The Role of Micronutrients in Alopecia Areata: A Review

Alopecia areata (AA) is a common, non-scarring form of hair loss caused by immune-mediated attack of the hair follicle. As with other immune-mediated diseases, a complex interplay between environment and genetics is thought to lead to the development of AA. Deficiency of micronutrients such as vitamins and minerals may represent a modifiable risk factor associated with development of AA. Given the role of these micronutrients in normal hair follicle development and in immune cell function, a growing number of investigations have sought to determine whether serum levels of these nutrients might differ in AA patients, and whether supplementation of these nutrients might represent a therapeutic option for AA. While current treatment often relies on invasive steroid injections or immunomodulating agents with potentially harmful side effects, therapy by micronutrient supplementation, whether as a primary modality or as adjunctive treatment, could offer a promising low-risk alternative. However, our review highlights a need for further research in this area, given that the current body of literature largely consists of small case-control studies and case reports, which preclude any definite conclusions for a role of micronutrients in AA. In this comprehensive review of the current literature, we found that serum vitamin D, zinc, and folate levels tend to be lower in patients with AA as compared to controls. Evidence is conflicting or insufficient to suggest differences in levels of iron, vitamin B12, copper, magnesium, or selenium. A small number of studies suggest that vitamin A levels may modify the disease. Though understanding of the role for micronutrients in AA is growing, definitive clinical recommendations such as routine serum level testing or therapeutic supplementation call for additional studies in larger populations and with a prospective design.

Zinc supplementation, mental development and behaviour in low birth weight term infants in northeast Brazil

OBJECTIVE

To test whether zinc supplementation reduces the deficits in mental development and behaviour that are found in term infants of low birth weight in the study population.

DESIGN

A prospective double-blind, part-randomised efficacy trial.

SETTING

A low-income population in Pernambuco, northeast Brazil, where the economy is largely dependent on sugar-cane production, and where over 90% of deliveries occur in health facilities.

SUBJECTS

During a 20-month period, all singleton, term infants weighing 1500-2499 g born to families of low income ( < US $280/month) were enrolled at birth (n = 205). At 6 and 12-months, the numbers tested were 163 and 138 respectively.

INTERVENTION

Infants born from January 1993-January 1994 were randomly assigned to receive daily, except Sundays, a placebo (n = 66) or 1 mg zinc (n = 68). Those born February-August 1994 were given 5 mg zinc (n = 71). Supplementation was for eight weeks, starting at birth. Field workers visited each infant at home to administer the supplement.

RESULTS

At 6 and 12-months, mental and psychomotor development was assessed with the Bayley Scales of Infant Development and no significant differences in the scores of the three groups were found. At 12-months, behaviour was also assessed on 5 ratings. Ratings were highest in infants given 5 mg zinc (P = 0.042).

CONCLUSIONS

Zinc supplementation (5 mg/d) for eight weeks may reverse some of the poor behaviours, particularly responsiveness, exhibited by low birth weight infants. No amelioration of their mental and psychomotor deficits was found.

The effect of long-term calcium supplementation on indices of iron, zinc and magnesium status in lactating Gambian women

The effect of long-term supplementation with CaCO3 on indices of Fe, Zn and Mg status was investigated in a randomized, double-blind intervention study of sixty lactating Gambian women. The supplement contained 1000 mg Ca and was consumed between meals 5 d/week, for 1 year starting 1.5 weeks postpartum. Compliance was 100%. Plasma ferritin concentration, plasma Zn concentration and urinary Mg output were measured before, during and after supplementation at 1.5, 13, 52 and 78 weeks postpartum. No significant differences in mineral status were observed at any time between women in the supplement and placebo groups. Analysis of the longitudinal data series showed that plasma ferritin and Mg excretion were characteristic of the individual (P < 0.001). Within individuals, ferritin concentration was higher at 1.5 weeks postpartum than later in lactation (P = 0.002). Plasma Zn concentration was lower at 1.5 weeks postpartum than at other times (P < 0.001), an effect which disappeared after albumin correction. Low plasma concentrations of ferritin and Zn indicated that the Gambian women were at high risk of Fe and Zn deficiency. Measurements of alpha 1-antichymotrypsin suggested that the results were not confounded by acute-phase responses. The results of the present study indicate that 1000 mg Ca as CaCO3 given between meals does not deleteriously affect plasma ferritin and Zn concentrations or urinary Mg excretion in women who are at risk of Fe and Zn deficiency.

