utd_medknow
International Journal of Trichology International Journal of Trichology
 Print this page Email this page Small font sizeDefault font sizeIncrease font size
 
 
  Home | About IJT | Editorial board | Search | Ahead of print | Current Issue | Archives | Instructions | Online submission | Subscribe | Advertise | Contact us | Login   
 


 
 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 5  |  Issue : 1  |  Page : 40-42  

Zinc deficiency associated with hypothyroidism: An overlooked cause of severe alopecia


Department of Dermatology and Venereology, Government Medical College, Calicut, Kerala, India

Date of Web Publication6-Jul-2013

Correspondence Address:
M P Binitha
Haritha, P.O. Beypore, Calicut - 673 015, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-7753.114714

Rights and Permissions
   Abstract 

Hypothyroidism is a common and well recognized cause of diffuse hair loss. Zinc and other trace elements such as copper and selenium are required for the synthesis of thyroid hormones, and deficiency of these can result in hypothyroidism. Conversely, thyroid hormones are essential for the absorption of zinc, and hence hypothyroidism can result in acquired zinc deficiency. The hair loss attributed to hypothyroidism may not improve with thyroxine unless zinc supplements are added, as demonstrated in our case.

Keywords: Alopecia, hypothyroidism, zinc deficiency


How to cite this article:
Betsy A, Binitha M P, Sarita S. Zinc deficiency associated with hypothyroidism: An overlooked cause of severe alopecia. Int J Trichol 2013;5:40-2

How to cite this URL:
Betsy A, Binitha M P, Sarita S. Zinc deficiency associated with hypothyroidism: An overlooked cause of severe alopecia. Int J Trichol [serial online] 2013 [cited 2023 Jun 6];5:40-2. Available from: https://www.ijtrichology.com/text.asp?2013/5/1/40/114714


   Introduction Top


The metabolism of zinc and thyroid hormones are closely interlinked. We describe a patient with a concurrent onset of hypothyroidism and zinc deficiency who presented with severe diffuse hair loss, and briefly discuss the association.


   Case Report Top


A 28-year-old woman presented with weakness, lack of appetite, diffuse hair loss, and asymptomatic scaly skin lesions of 2 months duration. There was no history suggestive of connective tissue disease or malabsorption. On physical examination, the patient appeared depressed. She had pallor and puffiness of the upper part of the face. There was diffuse, dry scaling over the face and extremities, along with annular, erythematous, scaly patches over the nape of the neck. The notable finding on the scalp was profound diffuse alopecia [Figure 1] with marked hair loss over the occipital area [Figure 2]. There was also severe thinning of the hair of the eyebrows and eyelashes [Figure 3]. A hair pull test done from five different sites on the scalp was positive. Light microscopic examination of the hair revealed telogen type hair roots without any hair shaft abnormalities. Thyroid function tests were as follows: T3 70 ng/dl (normal 80-200), T4 2 mcg/dl (normal 4-12), and Thyroid Stimulating Hormone 64 IU/ml (normal 0.30-4.5). All routine investigations including antinuclear antibody profile were within normal limits, except for a low hemoglobin level of 9 g/dl. Histopathological examination of an annular scaly lesion showed minimal epidermal hyperplasia with a mild perivascular inflammatory infiltrate.
Figure 1: Diffuse alopecia of the scalp

Click here to view
Figure 2: Annular, erythematous, and scaly patches over the nape of neck

Click here to view
Figure 3: Scaling of the face with loss of eyebrows and eyelashes

Click here to view


Thyroid hormone supplements were started, but the scaly lesions persisted and there was no detectable improvement in the hair loss. Since a definite diagnosis of the annular scaly lesions could not be made, plasma zinc level was estimated, which was 62 mcg/dl (normal 66-144 mcg/dl and optimal levels 90-150 mcg/dl). [1] Zinc monohydrate 140 mg capsules containing 50 mg of elemental zinc was given twice a day, along with other multivitamins. One month later, the skin lesions had cleared completely, and there was such a remarkable improvement in her mental depression and facial puffiness, that her facies was totally unrecognizable when compared to her previous appearance [Figure 4]. Subsequent follow-up demonstrated complete regrowth of hair over a course of 4 months [Figure 5].
Figure 4: Complete alteration of the appearance following thyroxine and zinc supplementation

Click here to view
Figure 5: Subsidence of the skin lesions and regrowth of hair following zinc supplementation

Click here to view



   Discussion Top


Acrodermatitis enteropathica usually presents in children as a triad of dermatitis, diarrhea, and alopecia. Conditions that cause acquired zinc deficiency include inadequate intake, parenteral nutrition, pregnancy and lactation, extensive burns, exfoliative dermatitis, intestinal malabsorption syndromes, cystic fibrosis, alcoholism, HIV infection, malignancies, and chronic renal disease. [2] The formation of insoluble complexes with calcium, fiber, and phytates markedly decrease the intestinal absorption of zinc.

