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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 12  |  Issue : 4  |  Page : 533-537

Reversal of alopecia by insulin therapy in uncontrolled type 2 DM: A case report


1 Division of Diabetes and Metabolism, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Dermatology, Government Doon Medical College, Dehradun, Uttarakhand, India
3 College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission27-May-2021
Date of Decision07-Jul-2021
Date of Acceptance06-Aug-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
Ms. Kalpana Thakur
College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_66_21

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  Abstract 

Diabetes mellitus is a chronic metabolic disease that results in micro-vascular and macro-vascular complications. Further, uncontrolled hyperglycemia can damage blood vessels and alters the anagen and telogen phases of hair growth leading to alopecia. We report a case of a 54-year-old woman diagnosed with type 2 diabetes mellitus (DM) and hypertension suffering from hair loss on the right side of scalp without any signs and symptoms of scalp inflammation. All the possible causes such as lipid profile, side effects of hypoglycemic agents and anti-hypertensive therapy, trichotillomania, and dermatological diseases were ruled out. Here, we emphasize that damaged blood vessels that hinder oxygen supply and nutrients to hair follicles could be the reason behind alopecia in DM patients. Furthermore, insulin plays an important role in cell proliferation and regrowth of hair follicles. It was also noted that patients’ response to glycemic control was remarkable, and timely initiation of insulin in patients with DM and alopecia restores normal hair growth. Still, more extensive research is required in this field, which will ultimately be helpful in the prevention of alopecia in DM patients.

Keywords: Diabetic complications, hair fall, HbA1c level, insulin therapy, team approach


How to cite this article:
Kant R, Barnwal S, Sharma SK, Thakur K. Reversal of alopecia by insulin therapy in uncontrolled type 2 DM: A case report. J Diabetol 2021;12:533-7

How to cite this URL:
Kant R, Barnwal S, Sharma SK, Thakur K. Reversal of alopecia by insulin therapy in uncontrolled type 2 DM: A case report. J Diabetol [serial online] 2021 [cited 2022 Jan 27];12:533-7. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/4/533/335596




  Introduction Top


Type 2 diabetes mellitus (T2DM) remains a problem in India, despite recent advancements in hypoglycemic therapy. It is a chronic disease that requires long-term treatment and continuous follow-ups to limit the advancement of micro-vascular and macro-vascular complications, which occurs among one-third to one-half of the diabetic population.[1],[2] As per the WHO factsheet, every year around 3.4 million people globally and 1 million from South-East Asia lose their lives because of high blood glucose levels.[3]

Prolonged hyperglycemia also plays a crucial role in causing structural and metabolic alterations which ultimately lead to vascular complications.[4],[5] It has been documented in literatures that alopecia areata whether totalis or universalis is commonly associated with DM, psoriasis, thyroid disorders, and vitiligo. Surprisingly, there are insufficient data to describe the impact of continuously increased blood glucose level on alopecia or patients’ hair loss, which is a commonly reported complaint among diabetic clients. The possible explanation for diffuse and acute hair shedding among diabetic patients could be the damaged blood vessels that hinder oxygen supply and nutrients to hair follicles; ultimately, it reduces the length of anagen phase and increases the duration of telogen phase in normal growth cycle, thus resulting in alopecia. Further, this phenomenon can be explained as telogen effluvium in which hairs suspended in this resting phase are then removed from hair follicles, further leading to hair thinning and shedding. Hair loss adds on to the physical and psychological discomfort among diabetic patients.[6],[7] Alopecia among T2DM patients cannot be ignored; possible pathogenesis other than medications’ side effects and role of insulin in stimulating growth of hair follicles need to be explored. To the best of our knowledge, no case on the impact of increased HbA1c level on hair volume and density has been discussed, and this case would put light on the unnoticed impact of increased glycated hemoglobin levels and importance of timely initiation of insulin therapy.


  Case Presentation Top


A 54-year-old woman, diagnosed case of T2DM and hypertension for 17 years, presented in diabetic clinic with chief complaint of progressive right-sided scalp hair loss without any signs and symptoms of scalp inflammation [Figure 1]. As reported, she had noticed significant hair fall while combing for the last 2 months. The hair fall was almost handful in a day, and there was progressive worsening of alopecia in the form of exaggerated scalp visibility. Apart from hair fall, she had aches and pains throughout the body and muscle weakness along with tingling in bilateral lower limbs. The patient was suffering from mild peripheral neuropathy, and there was no history of other diabetes-related complications. None of the family members was suffering from alopecia, and she has denied any use of chemical products on hairs.
Figure 1: Before treatment: right-sided scalp (hair loss)

