types of male pattern baldness (ranging from 20 to 31.2 nmol/l, and mean serum vitamin D was 24.6 ± 3.9 nmol/l), in direct cases it ranged from 12.7 to 36.8 nmol/l with a mean serum vitamin D level of 29.5 ± 6.5 nmol/l, and the most elevated serum vitamin D level was identified in the gentle instances of male pattern baldness (14.9 ± 62 nmol/l, and mean serum vitamin D level was 31.6 ± 11.1 nmol/l). Mean serum vitamin D level was fundamentally higher in mellow cases in contrast with extreme cases and in direct cases in contrast with serious cases.

Our outcomes concur with the study conducted by Kumar et al. [13] that demonstrated that the serum level of vitamin D demonstrated a significant reduction in level with expanded seriousness or review of FPHL.

Then again, the study conducted by Modeib et al. [12] shows surprisingly that the highest level was in degree III compared with degrees I and II. The mean serum vitamin D level in degree III was 25.00 ± 5.35, whereas in degrees I and II it was 12.96 ± 7.52 and 14.16 ± 5.68, respectively. They reported that the purpose behind this expansion in 25(OH)D levels in their patients was not known, but rather they propose that it may be identified with an expanded presentation to sunlight because of more diminished scalp hair thickness. Other authors share similar findings and have additionally clarified that telogen hair follicles do not demonstrate melaninin in their undifferentiated melanocytes/melanoblasts, which may at last increment utraviolet introduction and vitamin D amalgamation in the skin [6],[10], but this explanation could not be accepted on the grounds that the majority of the Egyptian women cover their head and body, and the entire body should be exposed to ultraviolet B radiation in the minimal erythema dose for 15–20 min to actuate the generation of up to 250 mg vitamin D (10 000 IU).


  Conclusion Top


The lack or inadequacy of vitamin D may assume a conceivable part in the pathogenesis of FPHL.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Oslen EA. Female pattern hair loss. J Am A Cad Dermatol 2001;45:70–80.  Back to cited text no. 1
    
2.
Siah TW, Muir-Green L, Shapiro J. Female pattern hair loss: a retrospective study in A teriary refferal center. Int J Trichol 2016; 8:57–61.  Back to cited text no. 2
    
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Cotsarelis G, Millar SE. Towards a molecular understanding of hair loss and its treatment. Trends Mol Med 2001;7:293–301.  Back to cited text no. 3
    
4.
Bolland MJ, Ames RW, Grey AB, Home AM, Mason BH, Gamble GD, et al. Does degree of baldness influence vitamin D status?. Med J Aust 2008; 189:674–675.  Back to cited text no. 4
    
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Sinclair RD, Dawber RPR. Androgenetic alopecia in men and women. Clin Dermatol2001;19:167–178.  Back to cited text no. 5
    
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Orme S, Cullen DR, Messenger AG. Diffuse female hair loss: are androgens necessary?. Br J Dermatol 1999;141:521–523.  Back to cited text no. 6
    
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Vanchinathan V, Lim HW. A dermatologist's perspective on vitamin D. Mayo Clin Proc 2012;87:372–380.  Back to cited text no. 7
    
8.
Rosen CJ, Adams JS, Bikle DD, Black DM, Demay MB, et al. The nonskeletal effects of vitamin D: an endocrine society scientific statement. Endocrine Reviews2012;33:456–492.  Back to cited text no. 8
    
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Kim DH, Lee JW, Kim MN. Successful treatment of alopecia areata with topical calcipotriol. Ann Dermatol 2012; 24:341–344.  Back to cited text no. 9
    
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Amor KT, Rashid RM, Mirmirani P. Does D matter? The role of vitamin D in hair disorders and hair follicle cycling. Dermatol Online J 2010;16:3–8.  Back to cited text no. 10
    
11.
Rasheed H, Mahgoub D, Hegazy R, Elkomy M, Hay A, Hamid MA. Serum ferritin and vitamin D in female hair loss: do they play a role?. Skin Pharmacol Physiol 2013;26:101–107.  Back to cited text no. 11
    
12.
Moneib H, Fathy G, Ouda A. Possible association of female pattern hair loss with alteration in serum 25-hydroxy vitamin D levels. Egypt J Dermatol Venereol 2014;34:15–20.  Back to cited text no. 12
    
13.
Kumar B, Kumar P, Chaudhary RKP. Evaluation of serum 25-hydroxy vitamin D and zinc in patients of female pattern hair loss. Indian Dermatol 2016;5:486–488.  Back to cited text no. 13
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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