Clinical Review & Education

JAMA Dermatology | Review

Evaluation of the Safety and Effectiveness

of Nutritional Supplements for Treating Hair Loss
A Systematic Review
Lara Drake, BA; Sophia Reyes-Hadsall, BS; Jeremy Martinez, BS; Christina Heinrich, MS;
Kathie Huang, MD; Arash Mostaghimi, MD, MPH, MPA

Supplemental content
IMPORTANCE Despite the widespread use of nutritional supplements and dietary
interventions for treating hair loss, the safety and effectiveness of available products
remain unclear.

OBJECTIVE To evaluate and compile the findings of all dietary and nutritional interventions
for treatment of hair loss among individuals without a known baseline nutritional deficiency.

EVIDENCE REVIEW The MEDLINE, Embase, and CINAHL databases were searched 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 or hair loss without a known baseline nutritional deficiency. Quality was assessed
with Oxford Centre for Evidence Based Medicine criteria. Outcomes of interest were
disease course, both objectively and subjectively measured. Data were evaluated
from January 3 to 11, 2022.

FINDINGS The database searches yielded 6347 citations to which 11 articles from reference
lists were added. Of this total, 30 articles were included: 17 randomized clinical trials (RCTs),
11 clinical studies (non-RCT), and 2 case series studies. No diet-based interventional studies
met inclusion criteria. Studies of nutritional interventions with the highest-quality
evidence showed the potential benefit of Viviscal, Nourkrin, Nutrafol, Lamdapil,
Pantogar, capsaicin and isoflavone, omegas 3 and 6 with antioxidants, apple nutraceutical, Author Affiliations: Tufts University
total glucosides of paeony and compound glycyrrhizin tablets, zinc, tocotrienol, School of Medicine, Boston,
Massachusetts (Drake, Heinrich);
and pumpkin seed oil. Kimchi and cheonggukjang, vitamin D3, and Forti5 had low-quality University of Miami Miller School of
evidence for disease course improvement. Adverse effects were rare and mild for all Medicine, Miami, Florida
the therapies evaluated. (Reyes-Hadsall); Department of
Dermatology, Harvard Medical
CONCLUSIONS AND RELEVANCE The findings of this systematic review should be interpreted in School, Boston, Massachusetts
(Martinez, Huang, Mostaghimi);
the context of each study’s design; however, this work suggests a potential role for nutritional
Department of Dermatology,
supplements in the treatment of hair loss. Physicians should engage in shared Brigham and Women’s Hospital,
decision-making by covering the potential risks and benefits of these treatments with Boston, Massachusetts (Huang,
patients experiencing hair loss. Future research should focus on larger RCTs with active Mostaghimi).
comparators. Corresponding Author: Arash
Mostaghimi, MD, MPA, MPH,
Department of Dermatology,
JAMA Dermatol. 2023;159(1):79-86. doi:10.1001/jamadermatol.2022.4867 Brigham and Women’s Hospital,
Published online November 30, 2022. 221 Longwood Ave, Boston, MA 02115
([email protected]).

A
lthough nutritional supplements—vitamins, nutraceuti- we aimed to evaluate the data behind supplements and
cals, and botanicals—for hair loss are common, dietary changes among patients with no known baseline nutri-
data around their effectiveness and adverse effects tional deficiency.
are highly variable.1 Complementary medications are commonly
used for the treatment of alopecia areata (AA) and androgenic
alopecia (AGA); a study found that in a hair loss clinic, 81% of
Methods
patients used supplements. 2-4 The most common hair loss
supplements were found to be biotin, vitamin B12, and B-complex This systematic review was exempted from institutional review
multivitamin.5 Although the benefit of nutritional interventions board approval and informed consent because all data came from
is unknown, their use can be expensive, lead to toxic effects previously published studies. The study followed the Preferred
in high doses, and interact with medications and test results.1 Reporting Items for Systematic Reviews and Meta-analyses
Given the frequency of supplement use in hair loss patients, (PRISMA) reporting guidelines.6

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 Clinical Review & Education Review Nutritional Supplementation for Hair Loss

