Hair Loss After Sleeve Gastrectomy and Effect of Biotin Supplements

Abstract

Aim:

In this study, we aimed to determine the incidence of hair loss in patients who underwent laparoscopic sleeve gastrectomy (LSG), and to observe whether use of Biotin has an impact on hair loss.

Methods:

This study included 156 female patients who underwent LSG for obesity and completed a 1-year follow-up. All patients with vitamin deficiency were screened in the pre- and postoperative period. Hair loss was defined as the subjective perception of the women of losing a higher amount of hair when compared with normal situation.

Results:

Hair loss was observed in 72% of the patients after LSG (n = 112). Seventy-nine percent of the patients reported hair loss between the third and fourth-month interval, and continued for an average of 5.5 ± 2.6 months. Permanent alopecia was not observed in any of the patients. Patients who experienced hair loss and Biotin deficiency after LSG were prescribed 1000 mcg/day of Biotin for 3 months. Of these 22 patients; only 5 (23%) patients reported a remarkable decline in hair loss. İn addition, 29 patients were found to take 1000 mcg/day of Biotin for average 2.5 months after onset of hair loss by their own initiative, despite optimal blood Biotin levels. Eleven (38%) patients reported a remarkable decline in hair loss. The effect of biotin use on hair loss in patients with and without biotin deficiency was compared. There was no significant difference (P = .2).

Conclusion:

Temporary hair loss after LSG is common. It was found that biotin supplementation used to prevent hair loss does provide low efficacy.

Introduction

Obesity is a chronic disease, and currently, bariatric surgery is the most effective treatment to combat with it.^1,2 Laparoscopic sleeve gastrectomy (LSG) as a surgical method has become the most commonly performed technique particularly in the recent years.^3,4 Despite its popularity, there may be some undesirable side effects post-LSG, such as hair loss.

The hair follicle development has 2 phases. These are the anagen phase, which involves the active growth phase of hair, and the telogen phase as the inactive phase. All hair follicles start to grow in the anagen phase of the cycle, grows for a while, and then enters the telogen phase. This cycle lasts for 100–120 days and subsequently hair falls out. If this cycle is accelerated for any reason and there is sudden hair loss, this is termed as telogen effluvium. The factors leading to telogen effluvium may include use of some drugs, hyper or hypothyroidism, rapid weight loss, anorexia, low protein intake, deficiency of some vitamins (Iron, B12, zinc, Biotin), and heavy metal toxicity.^5,6 Hair loss due to rapid weight loss, inadequate protein intake, or deficiency of vitamins after bariatric surgery may be observed.⁷

In our study, we aimed to determine the incidence of hair loss in patients who underwent LSG and to observe whether use of Biotin has an impact on hair loss.

Materials and Methods

The study was approved by the Institutional Ethics Committee (ATADEK-2013-20123). All patients were informed about the study in detail, and written consents were obtained. This study included 156 female patients who had undergone LSG for morbid obesity between March 2018 and June 2019 and completed at least a 1-year follow-up duration. All the patients were screened by comprehensive laboratory tests with respect to metabolic parameters (liver, kidney, thyroid function tests, lipid profile, fasting blood glucose, blood insulin level, Hba1c, uric acid) and vitamin deficiency (Ferritin, B12, Folic acid, Vitamin D) in the preoperative preparation period. Biotin was not screened at the preoperative period. The patients that were found to be vitamin deficient were supplemented accordingly. Each patient was evaluated by a multidisciplinary team (dietitian, psychiatrist, cardiologist, pulmonologist, endocrinologist, and anesthetist) in the preoperative preparation period.

Surgical technique

All operations were done by the same team. Using an optical trocar for first entry, with a 5-trocar technique and LSG, starting 3–4 cms away from the pylorus was performed. The entire length of the staple line was reinforced using 6″ barbed suture by continuous suturing (V-Loc 180; Medtronic, Minneapolis, MN).

Postoperative medication

Each patient was postoperatively prescribed proton pomp inhibitor (40 mg/day) for 6 months and multivitamin supplement (Barifit tb/day) for 1 year. Composition of the multivitamin supplement is shown in Table 1.

Table 1.

Composition of the Multivitamin Supplement

	Dose	Percent recommended daily allowance
Vitamin A	1000 mcg	125
Thiamine (Vitamin B1)	1.5 mg	136.36
Riboflavin (Vitamin B2)	1.7 mg	121.42
Niacin (Vitamin B3)	30 mg	187.5
Pantothenic acid (Vitamin B5)	10 mg	166.66
Vitamin B6 (Pyridoxine HCL)	4 mg	285.71
Folic acid	400 mcg	200
Vitamin B12 (Cobalamin)	350 mcg	14,000
Vitamin C	60 mg	80
Vitamin D	25 mcg	500
Vitamin E	15 mg	125
Biotin	600 mcg	1.200
Iodine	150 mcg	100
Iron	14 mg	100
Copper	1000 mcg	100
Magnezium	60 mg	16
Zinc	15 mg	150
Chromium	120 mcg	300
Molybdenum	200 mcg	400
Folic acid	400 mcg	200
Selenium	70 mcg	127.27

It was observed in early follow-up after LSG that protein intake may be insufficient in some patients, therefore, 60–70 g daily protein supplementation (Barifit isolated whey protein) was recommended to all patients for at least 6 months as our routine protocol.

