10.5826/dpc.1303a202
Introduction:Telogen effluvium (TE) is a common form of non-scarring alopecia that may manifest as acute or chronic hair shedding. Several studies evaluated a possible relationship between various vitamin and mineral deficiencies and TE, but it is still a controversial topic.
Objectives: This study aimed to investigate the status of vitamin and mineral deficiencies in patients diagnosed with TE and to evaluate their correlation with anagen hair ratios (AHR) calculated with an automated digital phototrichogram (ADCP).
Methods:Electronic records of 973 TE patients were retrospectively analyzed. Demographic, clinical data, parameters such as ferritin, vitamin B12 (Vit-B12), vitamin D (Vit-D), folic acid, zinc and hemoglobin (HGB) serum levels were evaluated. Anagen to telogen hair ratios were also assessed in forty-two patients via ADCP.
Results: 
The rates of anemia, low ferritin level, and Vit-B12, folate, Vit-D, and zinc deficiencies were 11.9% (N = 109), 44% (N = 332), 1.5% (N = 13), 2.5% (N = 14), 87% (N = 51), and 4.5% (N = 2), respectively. A positive correlation was found between HGB levels and AHR in female patients (Spearman rank, r = 0.417, P = 0.008). No statistically significant relationship was found between ferritin, Vit-B12, folate, zinc serum levels and AHR. The relationship between Vit-D and AHR could not be assessed due to the insufficient number of patients with Vit-D data.
Conclusions:HGB value is the only marker that is positively correlated with the AHR of patients with TE. Ordering HGB can be used as an initial test for managing TE patients cost-effectively.
 
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Dermatology Practical & Conceptual
Mineral deficiencies
Micronutrient Deficiencies and Digital Computerized Phototrichogram Analysis in Telogen Effluvium: A Retrospective Correlation Study in a Tertiary Medical Center
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2023-01-15
2023-07-31
2023-08-24
e2023202
Dermatol Pract Concept
Introduction:Telogen effluvium (TE) is a common form of non-scarring alopecia that may manifest as acute or chronic hair shedding. Several studies evaluated a possible relationship between various vitamin and mineral deficiencies and TE, but it is still a controversial topic.
Objectives: This study aimed to investigate the status of vitamin and mineral deficiencies in patients diagnosed with TE and to evaluate their correlation with anagen hair ratios (AHR) calculated with an automated digital phototrichogram (ADCP).
Methods:Electronic records of 973 TE patients were retrospectively analyzed. Demographic, clinical data, parameters such as ferritin, vitamin B12 (Vit-B12), vitamin D (Vit-D), folic acid, zinc and hemoglobin (HGB) serum levels were evaluated. Anagen to telogen hair ratios were also assessed in forty-two patients via ADCP.
Results: 
The rates of anemia, low ferritin level, and Vit-B12, folate, Vit-D, and zinc deficiencies were 11.9% (N = 109), 44% (N = 332), 1.5% (N = 13), 2.5% (N = 14), 87% (N = 51), and 4.5% (N = 2), respectively. A positive correlation was found between HGB levels and AHR in female patients (Spearman rank, r = 0.417, P = 0.008). No statistically significant relationship was found between ferritin, Vit-B12, folate, zinc serum levels and AHR. The relationship between Vit-D and AHR could not be assessed due to the insufficient number of patients with Vit-D data.
Conclusions:HGB value is the only marker that is positively correlated with the AHR of patients with TE. Ordering HGB can be used as an initial test for managing TE patients cost-effectively.
 
