Forty-six women with diffuse alopecia received 200 mg per day of oral vitamin B5 plus daily intramuscular injections of vitamin B6 for 20–30 days. The treatment was repeated after six months and resulted in improved hair condition and reduced hair loss (Brzezinska-Wcislo 2001). Results from animal studies demonstrated vitamin B6, in combination with the amino acid L-cystine, prevented hair loss caused by the chemotherapy drug doxorubicin (D'Agostini 2007; D'Agostini 2013).
Severe biotin (vitamin B7) deficiency can occur as the result of certain genetic mutations, causing hair loss as well as several other serious health problems (Zempleni 2008). In one study, 38% of women with self-reported hair loss exhibited biotin deficiency (Trueb 2016). In dogs, biotin supplementation may help improve hair growth (Frigg 1989), but human clinical trials have yet to verify this finding. Some preliminary evidence suggests that biotin supplementation may help treat alopecia caused by the medication valproic acid (Famenini 2014).
A growing body of evidence shows that vitamin D participates in regulation of the hair cycle (Amor 2010; Malloy 2011; Vegesna 2002; Aoi 2012). In a case series of 210 women with female pattern hair loss, over 60% had below-normal vitamin D levels (Siah 2016). Low serum vitamin D levels are associated with autoimmune disorders including alopecia areata (Mahamid 2014; Aksu Cerman 2014). Telogen effluvium has been associated with vitamin D deficiency (Cheung 2016), and low vitamin D levels have been linked to greater hair loss in women with telogen effluvium and female pattern hair loss (Rasheed 2013).
In a 12-week trial, 48 patients with mild-to-moderate alopecia areata were treated twice daily with a topical solution containing calcipotriol, a synthetic form of vitamin D. At the end of the trial, more than 62% of participants had 75% or better hair regrowth, and 27% of participants had 100% hair regrowth (Cerman 2015). The case of a 7-year old boy with alopecia areata is also compelling: after failing to respond to topical minoxidil plus hydrocortisone, the boy experienced complete hair regrowth after three months of treatment with topical calcipotriol (Kim, Lee, Kim 2012). A study on 20 children with alopecia areata and 34 healthy controls found that vitamin D levels were inversely related to alopecia severity scores—as vitamin D levels went up, alopecia severity scores went down (Unal 2017).
Animal and preclinical models indicate topical vitamin D as well as calcipotriol may help prevent chemotherapy-induced alopecia, with some evidence suggesting this treatment can enhance hair regrowth (Jimenez 1992; Schilli 1998; Paus 1996; Wang 2006). In one study, topical vitamin D significantly reduced chemotherapy-induced hair loss in female mice (Chen 1998).
Saw palmetto (Serenoa repens) is popularly used to treat prostate enlargement and androgenetic alopecia (Murugusundram 2009). A randomized controlled trial in 26 men aged 23‒64 with mild-to-moderate androgenetic alopecia found a combination of 200 mg saw palmetto extract, 50 mg beta-sitosterol, along with complementary amounts of lecithin, choline, inositol, niacin, and biotin was effective for measures of hair growth and quality. Self-assessment of satisfaction with hair growth and appearance, and investigative staff assessment of hair density both markedly improved (Prager 2002). An uncontrolled study in 50 men aged 20 to 50 years with androgenetic alopecia found a topical saw palmetto extract increased hair count (Wessagowit 2015). Another trial compared the effects of 320 mg oral saw palmetto extract daily to 1 mg finasteride daily in 100 men with mild-to-moderate androgenetic alopecia over two years. Finasteride led to hair regrowth in 68% of subjects, while 38% of those in the saw palmetto group experienced improved hair growth; treatment with saw palmetto was well tolerated (Rossi 2012). Researchers believe saw palmetto’s ability to inhibit 5-alpha reductase is at least partly responsible for its positive effects (Murugusundram 2009), and some have proposed that combining saw palmetto or beta-sitosterol with anti-inflammatory agents such as carnitine and alpha-lipoic acid may enhance its effectiveness (Chittur 2011; Chen, Wang, Mouser 2016).