The patients were followed between 3- and 6-month intervals in the first year, and annually thereafter. The follow-up examinations included monitoring weight changes and laboratory tests for Hg, ferritin, B12, folic acid, Vitamin D, Vitamin A, Thiamine, Biotin, and Zinc levels.

Definition of hair loss

Hair loss was defined as the subjective perception of the women of losing a significantly higher amount of hair when compared with normal situation. The patients were asked to rate the severity of hair loss between a scale of 1 to 10. It was evaluated as 1–4 mild, 5–7 moderate, and 8–10 intense hair loss. Patients were asked to rate the effect of biotin use on hair loss in the same way.

During follow-up visits, patients were evaluated about hair loss and its severity, whether they were on biotin supplements or not, and blood tests were done for biotin deficiency. All data were retrospectively analyzed.

Exclusion criteria

Patients who had significant anemia, and did not use multivitamin and protein supplements regularly in the follow-up period were excluded from the study. In addition, the patients with concurrent deficiency of zinc, B12, folic acid or Vitamin A as well as deficiency of Biotin were also excluded.

Statistical analysis was performed using SPSS (version 21; SPSS, Inc., Chicago, IL). Standard deviation and mean values were used for the variables with normal distribution and median values were used for the variables that were not normally distributed. For continuous variables, paired-samples T-test was performed. Chi-square or Fisher's exact tests were used for categorical variables. P values <.05 were considered statistically significant.

Results

This study included 156 female patients who had undergone LSG and completed at least a 1-year follow-up duration. Mean age, mean body mass index (BMI), and mean excess weight of the patients were 39 ± 10.4 years, 40.7 ± 5.7 kg/m², and 43.5 ± 17 kg, respectively. Mean BMI regressed to 26.5 ± 3.8 kg/m² after 1 year (P < .001). Percent of mean excess weight loss and total weight loss were found to be 96% ± 25.4% and 34.1% ± 6.5%, respectively. The demographics of the patients are shown in Table 2.

Table 2.

Patient Demographics and Incidence of Hair Loss in the Postoperative First Year

Female, n (%)	156 (100)
Mean age, years	39 ± 10.4
Baseline mean BMI, kg/m²	40.7 ± 5.7
Baseline excess weight, kg	43.5 ± 17
First year mean BMI, kg/m²	26.5 ± 3.8
First year excess weight loss, %	96 ± 25.4 (40–168)
First year total weight loss, %	34.1 ± 6.5
Hair loss after LSG, n (%)	112 (72)
Hair loss time period, n (%)	Third to fourth month 88 (79) fifth to sixth month 22 (20)
Mean hair loss time, month	5.5 ± 2.6
Hair loss degree (severe), n (%)	93 (83)

BMI, body mass index; LSG, laparoscopic sleeve gastrectomy.

Hair loss was observed in 72% of the patients during the first year after surgery (n = 112).

Seventy-nine percent of the patients reported onset of hair loss between the third and fourth months and, 20% of the patients in the fifth to sixth months (n = 88) after LSG, respectively. Hair loss continued for an average of 5.5 ± 2.6 months. Of the patients; 83% (n = 93) reported intensive hair loss at an alarming rate. Permanent alopecia was not observed in any of the patients (Table 1).

Vitamin D deficiency was detected in 77% of patients in preoperative examinations (<30 ng/mL). Ferritin level of 26 patients with normal Hg level was below <20 ng/mL. Necessary support treatments were given to these patients before surgery. After the surgery, in the third- to sixth-month intervals, laboratory tests revealed 4 patients with biotin deficiency (<100 ng/L), and 21 patients with suboptimal level of biotin (100–200 ng/L). Patients with vitamin deficiency before and after surgery are shown in Table 3.

Table 3.

Preoperative and Postoperative Vitamin Deficiencies

	Anemia	Ferritin <20 μg/L	Vitamin D < 30 ng/mL	B12 < 200 pg/mL	Folic acid <3 ng/mL	Hypoalbuminemia <4 mg/mL	Thiamine <35 μg/dL	Zinc <70 mcg/dL	Biotin <200 ng/L	Vitamin A <300
Preoperative assessment, n (%)	0	26 (17)	120 (77)	0	0	0	N/A	N/A	N/A	N/A
Post-LSG third to sixth month, n (%)	0	11 (7)	50 (32)	12 (8)	4 (3)	0	0	6 (4)	25 (16)	11 (7)

LSG, laparoscopic sleeve gastrectomy.