Interactions between growth and nutrient status in school-age children of urban Bangladesh

The relationship between biochemical, anthropometric, and sociodemographic indexes was investigated in 242 children aged 5-12 y from five schools in Dhaka City, Bangladesh. As height-for-age increased so too did the mean serum concentrations of hemoglobin, protein, vitamin A, and zinc; serum copper concentrations were highest in the shortest group. Serum copper concentrations were highest in those with the lowest serum vitamin A concentrations. By multiple regression analysis, family income, age, weight-for-age, hemoglobin, and serum copper were strongly related to serum vitamin A. For every unit change in serum vitamin A there was a 4.92 unit change in hemoglobin, when all the other factors were taken into account. This study shows that there is a complex interaction between concentrations of biochemical indexes of nutritional status and other anthropometric, biochemical, and sociodemographic variables.

Serum and endometrial copper, zinc, iron and cobalt with inert and copper-containing IUCDs

Serum and endometrial copper (Cu), zinc (Zn), iron (Fe) and serum cobalt (Co) were measured in the mid-follicular and mid-luteal phases of the menstrual cycles in 30 Lippes loops users, 30 CuT-200 IUCD users and 24 matched controls by atomic absorption spectrophotometry. In the control group, there was no statistically significant difference in mean mid-luteal, compared to mid-follicular, levels of serum Cu, Zn, Fe and Co and endometrial Zn. Mid-luteal endometrium contained significantly higher mean Cu, and lower mean Fe levels. In Lippes loop users, compared to controls, the only statistically significant differences were lower mean mid-follicular serum Zn, lower mean endometrial Zn and Fe, and higher mean mid-luteal endometrial Fe. In CuT-200 users, compared to controls, there was significantly higher mean mid-follicular serum Zn and lower mean mid-luteal serum Co, higher mean mid-follicular endometrial Cu and lower mean mid-follicular endometrial Fe levels. Compared to Lippes loop, CuT-200 users had significantly higher mean mid-follicular serum Co and endometrial Cu and Zn, and lower mean mid-follicular endometrial Fe.

The effect of maternal smoking on the relationship between maternal and fetal zinc status and infant birth weight

We have previously reported a trapping of zinc in the placenta directly related to circulating cadmium that comes from cigarette smoke. The purpose of this study was to examine in detail the effect of smoking on (a) the relationship between maternal and fetal zinc status and (b) the relationship between zinc status and birth weight. One hundred and eighteen smokers and 172 nonsmokers without any medical complications during pregnancy were studied. Atomic absorption spectroscopy was used to assess zinc status in maternal and cord vein plasma and red blood cells. Plasma alkaline phosphatase was also determined as an index of zinc status. Thiocyanate was used as an index of smoking status. The data were analyzed using univariate correlations and repeated measures analysis of variance. Infants of smokers had a statistically significant decrease in plasma zinc (5%), alkaline phosphatase (13%), and in cord vein RBC zinc (12%). Furthermore, the results showed an altered relationship between maternal and fetal indices of zinc status and zinc status and birth weight due to maternal smoking. The infant of the nonsmoking mother appears to be able to maintain adequate zinc status due to depletion of maternal zinc. However, it appears that the infant of the smoking mother may be marginally zinc deficient. These findings support studies of zinc supplementation in the pregnancy complicated by smoking.

