Article ID: WMC004033 ISSN 2046-1690 A Case Control Study to Determine the Correlation Between Serum Ferritin Levels and Chronic Telogen Effluvium in a Tertiary Hospital, Mandya Corresponding Author: Dr. Pushpa Sarkar, Professor, Department of Biochemistry, Mandya Institute of Medical Sciences, Mandya - India Submitting Author: Dr. Pushpa Sarkar, Professor, Department of Biochemistry, Mandya Institute of Medical Sciences, Mandya - India Article ID: WMC004033 Article Type: Original Articles Submitted on:16-feb-2013, 10:18:07 AM GMT Article URL: http://www.webmedcentral.com/article_view/4033 Subject Categories:BIOCHEMISTRY Keywords:Serum ferritin level, Chronic telogen effluvium, Hemoglobin Published on: 16-Feb-2013, 12:48:44 PM GMT How to cite the article:sarkar P, Raghunatha H, Harish MR, Shashikumar BM. A Case Control Study to Determine the Correlation Between Serum Ferritin Levels and Chronic Telogen Effluvium in a Tertiary Hospital, Mandya. WebmedCentral BIOCHEMISTRY 2013;4(2):WMC004033 Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Source(s) of Funding: Nil Competing Interests: Nil WebmedCentral > Original Articles Page 1 of 7
A Case Control Study to Determine the Correlation Between Serum Ferritin Levels and Chronic Telogen Effluvium in a Tertiary Hospital, Mandya Author(s): Sarkar P, Raghunatha H, Harish MR, Shashikumar BM Abstract Background: Hair loss is a common problem which affects both sex of all ages. 10 Telogen effluvium is the common cause of diffuse non-scarring alopecia. A Low Iron store which is indicated by low serum ferritin level is one of the cause for chronic telogen effluvium. Objective: This study was undertaken to determine the correlation between serum ferritin levels and chronic telogen effluvium. Materials and method: Study was undertaken with 40 females with chronic hair loss as cases and 40 healthy age and sex matched females. Serum ferritin levels and hemoglobin were estimated for the case group and some other investigations were done in selected cases as indicated. For controls only measurements of hemoglobin and serum ferritin levels were done and were statistically compared. Results: 15 out of 40 patients had decreased SFL whereas only 7 out of 40 controls had decreased SFL, which is statistically significant and mean serum ferritn level is statistically significant in the cases compared with control group. Conclusion: Assessment of SFL in CTE and correcting it plays important role in the management of CTE. Introduction Telogen efuvium is a common form of non scaring alopecia characterised by loss of club (telogen) hair in disease states of the follicle. The term telogen efuvium was first coined in 1961 by Kligman. 1 Kligman s hypothesis was that whatever the cause of the hair loss, the follicle tends to behave in a similar way - the premature termination of anagen. The follicle is precipitated into catagen and transforms into a resting stage that mimics telogen. 2 Acute telogen efuvium is an acute-onset scalp hair loss that occurs 2 3 months after a triggering event such as a high fever, surgical trauma, sudden starvation or haemorrhage. 3,4,5 Unless the trigger is repeated, spontaneous complete regrowth occurs within 3 6 months. Chronic diffuse telogen hair loss refers to telogen hair shedding persisting for longer than 6 months. It can be a result of a primary chronic telogen efuvium(cte) or be secondary to a variety of causes including androgenetic alopecia(aga). Common causes of chronic diffuse telogen hair loss are thyroid disorders, profound iron deficiency anaemia, acrodermatitis enteropathica and malnutrition. 1 AGA leads to diffuse and episodic hair loss, and mimic a telogen efuvium. Profound iron: Deficiency anaemia can cause a diffuse telogen hair loss that is corrected by iron replacement. The relationship between iron deficiency with no anaemia or only mild anaemia and chronic diffuse hair loss is, however, more complex and controversial. 