özgür gündüz
2023/07/31
10.5826/dpc.1303a202
e2023202
Department of Dermatology, University of Kırıkkale, Kırıkkale, Turkey
2160-9381
Mineral deficiencies
en
e2023202
Kil MS, Kim CW, Kim SS. Analysis of serum zinc and copper concentrations in hair loss. Ann Dermatol. 2013;25(4):405-409. DOI: 10.5021/ad.2013.25.4.405. PMID: 24371385. PMCID: PMC3870206.
Micronutrient Deficiencies and Digital Computerized Phototrichogram Analysis in Telogen Effluvium: A Retrospective Correlation Study in a Tertiary Medical Center
https://dpcj.org/index.php/dpc/article/download/3154/2120
       Micronutrient Deficiencies and Digital
 Computerized Phototrichogram Analysis in Telogen
   Effluvium: a Retrospective Correlation Study
            in a Tertiary Medical Center
                                              Hakan Arslan1, Özgür Gündüz2


1 Department of Dermatology, University of Health Sciences Dr Sami Ulus Maternity and Children’s Hospital, Ankara, Turkey
2 Department of Dermatology, University of Kırıkkale, Kırıkkale, Turkey



Key words: telogen effluvium, trichoscan, automated digital photothrichogram, vitamin deficiencies, mineral deficiencies
Citation: Arslan H, Gündüz Ö. Micronutrient Deficiencies And Digital Computerized Phototrichogram Analysis in Telogen Effluvium:
A Retrospective Correlation Study in a Tertiary Medical Center. Dermatol Pract Concept. 2023;13(3):e2023202. DOI: https://doi
.org/10.5826/dpc.1303a202
Accepted: March 11, 2023; Published: July 2023
Copyright: ©2023 Arslan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Hakan Arslan, Department of Dermatology, University of Health Sciences Dr Sami Ulus Maternity and Children
Training and Research Hospital, 06080, Ankara, Turkey. Orcid ID: 0000-0002-4880-7335 Telephone Number: +905436036105
E-mail: drarslanhakan@gmail.com
Abbreviations: ADCP: Automated digital computerized phototrichogram, AHR: Anagen hair ratio, HGB: Hemoglobin, TE: Telogen
effluvium, Vit-B12: Vitamin B12, Vit-D: Vitamin D




  ABSTRACT             Introduction: Telogen effluvium (TE) is a common form of non-scarring alopecia that may manifest
                       as acute or chronic hair shedding. Several studies evaluated a possible relationship between various
                       vitamin and mineral deficiencies and TE, but it is still a controversial topic.
                       Objectives: This study aimed to investigate the status of vitamin and mineral deficiencies in patients
                       diagnosed with TE and to evaluate their correlation with anagen hair ratios (AHR) calculated with an
                       automated digital phototrichogram (ADCP).
                       Methods: Electronic records of 973 TE patients were retrospectively analyzed. Demographic, clini-
                       cal data, parameters such as ferritin, vitamin B12 (Vit-B12), vitamin D (Vit-D), folic acid, zinc and
                       hemoglobin (HGB) serum levels were evaluated. Anagen to telogen hair ratios were also assessed in
                       forty-two patients via ADCP.
                       Results: The rates of anemia, low ferritin level, and Vit-B12, folate, Vit-D, and zinc deficiencies were
                       11.9% (N = 109), 44% (N = 332), 1.5% (N = 13), 2.5% (N = 14), 87% (N = 51), and 4.5% (N = 2),
                       respectively. A positive correlation was found between HGB levels and AHR in female patients




Original Article | Dermatol Pract Concept. 2023;13(3):e2023202                                                                      1
                      (­Spearman rank, r = 0.417, P = 0.008). No statistically significant relationship was found between
                       ferritin, Vit-B12, folate, zinc serum levels and AHR. The relationship between Vit-D and AHR could
                       not be assessed due to the insufficient number of patients with Vit-D data.
                      Conclusions: HGB value is the only marker that is positively correlated with the AHR of patients with
                      TE. Ordering HGB can be used as an initial test for managing TE patients cost-effectively.