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Patient was on oral hypoglycemic agent (OHA) (empagliflozin) and anti-hypertensives (telmisartan and amlodipine). It can be stated that patients’ hair loss was not due to any side effects of hypoglycemic agent or anti-hypertensive drug because DPP4 inhibitors/gliptins and angiotensin-converting enzyme inhibitors were not used for her treatment which are known to cause hair fall. For the problem of her hairfall, she consulted a dermatologist and was given anti-histamine (Tab. Allegra 180 mg) and minoxidil (mini-check lotion for local application), which did not benefit. The patient was also examined for hair pulling disorder and there was no evidence of trichotillomania. The hair loss shedding visual scale[7] for medium length hair was used and the patient score was 07 which was indicative of excessive hair shedding [Figure 2]. Her laboratory investigations revealed escalated HbA1c levels 14%, glucose fasting 308.0 mg/dL, and glucose postprandial 593.1 mg/dL. Other investigations including FT4, TSH, serum creatinine, and blood urea are unremarkable, except for the increased total cholesterol 270.0 mg/dL (123–200 mg/dL).
Figure 2: Before treatment: excessive hair shedding

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Taking into consideration the complete history and examination, actions were required to lower patient’s blood glucose level as it could be the possible contributor for excessive hair loss. Therefore, her treatment regimen was changed, and Freestyle Libre Glucose Monitoring Sensor[8] was applied with an aim to trace and target increased blood glucose values [Graph 1], top]. The patient was treated with a combination of OHAs and insulin including human insulin R (12 U before breakfast; 10 U before lunch; 10 U before dinner), glargine (16 U at bedtime), glibenclamide, metformin, telmisartan, rabeprazole, and levosulpiride along with pregabalin and nortriptyline. In addition, the patient was asked to follow dietician’s recommendations for diet and exercise. The patient was called for follow-up visit after 15 days and her blood glucose values were approaching normal values, and there was no episode of hypoglycemia [Graph 1, bottom]. The patient was told to continue the same treatment except a minor change in HIR dosage (10 U before breakfast; 10 U before lunch; 10 U before dinner) and was told to keep a watch on her hair loss volume. After 2 months, she was reviewed again in diabetic OPD and we received an overwhelming response on regaining of hair as it was quite evident [[Figure 3]. The patient herself was experiencing a significant reduction in hair fall while combing and this was confirmed with the score of 04 on hair loss shedding visual scale [Figure 4]. In subsequent follow-up visits, she showed signs of remarkable improvement.
Graph 1: Before treatment: AGP graph (top); after treatment: AGP graph (bottom)

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Figure 3: After treatment (2 months): right-sided scalp (hair regrowth)

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Figure 4: After treatment: normal hair shedding

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  Discussion Top


It is evident in literature that micro-vascular and macro-vascular complications[1],[2] resulting from diabetes can cause severe irreversible damage and also negatively impact quality of life. Although alopecia areata and alopecia due to OHA side effects have been reported in literatures,[9],[10] poorly controlled glycated hemoglobin can also damage hair follicles and negatively impact normal hair growth cycle that further results in alopecia.

Drug-induced hair loss has been reported in literatures, especially with DPP4 inhibitors and gliptins.[11] On the contrary, in the present case study, the patient reported severe hair fall but there was no evidence indicating side effects of OHAs. As per detailed assessment of history and examination, increased HbA1c leading to telogen effluvium could be considered as the only reason for patient’s hair loss. It was interesting to note that our patient was much concerned about her hair fall than her significantly raised blood glucose level.

There are various guidelines on the treatment of diabetes and its associated complications, but individual approach based on physicians’ judgment in the best interest of clients is considered to be the most effective.[12] Involvement of multi-disciplinary team in diabetic clinic is a progressive approach that could bring desired results and positive outcome in terms of better HbA1c control and minimum complications.[13] The present case of uncontrolled blood glucose level with alopecia was managed with a combination of OHAs and insulin therapy with a goal to control blood glucose level followed by hair regrowth. Moreover, diabetic nurse educators also played an important role by educating and training patients in self-monitoring of blood glucose, insulin administration, and management of hypoglycemic emergency.

The literature suggests that growth hormones do not have impact on hair follicles growth in the absence of insulin.[14] Impact of insulin on in vitro growth of isolated human hair follicles has also been reported in literature causing morphological changes and structural hair defects. Furthermore, it was documented that absence of insulin leads to early entry of hair follicles into anagen–catagen stage of hair growth cycle and therefore inhibits hair follicles growth and end result will be thinning of hair and alopecia.[14],[15],[16] It has been stated by Wolf et al.[17] that stimulation of IGF-1 or insulin may help in reduction of hair loss. Practically, our patient’s outcome in terms of better glycemic control and hair regrowth also favors insulin for the treatment of alopecia in T2DM patients. After 2 months of insulin administration, the patient had reported significant reduction in hairfall which was clinically confirmed by the hair shedding scale. Remarkable improvement in clients’ complaint of alopecia with initiation of insulin therapy has brought insight into clinical importance of insulin for the treatment of alopecia.

