Nutritional supplements should only be considered for a small subset of patients with alopecia areata, said Leslie Castelo-Soccio, M.D., Children’s Hospital of Philadelphia. Over supplementation can actually lead to secondary hair loss, she warned, and most patients do not even need testing for biotin or vitamin D deficiency or celiac disease.
Researchers in the 1950s found that mice fed a diet high in egg white experienced decreased hair growth, and that hair growth resumed if they were given biotin supplementation, and advertising and marketing purports the benefits of biotin for hair growth.
However, primary deficiency, which is characterised by hypotonia, red scaly patches and plaques, poor hair growth and neurological symptoms, is rare (1 in 60,000), Dr. Castelo-Soccio. Secondary deficiency of biotin is more common but still rare; it can occur in pregnancy, and be linked to increased raw egg consumption, alcoholism, intestinal malabsorption (i.e. short gut) or prolonged use of medications such as isotretinoin, valproic acid, other anticonvulsants, or antibiotics.
A literature search found just 18 reported cases of biotin deficiency in hair conditions and only one study looking at hair loss. This study which measured biotin levels in 541 women found just over a third (38%) had marginally low levels of biotin and all of these had a history of prolonged antibiotic use, concomitant isotretinoin or antiepileptics use, or had gastrointestinal disease.
Patients with hair loss can be tested for biotin deficiency if it is suspected, Dr. Castelo-Soccio said, but she admits she rarely recommends biotin supplements, recommending foods rich in biotin such as nuts, legumes, whole grains, unpolished rice and egg yolk in the diet instead.
Prevalence of celiac disease in North America and Western Europe is 0.5- 1.3% and in alopecia areata around 1.2%, and one study did find that almost two thirds (64%) of patients with celiac disease and alopecia areata grew hair when they followed a gluten free diet.
A gluten free diet may be beneficial if the patient has celiac disease, Dr. Castelo-Soccio said, but patients not exhibiting celiac disease symptoms should not be tested for the condition unless they have a first degree relative with coeliac disease or have specific genetic changes like trisomy 21, Williams syndrome, selective IgA deficiency or have type 1 diabetes or autoimmune thyroiditis. Current recommendation for testing from North American Society for Pediatric Gastroenterology, Hepatology and Nutrition does not include a diagnosis of alopecia areata.
In terms of vitamin D deficiency, subobtimal levels of vitamin D are often found in both adults and children with alopecia areata, but there is no data yet to support that vitamin D supplementation changes hair growth.
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v. Kaplan, L, Castelo-Soccio, L When you patients’ parent asks: My child’s alopecia areata is not getting better. Should he or she get tested for celiac disease? Pediatr Dermatol. 35(4): 535-538.
vi. Tsai T, Huang Y. Vitamin D deficiency in patients with alopecia areata: A systematic review and meta-analysis. J Am Acad Dermatol 2018;78(1):207-209.
vii. Putterman and Castelo-Soccio, May 2018 accepted Journal of American Academy of Dermatology – not epublished yet.