Information Sources and Search

A health sciences librarian (C. H.) performed a search of MEDLINE, Key Points
Embase, and CINAHL databases, from inception through October Question Are nutritional supplements or dietary interventions
20, 2021. The strategy combined diet or nutrition therapy and hair safe and effective for patients with hair loss?
loss, using keywords and subject headings for each. The search was
Findings In this systematic review of 30 studies of nutritional
limited to publications in English and excluded animal studies using
interventions, the highest-quality evidence suggests the potential
the Cochrane limit for studies in humans.7 Investigators scanned effectiveness of Viviscal, Nourkrin, Nutrafol, Lamdapil, Pantogar,
reference lists of relevant reviews to supplement database searches. Capsaicin and isoflavone, omega 3 and 6 with antioxidants,
The full search strategy is available in the eMethods in the Supple- apple nutraceutical, total glucosides of paeony and compound
ment. glycyrrhizin tablets, zinc, tocotrienol, and pumpkin seed oil.
No data for dietary interventions were identified.
Eligibility Criteria Meaning The findings of this systematic review indicate that
Included studies contained original data that evaluated diet and nutritional interventions may benefit select patients with hair loss,
nutritional interventions in adult and/or child participants with hair and although few adverse events were reported, physicians
loss. We excluded studies of animals or nonhumans; hair loss sec- should engage in shared decision-making with patients given the
lack of federal oversight of these regimens.
ondary to a nutritional deficiency, medication, toxin exposure, or un-
derlying disease; treatments accompanied by behavioral interven-
tions; and published in a language other than English. We included
articles with relevant outcomes, such as disease course and ad- assessed improvement in the intervention group compared with 11%
verse effects; randomized clinical trials (RCTs); clinical studies in the placebo group after 5 months, although it was not a statisti-
(non-RCTs); prospective and retrospective cohort studies; and cally significant difference.9 Another comparative effectiveness trial
case series and case reports. of S repens and oral finasteride in 100 men with mild-to-moderate
AGA found finasteride more effective at improving hair loss, while
Study Selection and Quality Assessment S repens stabilized hair loss after 24 months.10 Adverse events re-
Initially, the search yielded 6347 citations. After review of the ref- ported were mild and included nausea, diarrhea, and constipation.
erences and other resources, 11 articles were added. Ultimately, These findings suggest that S repens may stabilize hair loss, al-
30 articles met our criteria and were included in the analysis: 17 RCTs, though its effect is likely less than that of finasteride. Sexual dys-
11 clinical studies, and 2 case series (Figure). After initial screening function, an adverse effect associated with finasteride, was also
of the titles and abstracts, reviews of the full texts were performed seen with S repens but to a lesser extent.9,10,39 Physicians should be
by 3 independent reviewers (L. D., S. R. H., J. M.). A fourth reviewer aware that in men using S repens, there may be a theoretical risk of
(A. M.) mediated disagreement and reviewed final articles for missing early detection of prostate cancer given that 5AR inhibition
inclusion. Quality assessment of included articles was performed been associated with reduced levels of prostate cancer markers.10,40
independently by 2 reviewers (L. D., S. R. H.) using the Oxford
Centre for Evidence-Based Medicine criteria (Table 1).8 Data were Pumpkin Seed Oil
evaluated from January 3 to 11, 2022. Pumpkin seed oil has shown effectiveness in treating benign
prosthetic hyperplasia given its 5AR inhibition and antiandrogenic
properties.41,42 An RCT of pumpkin seed oil capsule use among 76
men with AGA demonstrated significantly superior hair growth
Results and patient-reported satisfaction among the intervention vs the
We reviewed the study design, nutritional intervention, and control group; adverse events (ie, pruritus and abdominal pain)
outcomes of each of the 30 included articles (eTables 1 and 2 in the were similar in both groups. Pumpkin seed oil may be a potential
Supplement). Table 29-38 provides a list of ingredients for each alternative to finasteride for treatment of AGA; however, to our
nutritional supplement. knowledge, no comparative study has been performed.11