Introduction                                                        day 1, the plate with a 1 cm2 circular incision was placed on
                                                                    the highest point of the patient’s right pinna. Subsequently, the
The hair is an ectoderm-originated skin appendage with high         hair in the selected area was trimmed to a length of 0.5 mm
cosmetic and psychological importance. It helps individuals         using a hair trimmer Rowenta® TN9160 (Rowenta Werke
maintain their self-esteem, which encourages healthy social         GmbH, Erbach) and photographed with 20× magnification
interactions.                                                       via FotoFinderdermoscope® (FotoFinder System GmbH). The
    Telogen effluvium (TE) is the most common cause of              patients were instructed not to bathe for three days and then
diffuse hair shedding [1]. The actual prevalence of TE is un-       to revisit our clinic. On the second visit, the trimmed area was
known because of its subclinical nature. Both sexes may be          stained with black dye (Wella®Koleston, Darmstadt). The dye
affected; however, women tend to seek more medical advice           was cleaned with 80% alcohol solution 15 minutes later, and
and be over-represented [2].                                        another set of images was taken at 20× magnification again.
                                                                    The most suitable image was selected, and the results were
                                                                    evaluated using automatic computerized phototrichogram
Objectives
                                                                    software (Tricholog GmbH), which is based on the principle
Although vitamin and mineral deficiencies have been associated      of analyzing hair length on each hair strand, and then differ-
with TE, this is still a controversial topic. This study aimed to   entiating and categorizing growing hairs (≥ 0.35 mm/day) as
investigate demographic features, define the detectable vitamin     anagen and non-growing hairs (<0.35 mm/day) as telogen.
and mineral deficiencies in patients with acute and chronic TE,        Statistical analysis was performed using IBM SPSS Sta-
and associate their levels with the anagen hair ratio (AHR) on      tistics for Windows, version 20.0 (IBM Corp). Descriptive
an automated digital computerized phototrichogram (ADCP).           statistics were presented as a number, percentage, mean,
                                                                    standard deviation, median, minimum, and maximum. The
                                                                    Kolmogorov–Smirnov test and graphics were used to inves-
Methods                                                             tigate whether the numerical data fit the normal distribu-
The study was approved by the local ethics committee (de-           tion. The independent t-test was performed for two groups,
cision no. 15/31, 01.10.2018). Laboratory results, electronic       whereas the one-way analysis of variance (ANOVA) test was
medical records, and ADCP findings of patients who were             performed for more than two groups with normal distribu-
diagnosed with TE between March 2015 and March 2018                 tions. Pearson correlation coefficient was used to analyze the
were retrospectively obtained from the medical electronic           relationship between two numeric variables when the data
and dermoscopy unit databases of our hospital.                      set showed normal distribution, whereas Spearman correla-
    The following demographic and clinical features were            tion was used for non-normally distributed ones. A P value <
extracted from the electronic medical records: age, sex,            0.05 was considered statistically significant.
application month, and biochemical test results, including
hemoglobin (HGB), ferritin, vitamin B12 (Vit-B12), folate,          Results
vitamin D (Vit-D), zinc, and AHR. Raw data were ano-
nymized. Patients were categorized into four groups accord-         A total of 973 patients diagnosed with TE who applied between
ing to age: <20, 20–29, 30–50, and >50 years. Normal values         March 2015 and March 2018 were included in this retrospec-
of variables were determined as follows: HGB, 14–18 g/dL            tive study. Of these patients, 86.3% (N = 840) were female, and
for men and 12–16 g/dL for women; ferritin, >40 μg/mL;              13.7% (N = 133) were male, with a female/male ratio of 6.31.
Vit-D, >25 ng/mL; Vit-B12, >200 pg/mL; folate, >4 ng/mL;            The mean age was 27.54 ± 9.42 (minimum, 13; maximum, 72)
zinc, >70 μg/dL; and AHR, 80%–100%.                                 years. Of the patients, 18.1% (N = 176) were < 20 years old;
    Hair examination data on ADCP were collected from our           51.8% (N = 504), 21–29 years old; 27.1% (N = 264), 30–50
clinic dermoscopy unit. The procedure was as follows: on            years old; and 3% (N = 29), ≥ 51 years (Table 1).