Biotin supplements (1000 mcg/day) were prescribed to 22 patients with low Biotin levels for hair loss for 3 months. Of those patients, 5 (23%) reported a remarkable decline in hair loss after the treatment. Fourteen patients have stated that treatment showed a low effect, whereas, 3 patients reported that treatment had no effect. In the follow-up period, 29 patients were found to take 1000 mcg/day of Biotin supplements for an average of 2.5 months (ranging between 1 and 4 months) after onset of hair loss by their own initiative, despite optimal blood Biotin levels. Eleven (38%) patients reported a remarkable decline in hair loss, whereas 15 patients stated a very low benefit from this treatment while 3 patients stated that they had no benefit (Table 4). The 2 groups were compared in terms of the effect of using biotin on hair loss. There was no statistically significant difference (P = .2).

Table 4.

Effect of Biotin Supplement in Deficiency and Nondeficiency Group

	High effect for hair loss, n	Low effect for hair loss, n	No effect for hair loss, n	Total, n (%)
Biotin treatment deficiency group, n (%)	5 (23)	14 (64)	3 (13)	22 (100)
Biotin treatment nondeficiency group, n (%)	11 (38)	15 (52)	3 (10)	29 (100)
Total, n (%)	16 (31)	29 (57)	6 (12)	51 (100)

In addition, 16 of the patients who received Biotin supplementation in the follow-up period were found to have blood Biotin levels above 1000 ng/L.

Discussion

There are few studies in literature that have evaluated hair loss after LSG. In a study of 42 patients, the incidence of hair loss after LSG was reported as 41%.⁸ In another study of 50 patients, the incidence of hair loss in the 6-month period after LSG was reported as 56%.⁹ In our study, the incidence of hair loss was determined as 72% in the first year after LSG. Hair loss in 79% of the patients was in between 3 and 4 months and lasted for 5.5 months in average. Eighty-three percent of the patients (n = 93) stated that their hair loss was too severe and worrying.

Rapid weight loss, low protein intake, and particularly deficiency of certain vitamins (iron, zinc, Biotin) are considered as the cause of hair loss.^8,10 Among them, Biotin is the most blamed vitamin. Biotin, known as Vitamin B7, is a water-soluble vitamin. It plays a critical role in the development of the hair follicles.¹¹ Deficiency of Biotin is a rare condition, except those with Biotinidase enzyme defect, which is a genetic disorder. The relationship between deficiency of Biotin and hair loss has been first observed in the patients who received total parenteral nutrition for a long period of time. It was observed that hair loss ceased after biotin supplementation in these patients.¹² Bruginsky have determined hair loss in 17% patients after operation in their study on 118 patients and observed that hair loss stopped in all the patients after administration of 100 mcg Biotin.¹³ It has been reported in another study that daily use of 1–2 mg Biotin was effective for hair loss in cases that were unresponsive to other therapies.¹⁴

In our study, patients who experienced hair loss and Biotin deficiency after LSG were prescribed 1000 mcg/day of Biotin supplementation for 3 months. Of these 22 patients; 5 reported a remarkable decline in hair loss, 14 patients have stated that treatment showed a low effect, whereas, 3 patients noted that treatment had no effect at all (Table 3).

Biotin supplementation is believed to prevent hair loss. In addition, it is thought that it provides hair growth and a lively appearance.⁷ That is the reason Biotin is very popular and included in many multivitamin supplements. The recommended daily dose for biotin in adults is 30 mcg.^7,15 However, Biotin usage that exceed physiological requirements are often used. Many people take Biotin supplements to prevent hair loss or improve hair quality and do not see this as a medicine.¹⁶ In our study too, 29 patients who experienced hair loss were found to be on 1000 mcg biotin supplements daily for an average of 1–3 months, despite their blood biotin levels being optimal. Eleven of these 29 patients stated that their hair loss decreased significantly, 15 of them saw very little benefit, and 3 patients did not benefit at all.

The effect of biotin use on hair loss in patients with and without biotin deficiency was compared. There was no significant difference (P = .2).

It has been also determined in our study that, 16 patients who were on biotin supplementation, blood Biotin levels were above 1000 ng/L during the follow-up blood examination visit. Some studies have shown that high-dose use of Biotin showed no toxic effect.^11,16 However, high levels of Biotin can cause misleading results by disrupting serological tests with the relationship of streptavidin/biotin at high blood levels. There are studies showing that patients mimic Graves' disease with high dose of Biotin intake or that they show results such as severe hyperthyroidism.^17,18 In our follow-up period after LSG, a patient using Biotin due to hair loss was misdiagnosed as Graves' disease in another center. The Federal Drug Administration (FDA) has published a report on this issue. A patient's troponin test result was contaminated due to high dose of biotin supplementation. The patient later died of missed myocardial infarction diagnosis.¹⁹ In this respect, especially if the laboratory results after LSG do not match the patient's clinical status, it should be questioned whether these patients are taking Biotin supplements or not.

Conclusion

Temporary hair loss after LSG is quite common. In this period, products containing biotin are frequently used to prevent hair loss, with or without deficiency. In our study, it was found that biotin supplementation used to prevent hair loss does provide low efficacy in most patients. Although, no toxicity was reported to date on using high doses of biotin, because it may impair laboratory test results, products containing high doses of biotin must be used with caution.

Footnotes

Disclosure Statement

The authors have no commercial associations that might be a conflict of interest in relation to this article.

Funding Information

No funding was received for this article.

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