The Important Role of Diet In Incidence of Alopecia

For more on hair loss, read The Evolution of Hair Beauty Supplements


Winter is coming! As hat and scarf season gets underway, all I can think about is hair drying and breaking, bad hair days and hair neglect. Don’t get me wrong, fall is a beautiful season. It’s what happens to our hair and skin with the loss of the summer humidity and social calendars winding down that concerns me.

Patients are always requesting a “natural alternative.” Sometimes supplements are natural, but it almost seems like that’s not enough. Nutrafol is all-natural, Viviscal is all-natural. I recommend these and other products to my patients, but for some, the act of swallowing a pill gives them the impression that it is not natural. Thus, after going over every single ingredient in every single aforementioned product, I discuss foods that should be incorporated and those that should be reduced or eliminated from their diets. Patients either take notes or they snatch the pills and schedule a follow-up appointment. In an effort to reach those who hear, but do not listen, I’ve decided to tackle the topic of and its effect on hair growth and hair health. Because, eventually, we will all have to make changes to our diet.

Practicing in the Washington, DC metropolitan area means that I see patients from a broad range of racial, ethnic and socio-economic backgrounds. As a result, I get to play with all types of hair every day. My population is predominantly skin of color. In this culture, for some, the term “good hair” has carried with it, cultural prejudices, privilege and other emotions. Today, I use it often because “Healthy Hair is Good Hair.” There is nothing like hair that bounces and springs back up when you pull it. There is nothing like an afro that is full, shiny, and “snaps back” with elasticity. That is “good hair”—because it is healthy.

Healthy hair requires adopting an entire lifestyle—including diet. The healthy hair diet includes:

• Diet rich in plant-based foods
• Fiber and antioxidants
• Adequate protein—Excess protein can cause renal damage
• Adequate hydration—oral, I.V. Centers
• Adequate good quality sleep
• Regular exercise
• Stress management—possibly supplementing with Ashwagandha
• Meditation/Mindfulness

The hair growth supplement market is surging along with consumers’ desire for healthy, fuller and longer hair. Why? Half of men and women are affected by pattern hair loss by age 50. Patients with hair loss often inquire whether supplements can help restore hair growth or prevent further hair loss. In fact, many start dietary supplements without consultation in an effort to stave off hair loss.

Oversupplementation?

Unfortunately, the supplement industry capitalizes on this population’s vulnerability. Hair follicles are among the most metabolically active in the body, and growth may be impacted by calorie and protein malnutrition as well as micronutrient deficiency, but the links are complex. Amazon.com alone has 923 products marketed for hair growth with “Best Sellers” containing vitamins A and E. This can become concerning as consumers seek to treat themselves and may accidentally overdo it. Over supplementation of vitamins A and E and selenium are actually linked to hair loss, among other more serious health risks.²

Nutritional deficiency may impact both hair structure and hair growth. Hair matrix cells are some of the most rapidly dividing cells in the body, making them susceptible to nutritional deficiencies. High-glycemic and inflammatory diets are associated with worsening of inflammation. Nutritional deficiency is associated with:

• Acute Telogen Effluvium (TE)
• Chronic TE
• Androgenetic Alopecia (AGA)
• Female Pattern Hair Loss (FPHL)
• Alopecia Areata (AA) ¹

Proteins

Proteins are the major components of hair. A cross-sectional study found severe protein intake deficiencies in Indian AGA, AA, and TE patients, supporting protein as an essential nutrient for hair. Plant-based proteins are a great alternative, but beware of processed foods high in sodium. Protein deficiency is associated with hair loss—a very rare occurrence in developed countries. The recommended daily allowance (RDA) for protein is 0.8g /kg – 0.36g/lb, about 40-60g a day for most people. Current estimates state that the average American woman gets at least 70g a day and the average man 100mg a day.

Iron Deficiency

Iron is a co-factor for DNA synthesis. Hair follicle (HF) matrix cells divide rapidly and iron is a co-factor for ribonucleotide reductase, the rate limiting enzyme for DNA synthesis.¹ Multiple genes in the human hair follicle are regulated by iron. Iron storage is measured by ferritin, but a normal ferritin level does not exclude iron deficiency (ID), as ferritin is an acute phase reactant (also affected by inflammation). Ferritin also has a very wide “normal range.”