The diagnosis of acquired zinc deficiency is often missed. It may present as psoriasiform, annular or crusted plaques, with decreased hair and nail growth. Hair changes include alopecia, loss of pigment, dryness, brittleness, hair shaft, and structural abnormalities leading to fragility and breakage. The hair loss starts in the occipital region and may extend over the rest of the scalp. Eyebrows and eyelashes may also be involved. In severe cases, there may be total loss of hair and nails. Nail manifestations include Muehrcke's nails, transverse leukonychia, brittle nails, onychorrhexis, and Beau's lines. [3]

Levels of zinc either in plasma or serum are not reliable indicators for establishing a diagnosis of zinc deficiency. Normal values may be obtained in the presence of subclinical zinc deficiency. Therapeutic response in suspected cases remains the gold standard of diagnosis. [1] Decreased levels of zinc may indicate a shift of zinc from plasma to another body pool. Serum copper levels tend to fluctuate inversely with serum zinc levels, and it has been suggested that the zinc-copper ratio may be used as an index of zinc levels. The concentration of zinc in hair is a more reliable indicator of chronic zinc deficiency. [4] Hair is a readily accessible specimen as well. A sample of hair cut close to the scalp from the back of the head or the nape of the neck is required. Normal values range from 150 to 240 mcg/g of hair. Levels of lesser than 70 mcg/g are indicative of zinc deficiency. The concentration of zinc in melanosomes range from 641 to 687 mcg/g, or about five times the concentration for the hair shaft as a whole. [5] The concentration of zinc in hair depends not only on the delivery of zinc to the root, but also on the rate of hair growth. The fact that zinc deficiency itself may impair the growth of hair has to be kept in mind. Though susceptible to environmental contamination from exogenous sources, the concentrations of copper and zinc in hair have not been found to be altered significantly by exogenous processes, and serve as useful bio-indicators. [6]

Several reports suggest that zinc deficiency is a cause of subclinical hypothyroidism. In Down's syndrome, early thymic involution is associated with low serum zinc levels, and thymic function has been shown to be in relation to the pituitary-thyroid axis. Zinc supplementation improved thyroid function in nine patients with low zinc levels. [7] In addition, zinc is required for the T3 receptor to adopt it's biologically active confirmation. Some of the effects of zinc deficiency therefore, may be due to loss of zinc from the T3 receptor and impairment of T3 action. [8] The intracytoplasmic zinc levels, which are only partially represented by the total plasma levels, would be more relevant for this effect. [9] Conversely, hypothyroidism reduces intestinal zinc absorption in rats. [10] Hence, an attempt to link the low levels of thyroid hormones and zinc is worthwhile.

In our patient, zinc deficiency may have contributed significantly to the development of hypothyroidism. Her mental depression, taste acuity, appetite, skin lesions, and hair loss showed a dramatic improvement not on initiation of thyroxine treatment, but with zinc supplementation. The effect of hypothyroidism on the metabolism of zinc should also not be overlooked. An evaluation for features of zinc deficiency, which is often under-recognized, is warranted in all cases of hypothyroidism.

 
   References Top

1.Alhaj E, Alhaj N, Alhaj NE. Diffuse alopecia in a child due to dietary zinc deficiency. Skinmed 2007;6:199-200.  Back to cited text no. 1
    
2.Kumar P, Lal NR, Mondal AK, Mondal A, Gharami RC, Maiti A. Zinc and skin: A brief summary. Dermatol Online J 2012;18:1.  Back to cited text no. 2
    
3.Seshadri D, De D. Nails in nutritional deficiencies. Indian J Dermatol Venereol Leprol 2012;78:237-41.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Gude D. Tracing elements in hair. Int J Trichology 2011;3:132-3.  Back to cited text no. 4
    
5.Solomons NW. On the assessment of zinc and copper nutriture in man. Am J Clin Nutr 1979;32:856-71.  Back to cited text no. 5
    
6.Kempson IM, Skinner WM, Kirkbride KP. The occurrence and incorporation of copper and zinc in hair and their potential role as bioindicators: A review. J Toxicol Environ Health B Crit Rev 2007;10:611-22.  Back to cited text no. 6
    
7.Napolitano G, Palka G, Lio S, Bucci I, De Remigis P, Stuppia L, et al. Is zinc deficiency a cause of subclinical hypothyroidism in Down syndrome? Ann Genet 1990;33:9-15.  Back to cited text no. 7
    
8.Freake HC, Govoni KE, Guda K, Huang C, Zinn SA. Actions and interactions of thyroid hormone and zinc status in growing rats. J Nutr 2001;131:1135-41.  Back to cited text no. 8
    
9.Bucci I, Napolitano G, Giuliani C, Lio S, Minnucci A, Di Giacomo F, et al. Zinc sulfate supplementation improves thyroid function in hypozincemic Down children. Biol Trace Elem Res 1999;67:257-68.  Back to cited text no. 9
    