6-8 Serum ferritin concentration is an indicator of the status of iron stores and the serum ferritin level (SFL) is directly related to the amount the iron stored in the body. 9 This study was undertaken to know the relation between chronic telogen effluvium and iron deficiency. Methods This study included 80 females attending the outpatient clinic of Dermatology of Mandya Institute Medical Sciences, Mandya. Their age ranged from 15-45 years. They were classified into 2 groups, the patient group included 40 females having hair fall for more than 6 months. They were diagnosed as chronic telogen effluvium by clinical examination, trichogram, hair pull test and punch biopsy. The hair pull test was recorded as positive when greater than 25% of hairs are in telogen after the forced extraction of around 20 hairs, confirming the diagnosis of telogen effluvium. Control group included 40 age and sex matched healthy female without hair loss and who attended hospital for different reason. The exclusion criteria included pregnancy and lactation or woman received any hormonal treatment such as estrogens, progesterone, androgen or thyroxin, dyeing, permanent waving or bleaching procedures, history of operation or exposure to chemical agents or irradiation, no evidence of WebmedCentral > Original Articles Page 2 of 7
systemic diseases or chronic illness, and not on any iron supplementation. Subjects with identifiable causes of hair loss were excluded from the study, e.g. patients with thyroid disease or hyperandrogenism as measured by appropriate tests (thyroid function tests, serum testosterone and dehydroepiandrosterone levels). Detailed history and through examination was done for the subjects. Hematocrit and SFL estimation was done for both cases and controls. Chi-square and Fisher's exact t-test was used for statistical analysis. Results The mean age of was 24.28 ± 6.17 years in patients and 23.11±4.67 years in control respectively. The mean disease duration among cases was 7.1 ± 1.42 months. The serum ferritin levels in patients and control ranged 12-144ng/ml and 14-156ng/ml respectively. Mean is SFL in cases and control were 32.6ng/ml and 39.2ng/ml respectively. Actual difference between the mean is 8.6 which is twice the standard error (SE=1.14) of difference between the two means and therefore low SFL in cases is statistically significant. SFL of 20ng/ml is taken as cut-off and values <20ng/ml is taken as decrease SFL in both cases and controls. A total of 22(27.5%) subjects had values <20ng/ml. 15 out of 40 patients had decreased SFL whereas only 7 out of 40 control had decreased SFL,which is statistically significant. Discussion Hair loss is a common problem which affects both sex of all ages. 10 Telogen effluvium is the common cause of diffuse non-scarring alopecia. In a study, women with laboratory anaemia, 88.9% had diffuse telogen hair loss. All women with iron deficiency anaemia had serum ferritin level lower than 30 ng/ml. 11 Generally, serum ferritin is directly related to intracellular ferritin and thus to total body iron stores. 12 Only iron deficiency causes very low serum ferritin concentrations; therefore, low serum ferritin level is very specific for iron deficiency. 13 Guyatt et al in their study concluded that serum ferritin has a greater predictive value than other tests of iron status, such as transferrin saturation and erythrocyte zinc protoporphyrin. 14 Mechanism leading to loss of telogen hair in iron deficiency anaemia is not fully understood but possible explanation is hair follicle matrix cells as the most rapidly proliferating cells in the body appear to have lower levels of ferritin and higher levels of free iron. 15,16 Another likely mechanism for the possible effect of iron on hair growth stems from its requirement as a cofactor for ribonucleotide reductase, the rate-limiting enzyme for DNA synthesis. Iron depletion could prevent proper function of this enzyme, resulting in inhibition of proliferation. 