2                                                                       Original Article | Dermatol Pract Concept. 2023;13(3):e2023202
    Patients were also distributed according to the months            found between sex and AHR (independent t-test, P = 0.247).
of admission: January, 7.9% (N = 77); February, 7.1%                  Additionally, no significant difference was found between
(N = 69); March, 5.5% (N = 54); April, 3.9% (N = 38); May,            age groups (≤ 20, 21–30, and 31–50) and AHR (ANOVA, P
6.3% (N = 61); June, 4.3% (N = 42); July, 6.4% (N = 62);              = 0.197). The age group > 50 years was not included in the
August, 8.2% (N = 80); September, 8.7% (N = 85); October,             analysis because there were not enough subjects.
12.7% (N = 124); November, 18.5% (N = 180); and Decem-                     The correlation analysis between biochemical tests and
ber, 10.4% (N = 101). November and April had the highest              AHR was conducted only for female patients (N = 39) be-
and lowest number of admissions, respectively (Figure 1).             cause there were not enough male patients for the correlation
    The following biochemical tests were evaluated: 94.1%             analysis (N = 3). For female patients, no significant relation-
(N = 916), 77.5% (N = 755), 86.4% (N = 841), 58.5% (N                 ship was found between ferritin, Vit-B12, and folate levels
= 570), 5.9% (N = 58), and 4.5% (N = 44) of the patients              and AHR (Spearman rank, r = −0.112, P = 0.523; r = 0.149,
had available HGB, ferritin, Vit-B12, folate, Vit-D, and zinc         P = 0.386; r = 0.186 and p = 0.346, respectively). No signif-
data, respectively. The rates of anemia, low ferritin level, and      icant relationship was found between zinc levels and AHR
Vit-B12, folate, Vit-D, and zinc deficiencies were 11.9% (N           (r = −0.423, P = 0.577). The relationship between Vit-D and
= 109), 44% (N = 332), 1.5% (N = 13), 2.5% (N = 14), 87%              AHR was not assessed because there were insufficient pa-
(N = 51), and 4.5% (N = 2), respectively.                             tients with Vit-D data. A positive correlation was available
    AHR obtained in the dermoscopy unit was available in              between the HGB levels and AHR of female patients (r =
4.3% (N = 42) of the patients. The mean AHR value of the              0.417, P = 0.008, Table 2 and Figure 2).
female patients was 68.57 ± 8.88%, and that of male pa-
tients was 74.73% ± 5.36%. No significant difference was
                                                                      Conclusions
                                                                      This study focused on the deficiency rates of HGB, ferritin,
  Table 1. Sociodemographic characteristics of
                                                                      Vit-B12, folic acid, Vit-D, and zinc levels in patients diag-
        patients with telogen effluvium.
                                                                      nosed with TE and correlation between the micronutrient
                                    N                  %
                                                                      levels and AHR.
 Sex           Male                133                13.7                 Hair follicle cells have a high-turnover rate. Thus, they
              Female               840                86.3
                                                                      need organic and inorganic molecules, minerals, and oxygen
 Age           ≤ 20                176                18.1
                                                                      for their metabolic activities. Congenital or acquired defi-
              21–29                504                51.8
              30–50                264                27.1            ciencies of these metabolites due to low intake, insufficient
               ≥ 51                 29                 3.0            absorption, or pathological losses may result in abnormalities




       200
       180
       160
       140
       120
       100
       80
       60
       40
       20
        0
               Jan        Feb       Mar        Apr        May        Jun       Jul      Aug       Sep       Oct       Dec

                                                             Number of Patients


   Figure 1. Number of the patients according to the month of admission.



Original Article | Dermatol Pract Concept. 2023;13(3):e2023202                                                                     3
                                Table 2. Distribution of the anagen hair ratios, zinc, and vitamin levels of the patients.
                                                          N             Mean             Median                 SD             Min            Max
           AHR, %                                         42             69.01              70                  8.78           50.7            84.2
           Ferritin, μg/mL                                755            33.56              22                 32.75             2             293
           Vit-B12, pg/mL                                 841          325.88             299.60             149.72            61.4           2000
           Folate, ng/mL                                  570             8.21             7.75                 3.45           1.73             20
           Vit-D, ng/mL                                    45            15.58             13.97                8.68           3.37           45.10
           Zinc, μg/dL                                     44            92.35             91.40               16.47            64            131.1

  AHR = anagen hair ratios; SD = standard deviation.