10.Chen SM, Kuo CD, Ho LT, Liao JF. Effect of hypothyroidism on intestinal zinc absorption and renal zinc disposal in five-sixths nephrectomized rats. Jpn J Physiol 2005;55:211-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


This article has been cited by
1 Necrolytic acral erythema associated with hypothyroidism in hepatitis C virus seronegative patient
Ihsan Baroudi, Ola Alakhras, Alaa Alkasem, Thaer Douri
Clinical Case Reports. 2023; 11(2)
[Pubmed] | [DOI]
2 Interaction Between Dietary Selenium and Zinc Intakes on Hypothyroidism
Lei Lu, Zhiqi Huang, Xinyang Wang, Jinpeng Chen
Biological Trace Element Research. 2023;
[Pubmed] | [DOI]
3 Dermatologic manifestations of thyroid disease: a literature review
Benjamin Cohen, Adam Cadesky, Shuchie Jaggi
Frontiers in Endocrinology. 2023; 14
[Pubmed] | [DOI]
4 The Association of Thyroid Nodules With Blood Trace Elements Identified in a Cross-Section Study
Huixian Zeng, Yuanyuan Hu, Yaosheng Luo, Yanshi Ye, Cheng Song, Genfeng Yu, Zhi Chen, Siyang Liu, Yongqian Liang, Lingling Liu, Heng Wan, Jie Shen
Frontiers in Nutrition. 2022; 9
[Pubmed] | [DOI]
5 Mediterranean Diet and Thyroid: An Interesting Alliance
Giuseppe Bellastella, Lorenzo Scappaticcio, Francesco Caiazzo, Maria Tomasuolo, Raffaela Carotenuto, Mariangela Caputo, Stefania Arena, Paola Caruso, Maria Ida Maiorino, Katherine Esposito
Nutrients. 2022; 14(19): 4130
[Pubmed] | [DOI]
6 Trace elements and the thyroid
Qing Zhou, Shuai Xue, Li Zhang, Guang Chen
Frontiers in Endocrinology. 2022; 13
[Pubmed] | [DOI]
7 Alopecia types, current and future treatment
H Rambwawasvika
Journal of Dermatology & Cosmetology. 2021; 5(4): 93
[Pubmed] | [DOI]
8 Protective effects of selenium and zinc against potassium dichromate–induced thyroid disruption, oxidative stress, and DNA damage in pregnant Wistar rats
Anfal Fedala, Ounassa Adjroud, Salwa Abid-Essefi, Rim Timoumi
Environmental Science and Pollution Research. 2021; 28(18): 22563
[Pubmed] | [DOI]
9 Diffuse Alopecia and Thyroid Atrophy in Sheep
Rubia Avlade Guedes Sampaio, Franklin Riet-Correa, Francisca Maria Sousa Barbosa, Daniela Dantas de Gois, Raquel Costa Lima, Iara Geovana da Silva, Vitória Maria da Silva, Alexandra Melo Oliveira, Sara Vilar Dantas Simões, Ricardo Barbosa Lucena
Animals. 2021; 11(12): 3530
[Pubmed] | [DOI]
10 A novel 3D-printed centrifugal ultrafiltration method reveals in vivo glycation of human serum albumin decreases its binding affinity for zinc
Monica J. Jacobs, Cody W. Pinger, Andre D. Castiaux, Konnor J. Maloney, Dana M. Spence
Metallomics. 2020; 12(7): 1036
[Pubmed] | [DOI]
11 Hypothyroidism-related zinc deficiency leads to suppression of T lymphocyte activity
María Alejandra Paulazo, Alicia Juana Klecha, Helena Andrea Sterle, Eduardo Valli, Horacio Torti, Florencia Cayrol, María Laura Barreiro Arcos, Graciela Alicia Cremaschi
Endocrine. 2019; 66(2): 266
[Pubmed] | [DOI]
12 Interacting effects of selected trace and toxic metals on thyroid function
Ram B. Jain,Y. Sammy Choi
International Journal of Environmental Health Research. 2015; : 1
[Pubmed] | [DOI]
13 Intravenous zinc therapy for acquired zinc deficiency secondary to gastric bypass surgery: a case report
Garrett Vick,Rod Mahmoudizad,Katherine Fiala
Dermatologic Therapy. 2015; : n/a
[Pubmed] | [DOI]
14 Thyroid Function and Serum Copper, Selenium, and Zinc in General U.S. Population
Ram B. Jain
Biological Trace Element Research. 2014;
[Pubmed] | [DOI]
15 Links between Insulin Resistance, Lipoprotein Metabolism and Amyloidosis in Alzheimer’s Disease
Ian James Martins,Rhona Creegan
Health. 2014; 06(12): 1549
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed20070    
    Printed367    
    Emailed2    
    PDF Downloaded136    
    Comments [Add]    
    Cited by others 15    

Recommend this journal