Essential Fatty Acids
A trial in 120 women with early-stage hair loss found six months of daily supplementation with 460 mg fish oil, 460 mg black currant seed oil (providing gamma-linolenic acid [GLA]), 1 mg lycopene, and small amounts of vitamins E and C led to improved hair density compared with a control group. The supplemented group also had more anagen-phase hair and less telogen-phase hair compared with placebo (Le Floc'h 2015).
In a rodent study, most animals taking docosahexaenoic acid (DHA), an omega-3 fatty acid found mainly in fish oil, were protected from chemotherapy-induced alopecia (Takahata 1999). In another study of six rhesus monkeys with hair loss, daily treatment with omega-3 (72 mg) and omega-6 (26 mg) fatty acids was associated with decreased alopecia (Hamel 2017). Several studies have found attaching DHA to paclitaxel (Taxol), a commonly used chemotherapy drug, reduced the drug’s toxic side effects, including alopecia (Bradley 2001; Wolff 2003; Harries 2004).
Protein deficiency is a well-established cause of hair loss, and one protein, keratin, is the main component and primary structural element of hair. Age-related decline in keratin synthesis may lead to deterioration of the stability and flexibility of the hair shaft (Giesen 2011; Mubki 2014b). This could leave hair vulnerable to dryness and breakage with brushing and use of styling products and tools.
In one study, a supplement containing a novel form of solubilized keratin (Cynatine) plus vitamins and minerals was compared with placebo in 50 women who had signs of stressed or damaged hair. Cynatine contains a specially-processed, highly bioavailable peptide form of keratin, a rich source of cysteine. After 90 days, the Cynatine formula group had less hair loss; improved hair strength; improved anagen phase, telogen phase, and anagen:telogen ratio; and better hair appearance compared with placebo (Beer 2014).
Silicon, a trace element present in the body in small quantities, is thought to function as a structural component of hair (Martin 2013). Silicon compounds are common in many edible plants (Jurkic 2013). Two studies have looked at the effect of supplementing with orthosilicic acid, which provides silicon, on hair health. In one study, 50 women were given 10 mg orthosilicic acid or placebo daily for 20 weeks. By the end of the study, hair brittleness decreased in women receiving the silicon supplement (Barel 2005). In the second study, 48 women with fine hair received the same compound or placebo for nine months; hair strength and elasticity were better preserved and hair thickness increased in the supplemented group compared with placebo (Wickett 2007).
Zinc deficiency has been associated with hair loss (Saper 2009; Kil 2013). Zinc plays an important role in normal hair follicle activity, preventing follicle regression and enhancing follicle recovery (Kil 2013). Also, zinc may act as an anti-androgen and modulator of 5-alpha reductase (Gupta 2014).
Men and women with androgenetic alopecia, telogen effluvium, and alopecia areata have all been found to have lower serum zinc levels than people with no hair loss (Kil 2013). Early research suggests using supplements to correct zinc deficiency in people with related telogen effluvium can improve hair loss (Karashima 2012).
Lower zinc levels in patients with alopecia areata have been correlated with increased severity, longer duration, and higher likelihood of treatment resistance (Abdel Fattah 2016; Bhat 2009). In one uncontrolled clinical study, 15 subjects with alopecia areata and low zinc levels (≤ 70 mcg/dL) received 50 mg zinc gluconate per day. After 12 weeks, hair regrowth was seen in nine subjects and was correlated with improved zinc status (Park 2009). In addition, case reports suggest continued zinc gluconate supplementation may help maintain hair recovery after treatment of alopecia areata in those who respond to ultraviolet light therapy plus zinc (Lux-Battistelli 2015).