The goal of iron supplementation should be to achieve ferritin level of 50 ug/L with dietary sources or 70 ug/L with oral supplementation, and this should be accomplished under the supervision of a physician. Simply purchasing iron supplements and not having iron levels checked can lead to problems—like overdoing it or not getting enough. Sometimes physicians need to prescribe higher doses of iron. This is especially true for those with bleeding concerns, those who do not ingest red meat, or those with various anemias. Iron supplements are also constipating, so DIY may lead to crankiness here. Studies on ID and hair loss have been conflicting. Some found low ferritin prevalent in TE, FPHL, AGA, & AA while others found no such link.² Risk Factors for ID include:

• Pre-menopause.
• Gastrointestinal Blood Loss (get those rectal occult blood tests and colonoscopies).
• Malabsorption disorders such as Celiac Disease.
• Achlorhydria (reduced acid) from antacids and reflux medications (H2 Blockers specifically). Iron requires an acidic environment for absorption.
• Vegans and vegetarians have a 1.8 times higher dietary requirement because non-heme iron in plants is less bioavailable than heme iron in meat and fish.

Vitamin D

Vitamin D deficiency is a global health problem. With all the medical advances of the century, vitamin D deficiency remains an epidemic. More than a billion people worldwide are vitamin D deficient or insufficient.¹ The two main sources of vitamin D are sun exposure and oral intake, including vitamin D supplementation and diet. Use of sunblock, common window glass in homes or cars, and clothing, all effectively block UVB radiation, even in the summer. People who are dark-skinned, aged, obese or who consciously avoid the sun, are at risk of vitamin D deficiency.

In vitro studies have shown increase in vitamin D receptor expression in the ORS keratinocytes (the cells that make up the skin, hair, and nails).² Fawzi et al. revealed significantly lower levels of tissue and serum vitamin D receptors (VDR) in AA than in a control group. The authors suggested that reduced expression of VDR in AA might be related primarily to suppression of cell differentiation. Decreased serum 25-hydroxyvitamin D concentration was demonstrated in patients with FPHL compared to control group.

Vitamin D supplementation is not limited to dairy. That is good news, since we now know that dairy intake increases inflammation in the body. Good sources of dietary vitamin D include cod liver oil (you can stop grimacing, it comes flavored now, in softgels, etc.), tuna, sockeye salmon, mackerel. Do consume larger fish such as mackerel and tuna in moderation as they tend to have higher levels or mercury. Have a glass of orange juice fortified with vitamin D with your breakfast—but watch the sugar.

Fatty Acids

Fatty acids aren’t just good for your heart health. Omega-3 fatty acids induce resolvins and protectins, which are anti-inflammatory. Short-chain fatty acids have anti-inflammatory effects through the regulation of T cells and interleukin-10.3 Unsaturated fatty acids may inhibit 5 α-reductase, which cause hair follicle miniaturization and hair loss, creating a finasteride-like effect. Arachadonic acid, an omega-6 fatty acid, may enhance hair follicle proliferation. Topical safflower oil, high in linoleic acid, has been documented to help with hair growth.²

A diet deficient of polyunsaturated essential fatty acids can lead to scalp and eyebrow hair loss, and even hair lightening. Deficiency in fatty acids may also result from malabsorption and inappropriate parenteral (IV, feeding tube) nutrition. Patients having undergone weight loss surgery such as gastric bypass patients can also experience hair loss due to malabsorption.

Biotin

When people experience hair loss, the first thing they seem to do is start taking biotin. Biotin strengthens structure of keratin, creating hair that is stronger, more resistant to breakage and thicker appearing. Biotin needs to be taken for 9-12 months regularly to know if it is helping. Studies recommend around 2.5-5mg a day for strengthening hair. It is not recommended to take mega doses of biotin (i.e., 10mg). High doses of biotin can cause thyroid function tests to be falsely low.⁴ A case series with patients taking 20-30mg biotin daily demonstrated that biotin can interfere with immunoassays. Lab test results normalized after 48-72 hours of discontinuation of biotin.⁴

Vitamins A, C and E

If you want to “ACE” having healthy hair, then incorporate these three vitamins, because they are not just for healthy skin anymore. Antioxidants are important, as pollution increases reactive oxygen species (ROS) in the hair follicle. Excessive free radical generation was shown to occur in the scalps of patients with AA accompanied by high levels of antioxidant enzymes that were unable to protect against the ROS. Polyphenols (green tea, resveratrol) are excellent antioxidants. While dietary antioxidants play a key role in reinforcing our endogenous antioxidant system, high doses of exogenous antioxidants may actually disrupt the balance between oxidation and antioxidation. Vitamin E, known as tocopherol, is already an ingredient in many hair growth supplements, topical hair growth stimulators, and shampoos and conditioners. Let’s unpack vitamins A and C.

