The prevalence of hair loss is estimated to be around 53.2% in adults.^[1] It can be caused by various factors, including genetic predisposition, hormonal imbalances, and nutritional deficiencies, all of which disturb the normal hair cycle.^[2,3,4] Vitamin D is a fat-soluble vitamin crucial for cell growth and hair follicle differentiation; therefore, its deficiency may be associated with hair loss.^[5,6,7,8]  Vitamin D is primarily synthesized in the skin through the action of ultraviolet B (UVB) radiation from sunlight, with smaller amounts supplemented through diet and nutrition.^[9] In the epidermal keratinocytes and fibroblasts, 7-dehydrocholesterol is converted to pre-vitamin D, which is then transported to the liver for hydroxylation into 25-hydroxyvitamin D (25(OH)D). The active form, 1,25-dihydroxyvitamin D (1,25(OH)D), is produced in the kidneys.^[10] Vitamin D exerts its physiological actions in epidermal keratinocytes and dermal papillary cells of the hair follicles via the vitamin D receptor (VDR). Therefore, disruption in vitamin D levels or VDR expression can inhibit keratinocyte differentiation, leading to abnormal hair follicle cycling. ^[11,12] VDR is an essential requirement for the initiation of the anagen phase. Experiments in VDR null mice have shown that a lack of VDR causes cessation of the anagen phase, with hair follicles entering in catagen phase prematurely and detaching from dermal papillae.^{[13,14,15,16,17]}  Whenever VDR expression becomes inadequate, there is a feedback rise in vitamin D levels that follows.^[18]  Paradoxically, in the context of vitamin-D deficiency, there can be normal or high levels of serum 1,25-dihydroxyvitamin-D, therefore, total serum 25-hydroxyvitamin-D is the best way to assess a patient's vitamin-D status.^[9,19] In addition to vitamin D deficiency, other metabolic disorders, such as Liver and chronic renal failure, are known to contribute to sparse scalp hair. ^[3]   Furthermore, iron deficiency, with or without anemia, has been linked to diffuse hair loss, although the relationship remains complex and somewhat controversial ^[20,21]. Thyroid hormones, particularly T3 and T4, are essential for the normal growth of all tissues, like skin, hair, and nails. Therefore, both hypothyroidism and hyperthyroidism can be an inducer for telogen hair loss. ^[3,22] 

In the light of increasing circulating parathyroid hormone levels, the Endocrine Society designated the threshold of vitamin-D deficiency at ≤ 50 nmol/L (20 ng/mL), the threshold of vitamin-D insufficiency at 50–75 nmol/L (20–30 ng/mL), the threshold of vitamin -D normal at ≥75 nmol/L (30 ng/mL).^[23,24] similarly, a low vitamin-B12 status (frank vitamin B12 deficiency) is generally defined as total serum vitamin-B12 levels of < 148 pmol/L, with levels between 148 and 221 pmol/L being considered as “borderline” or suggestive of “marginal deficiency”.^[25]  As  there is paucity of the study in Indian context evaluating prevalence of vitamin-D deficiency and other contributing factors in hair loss, we aimed to perform this study.

This prospective cross-sectional study was conducted in the department of dermatology at a tertiary referral centre of Chhattisgarh, India, after obtaining approval from the institutional ethical committee.  The duration of the study is from August 2024 to January 2025. A total of 100 patients aged between 18 to 45 years, presenting with increased hair loss, were included after taking a written informed consent. All participants underwent a detailed history taking, clinical examination, hair pull test, and trichoscopic scalp examination to rule out pattern hair loss and to exclude alopecia areata, cicatricial alopecia, trichotillomania, hair shaft deformity, psoriasis, folliculitis, and Lichen Planopilaris. The exclusion criteria included presence of any systemic chronic illnesses and scalp conditions that might be related to hair loss, a history of chemotherapy or radiation therapy within last 3 months, polycystic ovarian disease, and the use of certain medications such as antidepressants, immunosuppressant, retinoids, vitamin -D supplements or multivitamins containing vitamin- D. Pregnant and postmenopausal women were also not enrolled for this study. Based on clinical and trichoscopic examination diagnosis was categorized as FPHL, MPHL and TE.  An aliquot of 10 ml venous blood sample of all participants were withdrawn and laboratory test was performed in the biochemistry department to analyze for any chemical abnormality.

 Vitamin- D and B12 levels are measured using venous blood samples by chemiluminescence method.

Anaemia -hemoglobin concentration below a specific cut off point.

Normal adult male 13-16g/dl, female 12-14g/dl

 Mild anaemia 10g/dl to lower normal limit

 Moderate anemia 8-9.9g/dl

Severe anemia 6.5-7.9g/dl

 STASTICAL ANALYSIS

 All the numerical values were entered in Microsoft excel 2000. After that data were analyzed using SPSS 22.0 software. The mean and standard deviation were obtained; the categorical data were obtained with appropriate graph made.  Chi- square test was used for comparing mean levels between two groups. A p value of <0.05 was considered significant.

.

In this cross-sectional study total 100 patients 71 females and 29 males were included with complaint of increased hair loss from 3 to 18 months of duration, among them total 9 males and 36 females were vegetarian and 20 males, 35 females were non-vegetarian. Total 1 male and 4 females test result showed thyroid abnormalities, no obesity, hypertension, diabetes mellitus, and no smoking or alcoholism were presented.

