What is the treatment for hair loss in women with low ferritin (iron) levels?

Treatment of Ferritin-Related Hair Loss in Women

Iron supplementation should be initiated when ferritin is <60 ng/mL in women with hair loss, even in the absence of anemia, with treatment started within 6 months of onset for optimal prognosis. 1, 2

Diagnostic Workup

Essential laboratory testing includes:

• Complete blood count (CBC), serum ferritin, TSH, and transferrin saturation as baseline tests for any woman presenting with hair loss 1, 3
• Serum ferritin ≤15 μg/L confirms iron deficiency with 98% specificity in premenopausal women 1, 3
• If ferritin appears normal but microcytic anemia or low MCV is present, check transferrin saturation and serum iron/TIBC to confirm iron status 2
• Consider tissue transglutaminase (TTG) antibodies if unexplained iron deficiency is found to rule out celiac disease 1, 2

Treatment Threshold and Approach

The target ferritin level for hair health is ≥60 ng/mL, which corresponds to hemoglobin ≥13.0 g/dL. 2, 4 This is substantially higher than the traditional threshold for diagnosing iron deficiency anemia. The corresponding ferritin level for female anemia (Hb: 12.0 g/dL) is only 5.1 ng/mL, which is far below the adequate level needed for hair growth (40-60 ng/mL). 4

Treatment recommendations:

• The American Academy of Dermatology and Cleveland Clinic Foundation support treating iron deficiency without anemia (ferritin ≤15 μg/L, normal hemoglobin) in the context of hair loss 1
• Iron supplementation should be started within 6 months of hair loss onset for better prognosis 1, 3, 4
• Continue iron supplementation until ferritin reaches ≥60 ng/mL 2, 4
• Monitor hair condition, ferritin, and hemoglobin levels every 3 months after supplementation 4

Evidence Quality and Important Caveats

The evidence supporting iron supplementation for hair loss is mixed but clinically relevant:

• Multiple studies found lower ferritin levels in patients with diffuse hair loss, telogen effluvium, and androgenetic alopecia 1
• Iron deficiency accounted for 70.3% of female alopecia cases in one recent study, making it the most common etiology 4
• However, one study found no cessation or reversal of hair loss in women with low ferritin treated with iron supplementation alone 5
• Another review concluded there is insufficient evidence to recommend universal screening for iron deficiency in hair loss patients 6

Critical pitfall to avoid: Ferritin is an acute-phase reactant and can be falsely elevated during infection, inflammation, or chronic disease. 2 A "normal" ferritin in the presence of inflammation may mask true iron deficiency. If clinical suspicion remains high, check transferrin saturation and serum iron/TIBC. 2

Specific exception: The British Association of Dermatologists does not recommend routine iron testing for alopecia areata specifically, as studies have not confirmed increased iron deficiency in this autoimmune condition. 7, 1, 3, 2 This recommendation applies only to alopecia areata, not to other forms of hair loss such as telogen effluvium or androgenetic alopecia.

Clinical Context

Hair loss due to iron deficiency develops gradually over months, not acutely. 1, 3 Disease duration is an important prognostic factor—patients who begin treatment within 6 months have better outcomes. 4 Patients with subjective improvement of hair regrowth also demonstrate greater increases in ferritin levels after iron supplementation. 4