Safety and Effectiveness of 5-α Reductase Inhibitors Forti5

The enzyme 5-α reductase (5AR) converts testosterone to dihy- Forti5 (Q-SkinScience) is a nutritional supplement designed to
droxytestosterone (DHT), a mediator of AGA. Finasteride, cur- target AGA using antioxidants, melatonin, cholecalciferol, soy phy-
rently approved by the US Food and Drug Administration (FDA) toestrogens, and botanical 5AR inhibitors. A prospective case se-
for the treatment of AGA in men, inhibits 5AR. ries of Forti5 use among 10 adults with AGA showed investigator-
assessed improvement in 80% of participants at 24 weeks, with
Saw Palmetto significantly increased hair mass index.12 Despite favorable results
Serenoa repens, commonly known as saw palmetto, is a botanical with no adverse effects, the study was limited by its small sample
compound hypothesized to inhibit 5AR. Clinical studies of S repens size and lack of control group.
have shown efficacy for androgen-dependent conditions (eg, be-
nign prosthetic hyperplasia), which like AGA are also mediated Safety and Effectiveness of Micronutrients
by DHT.9,39 Micronutrients play a key role in the normal functioning of the
An RCT of active oral lipidosterolic extract of S repens use in 19 hair follicle. Many types of alopecia are characterized by lower
males with mild-to-moderate AGA showed 60% investigator- levels of micronutrients compared with controls.

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 Nutritional Supplementation for Hair Loss Review Clinical Review & Education

Figure. PRISMA Flow Diagram of Selected Studies Table 1. Nutritional Supplements for Hair Loss,
by Quality Level of Evidence and Potential Effectiveness Demonstrated
7001 Records identified through Quality
database search levela Potential effectiveness
2783 MEDLINE
2 Demonstrated effectiveness
638 CINAHL
3580 Embase Pumpkin seed oil capsules (Octa Sabal Plus)
Omegas 3 and 6 combined with antioxidants
Tocotrienol
654 Duplicate records removed before screening
Pantogar
Capsaicin and isoflavone
6347 Records screened
Viviscal (multiple formulations, Hairgain)
Nourkrin
6260 Records excluded based on title and abstract review Nutrafol
Apple nutraceutical
87 Full-text reports assessed Lamdapil
for eligibility Total glucosides of paeony and compound glycyrrhizin tablets
Zinc
68 Reports excluded Not demonstrated
27 No intervention Lipidosterolic extract of Serenoa repensb
9 Intervention not solely diet/nutrition
Serenoa repens
7 Systematic reviews
6 Abstract or poster presentations Miliacin soft gels
5 Patients had nutritional deficiency 3 Demonstrated effectiveness
4 Narrative reviews Vitamin D3
3 Low level of evidence (eg, expert opinion)
2 No alopecia or hair loss Kimchi and cheonggukjang (Mogut)
2 Patients had systemic disease Not demonstrated
1 Outcome was not disease course Zincb
1 In language other than English
1 Full text not found after exhaustive search
B12b
Omni-Threeb
4 Demonstrated effectiveness
11 Studies added from citations
or other sources Forti5
a
Quality defined by the Oxford Centre for Evidence Based Medicine, 2011 criteria8:
level 1, systematic review (not included in this analysis); 2, randomized clinical
30 Articles included
17 Randomized clinical trials trial, observational study with substantial effect, inception cohort study; 3, cohort
11 Clinical studies study, nonrandomized controlled cohort with follow-up study; 4, case series,
2 Case series case control, poor quality prognostic cohort study, or historically controlled
studies; and 5, mechanism-based reasoning.
b
Results were not statistically significant.
Vitamin D
Lower or deficient levels of vitamin D have been associated with AA, after 3 months of zinc supplementation. Larger, more rigorous
AGA, and telogen effluvium (TE) in some studies.43-45 A single-arm studies are needed to evaluate the association of zinc supplemen-
prospective study13 that assessed oral vitamin D3 supplementation tation with AA. An additional 4-arm comparative effectiveness
in 40 women with TE observed that at 6 months, 82.5% of the pa- study15 of zinc sulfate and calcium pantothenate, zinc sulfate, cal-
tients had improved results on hair pull test and 85% reported cium pantothenate, and 2% topical minoxidil use in 73 women
being satisfied; no adverse effects were reported. Given the with self-reported hair loss showed increased hair thickness and
self-resolving course of TE, lack of control group, and lack of baseline density in all groups, with the largest increase in density among
vitamin D assessment, these findings should be interpreted the minoxidil group and in thickness among the calcium mono-
with caution. therapy group at 4 months; no adverse effects were reported. The
study’s limitations included using self-perceived hair loss data
Zinc and the lack of a control group.
Zinc deficiencies can cause TE, hair breakage, and hair thinning.
Lower serum zinc levels have inconsistently been identified in B Vitamins
patients with AA compared with controls.46-48 The association The B vitamins include B7 (biotin) and B12. To our knowledge, biotin
between AA and zinc use is hypothesized to be its role in copper monotherapy for alopecia has not been studied but it is a compo-
and/or zinc superoxide dismutase, with decreased levels resulting nent of other nutritional supplements in this review. Biotin use is
in tissue oxidative damage.47 widely advertised for improving hair growth.49 The FDA has warned
A nonrandomized, double-blind, placebo-controlled study14 against biotin supplementation because it can interfere with some
of zinc sulfate use in 38 participants with AA, alopecia totalis, and laboratory testing such as troponin and hormonal tests.50
alopecia universalis with normal baseline zinc levels demonstrated Vitamin B12 is important for DNA synthesis and has been pro-
no improvement in hair outcomes at 3 months, while another posed to be beneficial for proliferating hair cells.46 A prospective
crossover study16 of zinc sulfate capsule use in 67 patients with AA study evaluated the use of oral B12 daily and injection monthly in 10
and baseline normal zinc levels showed significant hair regrowth participants with TE with dysesthesia17 (a subcategory of TE with