17 The mean SFLs in cases was 32.6ng/ml which is statistically significant indicating strong relation between CTE and low SFLs. Similar to present study, Deloche et al 18 and Obaidat et al 19 showed correlation between low SFL and CTE and provide further evidence that the iron status has to be taken into consideration when studying hair loss in women. Sinclaire eta al in his study showed no direct relationship between low serum ferritin and hair loss and disproved the usefulness of serum ferritin in the routine investigation of women with chronic diffuse telogen hair loss. 8 This discrepancy could be explained by difference in the design of studies and also serum SFLs measurement gives insight in evaluating CTE. Conclusion(s) Assessment of SFL in CTE and correcting it plays important role in the management of CTE. References 1. Kligman AM. Pathologic dynamics of human hair loss. I. Telogen effuvium. Arch Dermatol 1961; 83: 175 98. 2. MacKie RM, Quinn AG. Non-Melanoma skin cancer and other epidermal tumors. In: Burns T, Breathanach S, Cox N, editors. Rook's textbook of dermatology: 7 th ed. USA: Blackwell Publishing; 2004. p. 36.1-50. 3. Harrison S, Sinclair R. Telogen ef? uvium. Clin Exp Dermatol 2002; 27: 389 5. 4. Headington JT. Telogen ef? uvium. New concepts and review. Arch Dermatol 1993;129: 356 63. 5. Dawber RPR, Simpson NB, Barth JH. Diffuse alopecia: endocrine, metabolic and chemical in? uences on the follicular cycle. In: Dawber RPR ed. Diseases of the Hair and Scalp. Oxford: Blackwell Science, 1997: 123 50. 6. Rushton DH, Ramsay ID, James KC et al. Biochemical and trichological characterization of diffuse alopecia in women. Br J Dermatol 1990; 123: 187 97. 7. Hard S. Non-anemic iron de? ciency as an etiologic factor in diffuse loss of hair of the scalp in women. WebmedCentral > Original Articles Page 3 of 7
Acta Derm Venereol (Stockh) 1963; 43: 562 9. 8. Sinclair R. There is no clear association between low serum ferritin and chronic diffuse telogen hair loss. Br J Dermatol 2002; 147: 982 4. 9. Hoffman R, Benz Jr. EJ, Shattil SJ, Dover R. Hematology: Basic Principles and Practice. 4th ed. Philadelphia, Pa: Churchill Livingston; 2005;5:482. 10. Springer K, Brown M, Stulberg DL. Common hair loss disorders, Am Fam Physician 2003; 68: 93-108. 11. Moeinvaziri M, Mansoori P, Holakooee K, Naraghi ZS, Abbasi A. Iron status in diffuse telogen hair loss. Acta Dermatovenerol Croat 2009;17(4):279-284. 12. Brittenham GM. Disorders of iron metabolism: iron defciency and overload. In: Hoffman R, ed. Hematology: basic principles and practice. 3rd edn. New York: Churchill-Livingstone; 2000. pp. 397-428. 13. Trost LB, Bergfeld WF, MD, Calogeras E. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J Am Acad Dermatol 2006;54:824-44. 14. Guyatt GH, Oxman AD, Ali M, Willan A, McIlroy W, Patterson C. Laboratory diagnosis of iron-defciency anemia: an overview. J Gen Intern Med 1992;7:145-53. 15. Larsson LG, Ivhed I, Gidlund M, Pettersson U, Vennstrom B, Nilsson K. Phorbol ester induced terminal differentiation is inhibited in human U-937 monoblastic cells expressing a V-Myc oncogene. Proc Natl Acad Sci U S A 1988;85:2638-42. 16. Liau G, Chan LM, Feng P. Increased ferritin gene expression is both promoted by camp and a marker of growth arrest in rabbit vascular smooth muscle cells. J Biol Chem 1991;266:1819-26. 17. Elledge SJ, Zhou Z, Allen JB. Ribonucleotide reductase: regulation, regulation, regulation. Trends Biochem Sci 1992;17:119-23. 18. Deloche C, Bastine P, Chdouted S, Galan P. Low iron stores: a risk factor for excessive hair loss in non-menopausal women. Europ J Dermatol 2007; 17:507-12. 19. Obaidat NA, Rawashdeh BT, Abdul-Razzaq A, Awamleh AA: A potential relation between telogen effluvium and iron deficiency in adult females. JRMS 2005; 12:62-66. WebmedCentral > Original Articles Page 4 of 7
Illustrations Illustration 1 Table Illustration 1: Mean Hemoglobin & Serum ferritin levels Cases(n=40) Control(n=40) Mean age ±SD (in years) 24.28 ± 6.17 23.11±4.67 Mean Hb(mg/dl) 10.3±1.4 12.1±1.9 Mean serum ferritin level(ng/ml) 32.6±19.3 39.2±32.6 WebmedCentral > Original Articles Page 5 of 7
Illustration 2 Fig Illustration 2: Bar graph indicating serum ferritin levels in cases and control groups WebmedCentral > Original Articles Page 6 of 7
Disclaimer This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party. Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website. WebmedCentral > Original Articles Page 7 of 7