Numerous over-the-counter (OTC) nutritional supplements appear effective in treating hair loss, according to a systematic review published in JAMA Dermatology.
“This review was inspired by questions from my patients,” said senior author Arash Mostaghimi, MD, MPH, MPA, assistant professor of dermatology at Harvard Medical School. “Some patients with hair loss have questions about whether they should start taking nutritional supplements they see in advertisements or that are recommended by friends and family. Other patients are already spending a lot of money on supplements and wonder if they should continue taking them. Dermatologists are experts on pharmaceuticals but not on supplements and I wanted better answers.”
The review is the first step in understanding the body of evidence to help support dietary and nutritional supplement interventions.
The authors searched the MEDLINE, Embase, and CINAHL databases from inception through October 20, 2021, to identify articles written in English with original findings from investigations of dietary and nutritional interventions in individuals with alopecia and without a known baseline nutritional deficiency.
All 30 articles that comprised the review were nutritional interventions (no diet-based interventions met inclusion criteria): 17 randomized clinical trials (RCTs), 11 clinical studies (non-RCT), and two case series studies.
Studies of Viviscal, Nourkrin, Nutrafol, Lamdapil, Pantogar, capsaicin and isoflavone, omegas 3 and 6 with antioxidants, apple nutraceutical, total glucosides of paeony and compound glycyrrhizin tablets, zinc, tocotrienol, and pumpkin seed oil demonstrated the highest-quality evidence for potential benefit.
Conversely, Kimchi and cheonggukjang, vitamin D3, and Forti5 had low-quality evidence for disease course improvement.
Adverse events were rare and mild for all the supplements evaluated.
“Although the vast majority of supplements for hair loss have not been studied, I was surprised by the amount of data that existed, with varying levels of rigor or quality,” Mostaghimi told Dermatology Times. “There were some data to support the use of certain supplements for some patients.”
Based on the review, Mostaghimi encourages a patient who is inclined to take a nutritional supplement for hair loss to limit the choice to a supplement with better quality data. “I would then review that supplement’s data with the patient and manage their expectations,” he said. “The advantage of these studies in large part is not just that the medication works or not, but that we have a clear set of potential downsides like abdominal pains and diarrhea. As a physician, my goal is to help my patients make better choices. This is possible for at least some of these nutritional supplements.”
Physicians should engage in shared decision-making in the clinical setting, according to Mostaghimi, director of dermatology inpatient consultation service at Brigham and Women’s Hospital in Boston.
“Different types of hair loss were studied, so you cannot do head-to-head comparisons,” he said. “Some of the research was for hormonal pattern hair loss, while other research was confined to telogen effluvium.”
In addition, the evidence for these supplements is not nearly as rigorous as it is for an approved medication by the US Food and Drug Administration (FDA). “I do not believe we have enough data, even for supplements with higher-quality evidence, to say that one is better than another,” Mostaghimi said.
Mostaghimi noted that patients are seeking nutritional supplements, due to limited treatments for hair loss. “Because our pharmaceutical options are restricted, patients end up turning to alternative and complementary medications,” he said. “Often, the medications that we prescribe do not fulfill patients’ expectations.”
The paucity of offerings currently available “underscore our need as a field to continue to invest in understanding the biology of hair loss and creating additional solutions that can help patients restore their hair, the loss of which is a major psychological burden for many patients,” Mostaghimi said.
The major downside of nutritional supplements is economics. “These are typically very expensive treatments, and patients pay for them on an ongoing basis,” Mostaghimi said. “Patients interpret high prices as a sign of high quality or better outcomes, which is often not the case.”
Nutritional supplements can also interfere with blood tests or other laboratory tests, as has been seen with Biotin supplementation, while other supplements may interact with other medications and/or create headache, nausea, or diarrhea. “There definitely is a potential consequence to these medications,” Mostaghimi said.
Mostaghimi would like to see nutritional supplements trialed in larger patient populations and with more rigorous criteria, for both case definitions of participants and better outcome measures. “I would also love to see these supplements studied either in combination or compared to prescription medications,” he said. “However, without mandated FDA oversight, I do not think any company will take the risk and costs associated with doing those types of studies.”
Mostaghimi suspects that many nutritional supplements for hair loss would show no improvement over placebo if meticulous studies were conducted.
“As dermatologists, it is easy for us to dismiss the parts of medicine that are adjacent as pseudoscience not worth our time,” he said. “But if our patients are focused and spending their time, money, and energy on supplements, it behooves us to try to improve our own personal understanding and encourage higher standards for evaluation of these interventions.”
Mostaghimi has received consulting fees from Pfizer, Concert, Lilly, Hims and Hers, Equillium, AbbVie, Digital Diagnostics, and Bioniz; also grants from Pfizer.