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 Clinical Review & Education Review Nutritional Supplementation for Hair Loss

Table 2. Ingredients of Nutritional Supplements of Included Studies

Category Supplement Dosage and ingredients list

Androgen modulators Lipidosterolic extract of Serenoa Oral soft gel capsule with betasitosterol (50 mg), saw palmetto extract (200 mg;
repens and betasitosterol9 standardized to 85%-95% lipidosterolic content), lecithin (50 mg), inositol (100 mg),
phosphatidyl choline (25 mg), niacin (15 mg), biotin (100 μg)
S repens10 Dry plant extract (320 mg/die)
Pumpkin seed oil11 Capsules (400 mg; Octa Sabal Plus)
Forti512 Green tea extract, omegas 3 and 6 fatty acids, cholecalciferol, melatonin, beta-sitosterol,
and soy isoflavones
Micronutrients Vitamin D313 200 000 IUs
Zinc sulfate14 Capsules (220 mg)
Zinc sulfate, pantothenic acid15 Zinc sulfate capsules (220 mg equivalent to 50 mg zinc; Alhavi Co)
Pantothenic acid as calcium pantothenate tablets (100 mg; Mehr Darou Co)
Minoxidil solution (2%; Pak Darou Co)
Zinc sulfate16 Powder mixed with glucose powder (5 mg/kg/d)
Vitamin B1217 Oral and injection
Antioxidants Omegas 3 and 6 and antioxidants18 Lycopene, vitamins C and E
Tocotrienol19 Mixed capsules (50 mg; 30.8% alphatocotrienol; 56.4% gammatocotrienol; 12.8%
deltatocotrienol; 23 IUs alphatocopherol)
Immunomodulators TGPC and CGT20 TGPC oral capsule (300 mg, 3/d)
CGT oral tablet (25 mg, 3/d
Amino acids Pantogar21 L-cystine (20 mg), keratin (20 mg), medicinal yeast (100 mg),
calcium pantothenate (60 mg), thiamine nitrate (60 mg) and PABA (20 mg)
Probiotics Mogut22 Kimchi and cheonggukjang probiotic
Growth hormone Capsaicin and isoflavone23 Capsaicin (6 mg); isoflavone (75 mg)
modulators
MePL24 Softgel capsules of soybean oil (150 mg) and MePL (150 mg; original combination,
miliacin extracted from whole millet seeds and polar lipids extracted from wheat grain)
Marine protein-based Viviscal25 Extract of marine origin with a silica compound
supplements
Viviscal Man26 Vitamin C (from acerola powder and ascorbic acid), zinc (from zinc oxide), AminoMar
(shark powder and mollusk powder; 452.9 mg), horsetail (stem) extract (24.5 mg),
and flax seed extract (50 mg). Other ingredients include microcrystalline cellulose,
maltodextrin, hydroxypropyl methylcellulose, silicon dioxide, magnesium stearate,
glycerol, artificial orange flavoring, modified starch
Viviscal, maximum strength27 AminoMar (proprietary blend of shark and mollusk powder, organic form of silica from
Equisetum sp [horsetail], vitamin C from Malpighia emarginata [acerola cherry],
microcrystalline cellulose [E460], natural orange flavor, magnesium stearate,
hypromellose, glycerol)
Viviscal, professional strength28 Same as above plus procyanidin B2 (apple extract powder), L-cystine, and L-methionine
Viviscal, extra strength29 Oral marine protein supplement
Viviscal30 AminoMar protein complex
Hairgain (later marketed as Viviscal)31 Marine proteins extract, plant sterol, tribasic calcium phosphate, L-cysteine, zinc gluconate,
ascorbic acid, choline bitartrate, bamboo extract, magnesium oxide, iron fumarate,
L-methionine, povidone 30, D-alphatocopheryl oxide succinate, maltodextrin, calcium
D-pantothenate, stearic acid, magnesium stearate, corn starch, sodium copper chlorophyllin,
pyridoxine hydrochloride, hypromellose, thiamine mononitrate, riboflavin, gum arabic,
5-methyltetrahydrofolate
Nourkrin32 Marine proteins extract, acerola cherry extract, silica kieselguhr, horsetail extract,
and immunoglobulins
Multi-ingredient Nutrafol Women’s33 Capsules of synergen complex, curcumin, ashwagandha, saw palmetto, tocotrienols
supplements
Nutrafol Women’s Balance34 Capsules of synergen complex, maca, astaxanthin, tocotrienol-rich complex, capsaicin,
peperine, hydrolyzed marine collagen, organic kelp
Nutrafol35
Omni-Three36 Boswellia serrata, Curcuma longa, Vitis vinifera
AMS with maltodextrins vs AMSbza37 AMSbzs = AMS with maltodextrins (400 mg), biotin (0.20 mg), selenomethionine (80.0 μg),
zinc (21.0 mg)
Lambdapil38 2 capsules: L-cystine (1000 mg), S repens (100 mg), Equisetum arvense (7.14 mg),
silicon (0.50 mg), zinc (10 mg), vitamin B3 (16 mg), vitamin B5 (6 mg), vitamin B6 (1.4 mg),
D-biotin (50 μg), taurine (40 mg)
Abbreviations: AMS, AppleMets (a nutraceutical formulation of apple fruits of Annurca); AMSbza, AppleMets polyphenolic extract microencapsulated with
maltodextrins, biotin, selenomethionine, and zinc acetate; CGT, compound glycyrrhizin tablets; TGPC, total glycosides of paeony; MePL, miliacin encapsulated with
polar lipids; PABA, p-aminobenzoic acid

itch, pain, soreness, and/or burning) and normal baseline B12 lev- absent shedding, and 90% reported decreased or absent dyses-
els. At 4 months, all participants had experienced decreased or thesia, with no adverse effects. However, given the self-resolving

