A case series of trichoscopy patterns in hair loss patients with iron deficiency anemia

INTRODUCTION

Anemia is a common comorbidity frequently encountered in the daily outpatient department (OPD) patients, with approximately one-third of the world population affected by it. Hair loss results in low self-esteem in both men and women.^[1] Various authors have found a correlation between iron deficiency and different conditions presenting with diffuse hair loss, like telogen effluvium, patterned hair loss, and alopecia areata.^[2,3] However, to date, no one has described trichoscopy findings in patients with severe anemia. We narrate four cases of iron deficiency anemia presenting with hair loss, having concrete findings on dermoscopy using Heine dermatoscope and Dermalite 3 pro.

CASE SERIES

Case 1

A 15-year-old presented with diffuse hair loss over a period of 4-5 months. The teenager gave a history of food fads, preferring only rice in her diet and excluding vegetables, pulses, and non-vegetarian courses for over 2 years. Clinically, hair strands of different lengths, short hairs, and black dots were observed [Figure 1], but the history of plucking hair was strongly denied by both the patient and her parents. The patient complained that her hair would break in the middle of the shaft while combing. Trichoscopy showed short hair, corkscrew hair, bent hair, and hair diameter variability [Figure 2]. Histopathology showed the absence of fungal hyphae, a reduction in the number of follicles, miniaturization of terminal follicles, and an increased percentage of telogen hairs, suggesting telogen effluvium with early patterned hair loss [Figure 3]. The patient had hemoglobin of 6.9 g/dl, and the thyroid profile was within normal range. Only iron supplements were given, and the patient started showing improvement in her condition. During the eighth month of follow-up, hair loss was noticed to be reversed, and improvement in the length was observed [Figure 4], with the absence of the above-mentioned features on dermoscopy, including hair diameter variability. Her hemoglobin had reached a level of 12.2 g/dl.

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Figure 1: Hair strands of different length and short hairs

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Figure 2: Bent hair (red arrow), corkscrew-like hair (red cross). (Heine Delta 30; x10; Non-polarized)

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Figure 3: Histopathology showing absence of fungal elements and miniaturization of terminal follicles (black arrow) with increased percentage of telogen hair. (Hematoxylin and eosin [H&E] stain, x4)

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Figure 4: Length of hair is restored after 8 months of treatment.

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Case 2

A 19-year-old male from rural Maharashtra (India) presented with diffuse hair loss. Physical examination revealed diffuse hair loss on the parietal, vertex, and occipital areas. On trichoscopy, hair diameter variability, bent hair, and short hairs were observed [Figure 5]. The patient had been treated with minoxidil 5% for 6 months but seemed utterly dissatisfied with the results. His blood reports showed hemoglobin of 5.6 g/dl. The patient was asked to stop minoxidil and started on hematinics only. After 6 months, a drastic improvement with reversal of all the above features was seen dermoscopically

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Figure 5: Bent hair (thick single red arrow), hair diameter variability (thin double red arrow), fractured hair (red cross). (Heine Delta 30; x10; Non-polarized)

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Case 3

A 2-year-old male child was brought by the mother, concerned about sparse hair on the scalp [Figure 6]. Before assuring the mother to wait and watch for good hair growth before the age of five years, dermoscopy was used to visualize the scalp. Here, a few black dots, short hairs, and hair diameter variability were seen Figure 7. The patient had a hemoglobin value of 7mg/dl. The thyroid was normal. The potassium hydroxide (KOH) smear in this patient did not show any fungal elements. Two months after including iron syrup orally and coconut oil massage, the patient started showing good hair growth.

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Figure 6: Sparse hair of the toddler.

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Figure 7: Hair diameter variability (red arrows), fractured hair (red cross). (Dermalite DL3; x10; Non-polarized)

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Case 4

An 18-year-old female patient with food fads visited the clinic with her mother, complaining of sparse hair. Black dots were seen on naked eye inspection. Trichoscopy showed hair diameter variability, bent hair, short hairs of different diameters, and coiled hairs [Figure 8]. The patient did not give a history of pulling hair. The patient had hemoglobin of 8.3mg%. The mother recollected a similar episode of sparseness of hair, four years back, which improved on the addition of iron supplements. After 20 days of hematinics consumption, the black dots disappeared. Long-term follow-up wasn’t done.

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Figure 8: Multiple short hairs (red arrows) and coiled hairs (red cross). [Dermalite DL3; x10; Non-polarized]

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DISCUSSION

To date, no author has described trichoscopic findings in anemic patients. Some authors even refuted the relation between anemia and hair loss.^[4,5] In the above four cases, the consistent clinical findings were diffuse hair loss, hemoglobin less than 9 mg/dl, and reversal of hair loss with visible volume gain after addition of iron supplements only. Diagnostic modalities like biopsy in the first case and KOH smear in the second case were inconclusive. Trichoscopically, hair diameter variability with short hairs was also seen, which wasn’t apparent when the cases showed up for follow-up. Corkscrew hair and bent hair are features commonly encountered in tinea capitis,^[5] hair diameter variability is seen in patterned hair loss,^[6] and fractured hairs, a feature noted in trichotillomania,^[7] were seen in the above cases. The author has also observed that not all cases of anemia present with the above-mentioned features.

CONCLUSION

A complete blood count is a simple, cost-effective investigation that can be carried out in all patients presenting with hair loss. Further studies on a larger anemic population can show more thermoscopic features of the alopecia in anemic individuals.