As per the present case study, it can be stated that while treating diabetic patients, early identification of their insulin requirement needs to be considered. There is no single-line treatment for diabetes and its associated complications because management of this chronic illness requires lifestyle changes and team approach where patients are also involved in their treatment planning. Innovative thought process and inquisitiveness of treating physician to look for possible reasons of suddenly arising complications are the critical requirements for better quality of life among T2DM patients. Tracing patients’ history in detail and regular follow-up could be utilized as effective tools for identifying important areas, in which the increased blood glucose level may impact for early treatment and recovery. Our patient visited the physician weekly and follow-up with diabetic nurse was done twice a week. This was further supported by studies in literature, in which it has been reported that regular follow-up is important for effective treatment.


  Conclusion Top


Although various treatment alternatives or approaches are available for diabetes, it still is a challenge to manage diabetic complications. It is clearly observed in this case study that timely management of increased blood glucose level could be helpful in preventing long-term irreversible damage. However, it is of utmost importance that underlying cause or predictor of diabetic complications is identified at an early stage and further team approach can be utilized for better outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

No funding received for this article.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2014;37(Suppl. 1):S81-90.  Back to cited text no. 1
    
2.
World Health Organization. Diabetes action now booklet: A life-threatening condition. Available from: www.who.int/diabetes/BOOKLET_HTML/en/index3.html. Accessed January 31, 2021.  Back to cited text no. 2
    
3.
World Health Organization. Diabetes facts. Available from: http://www.who.int/mediacentre/factsheets/fs312/en/index.html. Accessed January 31, 2021.  Back to cited text no. 3
    
4.
Tuomilehto J, Lindström J, Eriksson JG, Valle TT, Hämäläinen H, Ilanne-Parikka P, et al; Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343-50.  Back to cited text no. 4
    
5.
Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.  Back to cited text no. 5
    
6.
Shrivastava SB. Diffuse hair loss in an adult female: Approach to diagnosis and management. Indian J Dermatol Venereol Leprol 2009;75:20-7; quiz 27-8.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Trueb RM. Diffuse hair loss. In: Blume-Peytavi U, Tosti A, Whiting DA, Trueb R, editors. Hair Growth and Disorders. 1st ed. Berlin: Springer; 2008. p. 259-72.  Back to cited text no. 7
    
8.
Blum A. FreeStyle Libre glucose monitoring system. Clin Diabet 2018;36:203-4.  Back to cited text no. 8
    
9.
Someili A, Azzam K, Hilal MA. Linagliptin-associated alopecia and bullous pemphigoid. Eur J Case Rep Intern Med 2019;6:001207.  Back to cited text no. 9
    
10.
Martínez-Velasco MA, Vázquez-Herrera NE, Maddy AJ, Asz-Sigall D, Tosti A . The hair shedding visual scale: A quick tool to assess hair loss in women. Dermatol Ther (Heidelb) 2017;7:155-65.   Back to cited text no. 10
    
11.
Agrawal PK, Gautam AK, Pursnani N, Agarwal A. Teneligliptin-induced hair loss: A case report. J Family Med Prim Care 2020;9:2552-4.  Back to cited text no. 11
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12.
International Diabetes Federation. IDF Diabetes Atlas 9th edition. Available from: https://www.diabetesatlas.org/en/. Accessed January 31, 2021.  Back to cited text no. 12
    
13.
Sharma S, Thakur K, Kant R, Kalra S. Nurse-led diabetes clinics in Southeast Asia: Scope, feasibility, challenges and facilitators. 2021. Medcraveonline.com. Available from: https://medcraveonline.com/JDMDC/JDMDC-07-00199.pdf. Accessed February 1, 2021.  Back to cited text no. 13
    
14.
Neely EK, Morhenn VB, Hintz RL’ Wilson OM, Rosenfeld RG. Insulin like growth factors are mitogenic for human keratinocytes and squamous cell carcinoma. Invest Dermatol 1991;96:104-10.  Back to cited text no. 14
    
15.
Greco V, Chen T, Rendl M, Schober M, Pasolli HA, Stokes N, et al. A two-step mechanism for stem cell activation during hair regeneration. Cell Stem Cell 2009;4:155-69.  Back to cited text no. 15
    
16.
Zhang YV, Cheong J, Ciapurin N, McDermitt DJ, Tumbar T. Distinct self-renewal and differentiation phases in the niche of infrequently dividing hair follicle stem cells. Cell Stem Cell 2009;5: 267-78.  Back to cited text no. 16
    
17.
Wolf R, Schönfelder G, Paul M, Blume-Peytavi U. Nitric oxide in the human hair follicle: Constitutive and dihydrotestosterone-induced nitric oxide synthase expression and NO production in dermal papilla cells. J Mol Med (Berl) 2003;81:110-7.  Back to cited text no. 17
    


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



 

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