Tocotrienols—members of the vitamin E family—are naturally found in barley, wheat germ, and certain types of grains and nuts (Ahsan 2015). Similar to tocopherols, the more familiar form of vitamin E, there are four tocotrienols labeled alpha, beta, gamma, and delta (Ahsan 2015; Peh 2016). Tocotrienols are recognized to have important vitamin E activity, particularly with regard to their anti-inflammatory, cholesterol-lowering, and radioprotective properties (Peh 2016; Jiang 2014).
Emerging evidence suggest tocotrienols may help promote healthy hair. In a study involving 38 women and men with various types and degrees of hair loss, those receiving supplements with 23 IU alpha-tocopherol plus 50 mg mixed tocotrienols experienced > 34% increase in hair numbers over eight months, while those receiving placebo experienced a slight decrease in hair numbers (Beoy 2010).
There is evidence that green tea and its main polyphenol, epigallocatechin gallate (EGCG), may help prevent hair loss and aid in hair regrowth. In a mouse study, a topical EGCG solution protected against testosterone-induced hair loss (Kim 2011). In a study in mice with spontaneous hair loss, a green tea polyphenol solution added to drinking water promoted hair growth versus no growth with plain water (Esfandiari 2005). EGCG stimulated dermal papilla cells and promoted hair growth in human hair follicles in a laboratory setting as well as in human subjects (Kwon, Han 2007).
Selenium intake is important for healthy hair follicle function, and selenium deficiency may play a role in hair loss (Sengupta 2010; Hwang 2011). In an eight-week randomized controlled trial in 64 women with polycystic ovary syndrome, 32 received 200 mcg supplemental selenium daily while the other half received placebo. At the end of the trial, the selenium group had a significant reduction in hair loss compared with placebo (Razavi 2016).
Melatonin may be helpful as a topical treatment for hair loss. While not yet known how melatonin might combat alopecia, its ability to counteract oxidative stress, thought to play an important role in hair loss (Trueb 2009), and its ability to stimulate hair follicle growth (Fischer 2012) have been suggested.
In an early controlled trial, 40 women with female pattern hair loss or diffuse alopecia applied 1 mL of either a 0.1% topical melatonin solution or placebo solution to their heads nightly. After six months, the topical melatonin group had significantly more hair in anagen phase (Fischer 2004).
A set of four studies in men and women with early-stage androgenetic alopecia evaluated melatonin combined with other topical agents as a treatment for hair loss. In the first study, a 0.0033% melatonin solution, also containing biotin and a Ginkgo biloba extract, was applied nightly to the scalps of 30 men and women for 90 days. Both investigators and participants reported a decrease in severity of alopecia on day 30 and an even greater improvement on day 90. In the second study, 35 men used the same solution nightly for six months. Investigators noted an average 29% increase in hair number and density after three months and an almost 43% increase in number and 41% increase in density after six months, with more than 50% of participants responding to treatment. The third study used a hair count test, in which participants counted the number of hairs lost during 60 seconds of combing each morning, as the measure of response. Lost hair counts decreased over the 90-day trial in 20 female participants but not in 40 male participants using the melatonin solution. The final study included 901 men and 990 women who applied the solution nightly. Hair pull tests showed no hair loss in nearly 62% and new hair growth in nearly 23% of participants after 90 days of treatment. In addition, treatment with melatonin solution appeared to improve seborrhea (red, itchy, scaly skin) in participants with this condition of the scalp (Fischer 2012).
Iron deficiency can cause telogen effluvium (Grover 2013; Levy 2013; Malkud 2015). Low levels of ferritin, an iron-storing protein, have been observed in women with female pattern hair loss (Park 2013; Rasheed 2013), telogen effluvium (Moeinvaziri 2009; Rasheed 2013), and premenopausal hair loss (Deloche 2007). One study found lowest ferritin levels were associated with most severe hair loss. Assessment of iron status, and iron supplementation if necessary, can be considered in women with hair loss (Rasheed 2013).
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