                                                                                        laboratories use different ferritin levels, ranging from 20 to
                       90,0
                                                                                        70 μg/mL; however, a cutoff below 41 μg/mL yields sensitiv-
                                                                                        ity and specificity of 98% [7]. Deloche et alinvestigated the
                                                                                        relationship between iron deficiency and hair loss in more
                       80,0
                                                                                        than 5000 women aged 35–60 [8]. They were divided into
                                                                                        three groups according to their hair loss status, namely, ab-
Anagen Hair Ratio, %




                                                                                        sence of hair loss, moderate, and excessive. Moreover, 59%
                       70,0
                                                                                        of the patients with ferritin levels < 40 µg/L were placed in
                                                                                        the excessive hair loss group, whereas this rate was 48% in
                                                                                        other participants. Their regression analysis revealed that the
                       60,0
                                                                                        probability of excessive hair loss increased by 28% with a 30
                                                                                        µg/L decrease in ferritin levels in women; in other words, the
                                                                                        severity of hair loss increases as the ferritin level decreases.
                       50,0
                                                                                        Moeinvaziri et al reported that ferritin levels were signifi-
                              10,0   11,0   12,0   13,0         14,0   15,0      16,0
                                             Hemoglobin, g/dl
                                                                                        cantly lower in their 30 patients with diffuse telogen hair
                                                                                        loss than in their 30 healthy volunteers without hair loss [8].
  Figure 2. Positive correlation between the hemoglobin level and an-                   However, some researchers did not find a direct relationship
  agen hair percentage of female patients.
                                                                                        between iron level and hair loss [9,10]. In their study, Sin-
                                                                                        clair investigated the relationship between iron deficiency
  in the structure of the hair, pigmentation changes, and hair                          and chronic telogen hair loss, and five of their patients were
  loss [3,4].                                                                           treated with iron to increase serum ferritin levels >20 µg/L;
                       In this study, 86.3% of the patients with TE who applied         however, hair loss did not improve during follow-up [10].
  to our dermatology department were female. These patients                             Another study investigated serum ferritin levels and telogen
  were mostly between 20 and 30 years old (51.8%), followed                             hair ratio in 181 female patients, who were divided into three
  by patients aged 30–50 (27.1%). The most frequent applica-                            groups according to their ferritin levels: ≤10 µg/L, 10–30
  tion month was November with 18.5% (N = 180), followed                                µg/L, and >30 µg/L. The telogen hair ratios of these groups
  by 12.7% (N = 124) in October. The incidence of TE changes                            were compared, and no significant statistical correlation was
  with seasonal transitions [5]. However, our hospital is lo-                           found [11]. In the present study, 755 patients had ferritin
  cated within the university campus, and the population of                             data, and 44% of these patients had low ferritin levels. How-
  the district where it is located doubles as other departments                         ever, no significant correlation was found between AHR and
  of the university start education in October–November.                                ferritin levels in patients with TE (r = −0.112, P = 0.523).
  The true incidence and seasonal fluctuations in TE are not                               Vit-B12 and folate have very important functions on
  well established due to the lack of data regarding particu-                           both hematologic and nervous systems. Vit-B12 is a cofactor
  larly subclinical cases. Furthermore, male patients are sig-                          for methylmalonyl-CoA mutase and homocysteine methyl-
  nificantly less likely to consult a physician than their female                       transferase, a folate-dependent pathway [12]. The critical
  counterparts. Therefore, large-scale field studies are needed                         importance of homocysteine methyltransferase is that the
  to determine the true incidence of TE.                                                reaction of the conversion of 5-methyltetrahydrofolate to
                       Iron deficiency is the world’s most common nutritional           tetrahydrofolate takes place at this stage, and it catalyzes a
  deficiency and is considered one of the most prevalent                                reaction associated with the synthesis of purine and pyrimi-
  causes of hair loss [6]. To define iron deficiency, different                         dine bases and thus DNA synthesis [12,13]. This makes both