Nutrition and the pill

Apart from their gynecologic influence as birth control agents, oral contraceptives (OCs) have been shown to affect a number of metabolic and nutritional processes, some insignificantly and others beneficially. The use of contraceptive pills has been shown to decrease the physiologic levels of six nutrients--riboflavin, pyridoxine, folacin, vitamin B12, ascorbic acid and zinc--and to increase the levels of four others--vitamin C, iron, copper and vitamin A. Women who take OCs and have adequate diets need little or no supplemental vitamins. Vitamin and mineral increases caused by OCs do not require treatment.

[Effects of anovulatory steroids on serum levels of zinc and copper]

Mean serum zinc (1.14 micrograms/ml) and copper (2.35 micrograms/ml) in 24 women taking oral contraceptive agents were compared against mean serum zinc (1.25 micrograms/ml) and copper (1.98 micrograms/ml) of 20 women of the same age range who served as controls. Serum zinc was significantly lower while serum copper was significantly higher for women taking the oral contraceptive agents. There was no significant correlation between the serum zinc and copper levels either in the control group (r = 0.04) or in the group taking the contraceptives (r = 0.36).

Zinc and copper nutriture of women taking oral contraceptive agents

A cross-sectional and follow-up study of young women taking oral contraceptive agents revealed a marked increase in serum copper levels. This increase was significant after the taking of oral contraceptive agents for 3 months. No significant effect of oral contraceptive agents on serum zinc and hair levels or copper were observed. There was no correlation between duration of oral contraceptive agent therapy and zinc or copper concentrations in serum or hair. Serum and hair concentration of zinc or copper were also not significantly correlated.

Nutritional effects of oral contraceptive use: a review

Oral contraceptives agents (OCA) have been in use for more than two decades, and at the present time, 150 to 200 million women are using the preparations. Apart from their gynecologic influence, the hormones have been shown to affect a number of metabolic and nutritional processes, some advantageously and others disadvantageously. Concern over the nutritional status of females consuming OCA prompted this review. Eight vitamins and three minerals were investigated. Contraceptive steroid ingestion was shown to depress the physiologic levels of six nutrients (riboflavin, pyridoxine, folacin, vitamin B12, ascorbic acid and zinc), elevate the levels of three others (vitamin K, iron and copper) and provide little or no change in one (alpha tocopherol) and questionable increases in another (vitamin A). It was concluded that females consuming OCA should pay particular attention to vitamin and mineral intake and, if warranted, consume physiologic supplements of needed nutrients.

Effects of oral contraceptive agents on copper and zinc balance in young women

Young adult women were selected from a group of volunteers on the basis of present and past use of oral contraceptive agents. Subjects were either those who had never used oral contraceptives or those who had used an agent for a minimum of two menstrual cycles. All subjects were fed diets that provided 2.02 to 2.11 mg of copper and 9.15 to 9.10 mg of zinc daily in an 18-day controlled metabolic study. Both oral contraceptive users and nonusers were in negative zinc balance and zinc excretion as not different (P > 0.05) for the groups. Oral contraceptives did not alter (P > 0.05) the metabolic balance of copper; the mean copper retention values were -0.16 mg/day for the nonusers and -0.13 mg/day for the users of oral contraceptives. As anticipated from reports in the literature, the plasma copper levels were higher (P < 0.01) in the oral contraceptive group, but the levels of zinc were not different. Although blood levels of zinc and copper are usually changed with the use of oral contraceptives, the retention of the two nutrients appears not to be affected.

Effect of oral contraceptive agents on vitamin and mineral requirements

Oral contraceptive agents alter the metabolism of some nutrients, which could affect nutritional requirements. The effects of oral contraceptives on pyridoxine, folacin, thiamin, riboflavin, vitamin A, ascorbic acid, zinc, and copper as determined by studies done in the last five years are reviewed. Evidence for actual nutritional deficiencies due to the use of oral contraceptives is still insufficient, and more research is needed. Supplements are advised only for those women in whom other factors, such as disease, impair nutritional adequacy.