Demographic characteristics of participants are shown in table 1. There was total 71females  with age 18 to 46 yrs

(mean, SD 27.60+-7.80), body weight 37 to 75 kg ( mean, SD 54.2+-7.9), height 1.4 to 1.8 meter (mean, SD 157.10+-6.4) and BMI 14.45 to 29 (mean, SD 21.9+-2.9)  and total 29 males with age 18 to 42 yrs (mean, SD 25.9+-6.27), body weight 45 to 87kg (mean, SD 66.30+-9.56), height 1.5 to 1.8 meter (mean, SD 170.2+-7.4) and BMI 16.2 to 33 (mean, SD  22.93+-35)

                      SD- standard deviation, BMI- body mass index

Table -1 showing demographic characteristics

Laboratory test levels are reported in table 2.  FPHL presented with  serum vitamin-d (mean +-SD  22.87+-17.04) serum vit-B12 (mean+- SD 204.92+-158.85) and Hb (mean+-SD 11.08+-1.72)  in MPHL serum vit-d (mean +-SD 23.4+-16.3) serum vit-B12 (mean+-SD 137.4+-64.1) and Hb (mean+-SD 14.5+-1.49) and in TE vit-d (mean+-SD 16.12+-11.06), vit-B12 (160.19+-132.57) and Hb (11.22+-2.09).

Relatively higher proportions of patients with TE showed deficiency of vit-d3 (74.19%) than AGA (55.26%), vit-B12 (75.80%) than AGA (68.42%) and Hb (38.70%) than AGA (13.13), vit-d insufficiency was more in AGA (26.31%) than TE (16.12%). But it was statistically not significant (p<0.001).

In comparison to FPHL vs MPHL   vit-d3 levels (56.25%),(54.54%) respectively were almost similar in both groups, vit-B12 deficiency was more in MPHL (77.27%) than FPHL (56.25%) statistically not significant(p<0.001), Hb deficiency seen in (31.25%) of FPHL and nun in MPHL.

    FPHL -female pattern hair loss, MPHL-male pattern hair loss, TE-telogen effluvium

Table -2. Proportions of patients categorized according to type of hair loss with the Testing parameters distribution

Figure-1. Showing the duration of hair loss

It has been estimated that nearly 1 billion individuals worldwide^[26] and approximately 41.6% of US adults are vitamin-D deficient.^[27] Certainly, not all these individuals will present with alopecia, but in patients with hair loss, we suggest that vitamin D deficiency is an important factor to consider. Risk factors for vitamin-D deficiency include older age, obesity, dark skin types, residence in northern latitudes, and malabsorption syndrome. ^[27] The optimal serum 25-hydroxyvitamin-D level is controversial. Recommendations range between 20 to 40 ng/ml^[28] and 30 to 50 ng/ml. ^[29,30]

 Vitamin D deficiency was seen in a total of 67 cases of all types of hair loss (AGA 55.26%, TE 74.19%) in our study.  This can be compared with Conic et al. also found lower serum vitamin D levels in patients with AGA compared to controls.^[31] A case-control study by Jun Zhao et al. aimed to evaluate serum vitamin-D levels in Chinese patients with different types of alopecia, including AGA. The correlation between low serum vitamin-D level and male AGA was found to be statistically significant (P=0.0005).^[32] In a Turkish study conducted by Gulbahar Sarac et al., a correlation was again found between AGA, telogen effluvium, and low serum vitamin –D.^[33] Danane et al. evaluated the same factors in a tertiary care Indian hospital, and around 82% of AGA patients were found to be vitamin-D deficient.^[34] In another study including 60 subjects (30 patients of AGA and 30 age-matched healthy controls), the mean serum vitamin-D of patients with AGA was 37.1ng/ml compared to controls having a 44.2mg/ml level. This is statistically significant (p=0.02).^[35]

Having established the similarities between MPHL and FPHL, we searched for the prevalence of low serum vitamin D levels in female patients of AGA. In one case-control study, it was found that FPHL patients had much lower serum vitamin D3 levels than controls (P=0.004).^[36] In another study by Rasheed et al., serum vitamin D2 levels were also found to be lower in patients of FPHL than in controls.^[37]

Vitamin B12 deficiency was seen in a total of 73 of all types of hair loss cases in our study (AGA 68.42%, TE 75.80%). Which can be compared with konakhindra IN et.al. found that along with vitamin D, the patients with AGA also had lower levels of zinc, copper, magnesium, selenium, and vitamin B12.^[38] It is a well-known fact that a healthy, well-balanced diet is essential for healthy hair and to delay the signs of ageing. Vitamin B complex, vitamins E, A, and C; iron, zinc, and magnesium are all important for delaying the onset and severity of androgenetic alopecia. Also, Jin, Zhu, and Wu compared zinc, copper, iron, and manganese contents in the hair of patients with male pattern alopecia and healthy men, confirming low levels of nutrients in patterned hair loss.^[39]

Heamoglobin (HB) deficiency was seen in total 29 cases (TE 38.70, FPHL 31.25%) which can be compared with A study conducted by Oner compared deficiency incidence of various factors, including vitamin D, hemoglobin, ferritin, vitamin B12, as well as thyroid function, in patients with TE, AGA, AA, and hair loss. The study found that the four types of hair loss diseases did not significantly differ from one another, with vitamin D deficiency being the most prevalent deficiency among these individuals.^[40] Gowda et al indicated that a relatively higher proportion of participants with TE (20.37%) had iron deficiency compared to those with FPHL (16.67%) and male pattern hair loss (MPHL) (2.94%) (p = 0.069). Furthermore, transferrin saturation and ferritin levels were lower in patients with FPHL (41.67%) and TE (40.74%) than MPHL (11.76%).^[41] Iron deficiency was found to be related to gender rather than to the type of hair loss.

According to this study, the prevalence of vitamin-D is seen in both types AGA and TE of hair loss the risk of hair loss may be associated with decreased serum levels of Vitamin -D, and it is recommended to evaluate serum- D level along with other contributing factors to check the patient’s status. It may be considered that serum vitamin D could be a parameter for diagnosing the onset and severity of AGA and TE.

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