  4                                                                                         Original Article | Dermatol Pract Concept. 2023;13(3):e2023202
                  Table 3. Correlation study between biochemical tests and anagen hair ratio.
                                               Ferritin          Vit-B12            Folate             Zinc            Vit-D            HGB
                                      a
 Anagen hair ratio                   r         0.149             0.149              0.186           −0.423            0.149            0.417
                                     P         0.386 b           0.386 b            0.346 b          0.577 c          0.386 b          0.008 b

HGB = hemoglobin.
a
  Correlation coefficient
b
  Spearman rank correlation coefficient test
c
 Pearson correlation coefficient test


Vit-B12 and folate important for the high-turnover rates in                      In our study, large-scale TE patients’ biochemical tests
hair follicle cells. However, no sufficient evidence confirms              were evaluated in a tertiary care center. Also, correlation anal-
the association between Vit-B12 and folate deficiencies and                ysis was performed to detect essential ones which was only
hair loss. In this study, 841 patients had Vit-B12 data, of                HGB level. In order to manage TE patients cost-effectively,
which 1.5% had Vit-B12 deficiency, whereas 2.5% of 570                     a complete blood count can be used as an initial test.
patients with folate data had folate deficiencies. No signifi-
cant correlation was found between AHR and levels of these
vitamins (r = 0.149, P = 0.386).                                           References
    Vit-D modulates the growth and differentiation of hair
                                                                            1. İbiş S, Aksoy Saraç G, Akdağ T. Evaluation of MCV/RDW
follicle keratinocytes via nuclear Vit-D receptor (VDR)
                                                                               Ratio and Correlations With Ferritin in Telogen Effluvium
with the highest activity in the anagen stage [4]. VDR                         Patients. Dermatol Pract Concept. 2022;12(3):e2022151.
mutations cause Vit-D-dependent rickets type 2, which                            DOI: 10.5826/dpc.1203a151. PMID: 36159144. PMCID:
equates to full body hair loss and present evidence for                          PMC9464528.
the relationship between hair loss and Vit-D deficiency                     2.   Mysore V, Parthasaradhi A, Kharkar RD, et al. Expert consensus
                                                                                 on the management of Telogen Effluvium in India. Int J Trichol-
[15,16]. In this study, 87.9% of 58 patients with Vit-D
                                                                                 ogy. 2019;11(3):107-112. DOI: 10.4103/ijt.ijt_23_19. PMID:
data had low Vit-D levels. The correlation analysis be-
                                                                                 31360038. PMCID: PMC6580807.
tween Vit-D levels and AHR could not be performed be-                       3.   Cheung EJ, Sink JR, English Iii JC. Vitamin and Mineral De-
cause there were not enough subjects with Vit-D results                          ficiencies in Patients With Telogen Effluvium: A Retrospec-
and ADCP analysis.                                                               tive Cross-Sectional Study. J Drugs Dermatol. 2016;15(10):
    Zinc is an essential trace element involved in protein                       1235-1237. PMID: 27741341.
                                                                            4.   Yorulmaz A, Hayran Y, Ozdemir AK, et al. Telogen effluvium in
and nucleic acid synthesis and various metabolic pathways.
                                                                                 daily practice: Patient characteristics, laboratory parameters, and
Transient zinc deficiency in acrodermatitis enteropathica,
                                                                                 treatment modalities of 3028 patients with telogen effluvium. J
resulting in hair loss, demonstrated effects on hair. Kil et al                  Cosmet Dermatol. 2022;21(6):2610-2617. DOI: 10.1111
reported that zinc levels were significantly lower in patients                   /jocd.14413. Epub 2021 Aug 27. PMID: 34449961.
with alopecia areata, TE, and androgenetic alopecia (three                 5.    Liyanage D, Sinclair R. Telogen Effluvium. Cosmetics.
main hair loss diseases) compared with healthy volunteers                        2016;3(2):13. DOI:10.3390/cosmetics3020013.
                                                                            6.   Trost LB, Bergfeld WF, Calogeras E. The diagnosis and treat-
[17]. In our study, 4.5% of the 44 patients with serum zinc
                                                                                 ment of iron deficiency and its potential relationship to hair
data had zinc deficiency. Correlation analysis with AHR was
                                                                                 loss. J Am Acad Dermatol. 2006;54(5):824-844. DOI: 10.1016/j
not significant (r = −0.423, P = 0.577).                                         .jaad.2005.11.1104. PMID: 16635664.
    In our study, 916 patients had HGB data, of which                       7.   Shrivastava SB. Diffuse hair loss in an adult female: approach
12.3% of the female and 9.1% of the male patients were                           to diagnosis and management. Indian J Dermatol Venereol Lep-
anemic. In addition, a significant positive correlation was                      rol. 2009;75(1):20-72; DOI: 10.4103/0378-6323.45215. PMID:
                                                                                 19172026.
found between HGB level and AHR in female patients (r =
                                                                            8.   Deloche C, Bastien P, Chadoutaud S, et al. Low iron stores: a
0.417 and p = 0.008). This suggests that deficiencies in mi-
                                                                                 risk factor for excessive hair loss in non-menopausal women. Eur
cronutrients such as Vit-B12, folate, and iron can indirectly                    J Dermatol. 2007;17(6):507-512. DOI: 10.1684/ejd.2007.0265.
alter the severity of TE if they decrease HGB level.                             PMID: 17951130.
    The main limitation of our study was its retrospective                  9.   Olsen EA, Reed KB, Cacchio PB, Caudill L. Iron deficiency in
nature and that some analyses could not be performed due                         female pattern hair loss, chronic telogen effluvium, and con-
                                                                                 trol groups. J Am Acad Dermatol. 2010;63(6):991-999. DOI:
to missing data, such as Vit-D level and AHR correlation
                                                                                 10.1016/j.jaad.2009.12.006. PMID: 20947203.
and male patient’s correlation analysis. Also, our city is a
                                                                           10.   Sinclair R. There is no clear association between low se-
college town. Its population increases in the winter months.                     rum ferritin and chronic diffuse telogen hair loss. Br J Der-
This may affect the monthly admission rates and cause an                         matol. 2002;147(5):982-984. DOI: 10.1046/j.1365-2133
increase in patient numbers in certain months.                                   .2002.04997.x. PMID: 12410711.