Serum copper and zinc in hormonal contraceptive users

There has been a growing awareness of possible alterations in the trace element profiles of hormonal contraceptive users and their consequences. A study of serum copper and zinc levels in users of combined estrogen-progestogen contraceptives and in users of injectable progestogen was undertaken. Use of combined estrogen-progestogen contraceptives resulted in a significant decrease in serum zinc levels within 3 days and an increase in serum copper levels within 10 days. In users of combined estrogen-progestogen contraceptives the magnitude and time of occurrence of the decrease in zinc levels and the increase in copper levels was unaltered by chemical composition, dosage, route of administration, and duration of use beyond 3 months. With injectable progestogen (norethindrone enanthate, 20 mg/month), a significant decrease in serum zinc levels occurred within 24 hours after injection. Serum copper levels were not altered. With injectable progestogen, the type of drug, the dosage, and the duration of use beyond the 1st month had no effect on the magnitude of the decrease in serum zinc levels.

Vitamin B6 nutriture during pregnancy and lactation. I. Vitamin B6 intake, levels of the vitamin in biological fluids, and condition of the infant at birth

Vitamin B6 nutriture was assessed during pregnancy and lactation to determine possible relationships among vitamin B6 intake, levels of the vitamin in biological fluids and the condition of the infant at birth. Vitamin B6 levels were measured in maternal serum and in urine at 5 and 7 months gestation and at delivery, in cord serum and in milk at 3 and 14 days postpartum. Intake of vitamin B6, less than the Recommended Dietary Allowances (1974) for pregnancy and lactation, 2.5 mg/day, resulted in lower levels of the vitamin in maternal serum at delivery and in cord serum than higher intakes. Mothers whose infants had unsatisfactory Apgar scores at 1 min, (less than 7) had significantly low intakes of vitamin B6 and lower levels of the vitamin in both serum and milk than mothers whose infants had satisfactory scores, (greater than or equal to 7). At 5 months gestation, levels of vitamin B6 in maternal serum were significantly correlated with levels of the vitamin in cord serum and in milk at 14 days postpartum. This stage of gestation precedes the period of rapid growth of the central nervous system of the fetus, and is, therefore, a critical time for the assessment of maternal vitamin B6 nutriture.

Absorption of stable isotopes of iron, copper, and zinc during oral contraceptives use

The absorption of iron, copper, and zinc was determined in 22 women 19 to 25 years of age from the difference between intake and fecal output of the stable isotopes 58Fe, 65Cu, and 70Zn, as measured by neutron activation analysis. Of the 22 women, 14 were using oral contraceptive agents, and the other eight were not. Absorption in the group using oral contraceptive agents did not differ significantly from the group not using oral contraceptive agents. The overall iron absorption averaged 14%, copper 57%, and zinc 38%.

[Metabolic studies under administration of oral contraceptives. A review]

The use of oral contraceptives can produce changes in the metabolism of carbohydrates, lipids, proteins, vitamins, and minerals. Responsible for the alterations seems to be the used oestrogen- and gestagen derivative and not so much the type of the contraceptive. The most frequent findings are raised serum-glucose-, insulin-, and triglyceride levels; disturbances in protein-metabolism increase the risk of developing thrombosis and hypertonia. Little is known about the significance of oral contraceptives on the vitamin- and mineral metabolism--yet extreme deficiencies have not been observed so far. Oral contraceptives can become an extra risk factor when given to women with metabolic disturbances.

The effect of intrauterine devices containing zinc and copper on their levels in serum

Serum levels of copper and zinc were determined in 11 health women in whom Latex Leaf intrauterine devices (IUDs) containing copper and zinc had been inserted. Patients with low levels of serum copper or zinc before insertion usually had increased levels of either of these metals while using the device, but they did not exceed the upper limits of normal values. When the group was considered as a whole, the serum levels of zinc showed a slight tendency to increase with duration of IUD use, whereas there was no statistical difference between the serum levels of copper before and after insertion of the IUD.