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 Nutritional Supplementation for Hair Loss Review Clinical Review & Education

course of TE and lack of control group, these findings should be Safety and Effectiveness of Growth Hormone Modulators
interpreted with caution. Insulin growth factor-1 (IGF-1) plays an important role in hair follicle
development and in the hair growth cycle.58 Modulated by growth
Antioxidants hormone, deficiencies in either IGF-1 and/or growth hormone have
Oxidative stress has been suggested in the pathogenesis of AA, AGA, been associated with several causes and types of hair loss, includ-
and TE.51-53 Antioxidants—eg, selenium, carotenoids, and vitamins ing alopecia and TE.59
A, C, and E—are commonly included in supplements. Excessive
supplementation has been linked to toxic effects and hair loss.54,55 Capsaicin and Isoflavones
An expert-blinded RCT18 of fish oil, blackcurrant seed oil, vitamin E, Capsaicin is used as a topical analgesic and as a food additive to
vitamin C, and lycopene supplementation compared with no supple- provide a spicy flavor and a burning sensation. Isoflavones are
mentation among 118 women with Ludwig stage 1 AGA showed naturally occurring phytoestrogens of the bean and legume family.
significantly increased hair density and thickness in the interven- Both topical capsaicin and isoflavones may increase dermal IGF-1
tion group at 6 months. Another RCT evaluated mixed tocotrienols production,60 which is involved in hair growth. An RCT of capsa-
(vitamin E family)19 in 35 patients with unspecified hair loss showed icin and isoflavone use in 48 adults with either AGA or AA 23
significantly more hairs in the intervention group at 8 months. There showed significantly more hair growth in the capsaicin and
were no adverse events reported in either of these studies, and isoflavone group at 5 months; no adverse effects were reported.
their limitations included a lack of defined hair loss in the inclusion Limitations were its small sample size and the inclusion of various
criteria and small sample sizes. types of alopecia.

Safety and Effectiveness of Immunomodulators Miliacin Encapsulated by Polar Lipids

A subset of alopecia types, such as AA, are autoimmune condi- Miliacin is the main compound in millet, a type of small-seeded
tions. Therefore, it has been hypothesized that substances with im- grass, which is hypothesized to modulate IGF-1.61 An RCT of mili-
munomodulating properties may affect hair regrowth. Total glyco- acin encapsulated by polar lipids capsule use in 65 women with TE24
sides of paeony (TGPC) and compound glycyrrhizin tablets (CGT) are showed no difference between the intervention and placebo
Chinese herbal plant extracts that have been shown to regulate groups at 12 weeks; no adverse effects were reported. Limitations
T-cell activation.20 A comparative effectiveness study of TGPC, CGT, included the small sample size and the short time frame that mim-
and vitamin B2 vs CGT alone20 in 117 children with severe AA showed icked the natural resolution of TE.
a reduction in AA severity score compared with the baseline in
both groups, and a significantly better response among the TGPC Safety and Effectiveness of Marine
and CGT group compared with the CGT monotherapy group at 12 Protein-Based Supplements
months. Adverse events were mild and included abdominal pain Nutraceuticals containing marine protein supplements (MPS)
and increased stool frequency. have been hypothesized to decrease hair loss by providing essen-
tial nutrients to nourish thinning hair.29 Compounds with MPS
Safety and Effectiveness of Amino Acids as the primary component have been assessed in several clinical
Keratin is a structural fibrous protein that makes up hair; it has large trials for efficacy in treating hair loss.
amounts of the sulfur-containing amino acid cysteine. Supplemen-
tation with sulfur-containing amino acid was initially investigated Viviscal
in sheep, in which it increased wool production.56 An L-cystine Viviscal (Lifes2good Inc) is an oral supplement that primarily
deficiency makes hair thin, brittle, dry, and fragile, and ultimately contains the AminoMarTM marine complex, a proprietary blend of
results in hair loss. extracellular matrix components from sharks and mollusks.62
Pantogar (Merz Pharma) is a hair growth supplement that con- Use of Viviscal and its formulation, Viviscal Man, were studied in
tains L-cystine and keratin among other ingredients. An RCT of men with AGA and showed significant improvements in hair
Pantogar use in 30 adult women with TE21 showed significantly in- counts.25,26 Viviscal and other formulations were also examined in
creased anagen hair rates but no significant change in hair count, women with self-perceived hair thinning; they showed increased
density, and diameter in the intervention group compared with terminal hair counts and reduced shedding.27-30 Adverse effects
baseline at 6 months. Adverse events included gastrointestinal included mild bloating and stomach discomfort in both the pla-
symptoms, weight gain, and transient elevation of pancreatic en- cebo and intervention groups. The limitations of these studies
zymes. Limitations included a small sample size and short time included the subjective inclusion criteria of self-perceived
course that mimicked the natural resolution of TE. hair thinning, no baseline nutritional status or definition of the
hair loss pattern, small sample sizes, and funding by the product’s
Safety and Effectiveness of Probiotics manufacturer.
Probiotics are hypothesized to improve blood flow to the scalp.22,57 An additional RCT31 studied use of Hairgain (later marketed
A study of use of Mogut (Coenbio Co), a kimchi and cheonggukjang as Viviscal) in 60 adults with hair loss; there was a signi-
(fermented soybean paste) probiotic product, among 23 men ficant increase in hair counts among the intervention group
and 23 women with AGA22 showed significant improvement in hair at 12 months and no adverse effects. Limitations included a
thickness and/or hair count in 93% of patients at 4 months with no small sample size and inclusion of patients with various types
adverse effects reported. Limitations included small sample size of alopecia. All Viviscal formulations are summarized in eTable 2
and lack of a control group. in the Supplement.