Original Article | Dermatol Pract Concept. 2023;13(3):e2023202                                                                                   5
11. Bregy A, Trueb RM. No association between serum ferritin lev-     15. Vupperla D, Lunge SB, Elaprolu P. Vitamin D-Dependent Rickets
    els >10 microg/l and hair loss activity in women. Dermatology.        Type II with Alopecia: A Rare Case Report. Indian J Derma-
    2008;217(1):1-6. DOI: 10.1159/000118505. PMID: 18309237.              tol. 2018;63(2):176-179. DOI: 10.4103/ijd.IJD_434_17. PMID:
12. Brescoll J, Daveluy S. A review of vitamin B12 in dermatology.        29692463. PMCID: PMC5903051.
    Am J Clin Dermatol. 2015;16(1):27-33. DOI: 10.1007/s40257-        16. Santos R, Neves S, Gomes C, Neves F, Correia AJ. Raquitismo
    014-0107-3. PMID: 25559140.                                           vitamina D dependente tipo II [Rickets vitamin-D-dependent
13. Stabler SP. Clinical practice. Vitamin B12 deficiency. N Engl J       type 2]. Acta Med Port. 2009;22(6):861-866. PMID:
    Med. 2013;368(2):149-160. DOI: 10.1056/NEJMcp1113996.                 20350471.
    PMID: 23301732.                                                   17. Kil MS, Kim CW, Kim SS. Analysis of serum zinc and copper
14. Almohanna HM, Ahmed AA, Tsatalis JP, Tosti A. The Role of             concentrations in hair loss. Ann Dermatol. 2013;25(4):405-409.
    Vitamins and Minerals in Hair Loss: A Review. Dermatol Ther           DOI: 10.5021/ad.2013.25.4.405. PMID: 24371385. PMCID:
    (Heidelb). 2019;9(1):51-70. DOI: 10.1007/s13555-018-0278-6.           PMC3870206.
    PMID: 30547302. PMCID: PMC6380979.




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