Vitamin A—proceed with caution^1,2

• Antioxidant
• Helps regulate cell turnover
• Helps regulate sebum production
• Too much can cause hair loss

Vitamin C^1,2

• Enhances iron absorption
• Maintains collagen
• Potent antioxidant
• Regulates the immune system

Probiotics

Probiotics are not just for your gut. Recent research has pointed to the increasing significance of the microbiota in inflammatory conditions. The Western diet contains higher amounts of processed foods and fat, and lower fiber content, leading to lower amounts of short-chain fatty acids and altered gut bacteria. It all provides an environment that is more prone to inflammation. Mice-eating probiotic yogurt or purified Lactobacillus reuteri had a significantly thicker dermis, more anagen hair follicles, and more sebocytes leading to hair gloss. Interleukin-10 was found to be required in order to reproduce these benefits.⁵

Gut bacteria may degrade the intestinal epithelial barrier leading to inflammation and autoimmunity, highlighting the possibility that changes in diet may influence the gut microbiota.⁵ Two young men with alopecia universalis (hair loss from head to toe) and Clostridium difficile infection with/without Crohn’s disease, both refractory to steroid injections, were given a fecal microbiota transplant to treat C. difficile.⁵ After the fecal microbiota transplant and two intralesional steroid injections, significant regrowth was seen on the scalp and other body parts such as the face and arms.⁵

What Nature Offers

With growing consumer concerns about harmful chemicals, people seek  “natural” ways to achieve their beauty goals. Horsetail and saw palmetto present a great combination for hair growth. Remember that natural alternatives are still medicines and can still have side effects and that individuals should be encouraged to see their PCPs regularly for yearly physicals and age-appropriate cancer screenings prior to adopting any natural or alternative regimens.

Saw Palmetto

Saw palmetto is an extract from the berries of the Serenoa repens plant. It blocks 5-alpha reductase, decreasing androgen effects on the hair follicle.6 Saw palmetto was originally used to treat Benign Prostate Hypertrophy (BPH). The typical dose is 240mg to 320mg daily for hair growth.⁶ Saw palmetto can cause GI upset, which can be alleviated by taking it with food. Saw palmetto consumption can decrease PSA by up to 50% after 6-12 months,⁶ potentially making it harder to detect early prostate cancer (danger, danger).

Ashwagandha

I often tell my patients “stress is the devil.” Increased stress or lack of sleep increases cortisol and inflammation. Increased inflammation leads to overall exacerbation of inflammatory hair loss such as alopecia areata and cicatricial (scarring) alopecias. Ashwagandha (Withania somnifera) interacts with steroid receptors to effectively decrease cortisol levels. It mediates cortisol response to stress. One study showed that taking 125mg a day of ashwaghanda significantly decreased mHAM-A (Hamilton Anxiety Scale) at days 30 and 60, while there were no changes in placebo. Changes in mHAM-A were dose dependent with higher doses experiencing greater benefit. Decreased cortisol, C-reactive protein (CRP)—a marker of inflammation, pulse rate and blood pressure was seen in all groups taking Ashwagandha. This makes a compelling argument for ashwagandha and stress and anxiety control. It is important to note that Ashwagandha cannot do the work alone for those who need medical intervention as well.

We covered a lot this month. I hope it was helpful. We are truly what we eat, think and practice. 

References

1. Hind M. Almohanna . Azhar A. Ahmed . John P. Tsatalis . Antonella Tosti. The Role of Vitamins and Minerals in Hair Loss: A Review. Dermatol Ther. 2019: 9:51–70.
2. Guo, E. and Katta, R. Diet and hair loss: effects of nutrient deficiency and supplement use. Dermatol Pract Concept 2017;7(1):1
3. Levkovich, T. et al. Probiotic Bacteria Induce a ‘Glow of Health”. PLoS One 2013;8:e53867
4. Samih, Odhaib, et al How Biotin Induces Misleading Results in Thyroid Bioassays: Case Series. Cureus 11(5): e4727
5. Pham, C. Romer, Hind, . Almohanna, Tosti, et al. The Role of Diet as an Adjuvant Treatment in Scarring and Nonscarring Alopecia. Skin Appendage Disord 2020;6:88–96
6. Rossi et aL. Comparative effectiveness of Finasteride vs serenoa repens in male adrogenetic alopecia: a Two-year study. International journal of immunopathology and pharmacology. Vol 25, No. 4, 1167-1173

---

Sharleen St. Surin-Lord
Dermatologist
derm@visagederm
www.visagederm.com
@DermHairDoc
 
Dr. Sharleen St. Surin-Lord is a board-certified dermatologist who has been practicing for more than 16 years. She is in private practice at Visage Dermatology, Largo, MD. She is an assistant professor of dermatology at Howard University College of Medicine. She also practices at the University of Maryland Capital Regional Health System in Maryland. Dr. Sharleen is a member of the American Hair Research Society and you can follow her on Instagram as DermHairDoc.