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 Clinical Review & Education Review Nutritional Supplementation for Hair Loss

Nourkrin Lambdapil
Nourkrin (Pharma Medico) is another MPS. Dysregulated proteo- Lambdapil (Isdin SA) is a food supplement composed of L-cystine
glycan metabolism plays a mediatory role in the causes of hair loss. (keratin protein synthesis), S repens (5AR inhibitor), silicon
It has been hypothesized that Nourkrin acts as proteoglycan re- derived from Equistem arvense (for hair resilience), and other
placement therapy in treating hair loss.63 An RCT of Nourkrin use in ingredients.71 An RCT of Lambdapil treatment in 35 men with AGA
51 men and 4 women with unspecified hair loss32 showed signifi- and 35 women with TE showed a significant improvement in
cantly increased hair counts in the intervention group compared results of the hair pull test in the Lambdapil group compared with
with the placebo group at 12 months; no adverse effects were re- placebo group of women with TE, and a significant increase in the
ported. Limitations included the low number of female patients anagen to telogen ratio compared with baseline in men with AGA
and a lack of specific hair loss inclusion criteria. at 6 months.38 Adverse effects included bloating in the active
treatment group. Limitations included nonclinically relevant
Safety and Effectiveness of Multi-Ingredient Supplements outcomes and a small sample size.
The nutritional supplements in this section are composed of multiple
ingredients, each with unique mechanisms of action. Their ingredi-
ents and proposed mechanisms in combating alopecia were reviewed.
Discussion
Nutrafol This systematic review highlights the safety and effectiveness
Nutrafol (Nutraceutical Wellness Inc) contains the patented Syner- of several nutritional interventions for patients with hair
gen Complex, which is composed of plant-based active com- loss. Twelve of the 20 nutritional interventions had high-quality
pounds with anti-inflammatory, antioxidant, and DHT-inhibitory studies suggesting objectively evaluated effectiveness
properties.33 Nutrafol and its formulations were studied in women (Table 1). These findings should be interpreted in the con-
with self-perceived thinning hair33,34; the results showed signifi- text of each study’s methods and limitations—the quality of
cantly increased hair counts and decreased shedding; adverse ef- study design and the size of each study varied considerably.
fects, included nausea, bloating, and diarrhea, were reported among No studies of dietary interventions qualified for inclusion in
the intervention group. Limitations of these studies included sub- this review.
jective inclusion criteria of self-perceived hair thinning with no base- Currently, dietary supplements are categorized as food; how-
line nutritional status and funding by the product’s manufacturer. ever, the FDA does not govern their safety or effectiveness of
A case series study of 4 African American women with AGA, hair nutritional supplements before consumer marketing.72 Given the
thinning, and traction alopecia who used Nutrafol demonstrated ubiquitous use and substantial financial burden of nutritional
hair regrowth in 2 months to 2 years, with no adverse effects supplements, it is imperative that both physicians and patients be
reported.35 Lack of control, blinding, and inclusion of different types aware of the lack of FDA oversight and be vigilant when selecting a
of hair loss limited the generalizability of this study’s findings. supplement. Despite these limits, some patients with hair loss
may benefit from nutritional supplementation, and shared
Omni-Three decision-making with dermatologists should be encouraged to
Omni-Three (Omninutrition) is a patented nutritional supple- review risks and benefits of each treatment.
ment containing plant extracts that have demonstrated anti-
inflammatory and antioxidant properties in vitro and in vivo.64-66 Limitations
A prospective study of Omni-Three36 use in 27 adults with TE dem- Nonstandardized inclusion criteria, hair loss definitions, and
onstrated nonsignificant improvement for hair growth at 3 months; outcome assessments restricted comparisons between studies
no adverse effects were reported. Limitations included a small sample and limits generalizability to all patients with hair loss. Additionally,
size, lack of statistical significance, lack of a control group, and a short many studies were funded by their manufacturers, introducing
time course that mimicked the natural resolution of TE. potential biases.

Apple Nutraceutical
Topical procyanidin B2 has demonstrated efficacy in hair growth in
Conclusions
prior human trials.67 Procyanidins increase the anagen growth
phase, ultimately leading to increased hair density and terminal hair This systematic review of nutritional supplementation and dietary
formation.68,69 An apple variety of the Apple Fruits of Annurca interventions for hair loss found that few studies reported adverse
family has high procyanidin B2 content.70 A comparative study of events; however, adequately powered RCTs are warranted to fur-
use of 2 extract formulations from the Apple Fruits of Annurca37 va- ther assess the safety and effectiveness of these treatments.
riety in 250 adult participants with AGA showed significant in- Additionally, because finasteride and minoxidil are FDA-approved
creases in hair density, weight, and keratin content, from baseline first-line treatments for many types of alopecia, nutritional inter-
in both groups at 8 weeks; no adverse effects were reported. Limi- ventions should be evaluated as alternative or adjunct treatments
tations included a short duration and the lack of a control group. by future trials.

ARTICLE INFORMATION Published Online: November 30, 2022. Author Contributions: Ms Drake and
Accepted for Publication: September 18, 2022. doi:10.1001/jamadermatol.2022.4867 Dr Mostaghimi had full access to all the data in the

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 Nutritional Supplementation for Hair Loss Review Clinical Review & Education

study and take responsibility for the integrity of the 9. Prager N, Bickett K, French N, Marcovici G. 23. Harada N, Okajima K, Arai M, Kurihara H,
data and the accuracy of the data analysis. A randomized, double-blind, placebo-controlled Nakagata N. Administration of capsaicin and
Concept and design: Reyes-Hadsall, Heinrich, trial to determine the effectiveness of botanically isoflavone promotes hair growth by increasing
Huang, Mostaghimi. derived inhibitors of 5-alpha-reductase in the insulin-like growth factor-I production in mice and
Acquisition, analysis, or interpretation of data: treatment of androgenetic alopecia. J Altern in humans with alopecia. Growth Horm IGF Res.
All authors. Complement Med. 2002;8(2):143-152. 2007;17(5):408-415. doi:10.1016/j.ghir.2007.04.009
Drafting of the manuscript: Drake, Reyes-Hadsall, doi:10.1089/107555302317371433 24. Keophiphath M, Courbière C, Manzato L,
Martinez, Heinrich, Mostaghimi. 10. Rossi A, Mari E, Scarno M, et al. Comparative Lamour I, Gaillard E. Miliacin encapsulated by polar
Critical revision of the manuscript for important effectiveness of finasteride vs Serenoa repens in lipids stimulates cell proliferation in hair bulb and
intellectual content: Drake, Reyes-Hadsall, Huang, male androgenetic alopecia: a two-year study. Int J improves telogen effluvium in women. J Cosmet
Mostaghimi. Immunopathol Pharmacol. 2012;25(4):1167-1173. Dermatol. 2020;19(2):485-493. doi:10.1111/jocd.12998
Statistical analysis: Drake, Martinez. doi:10.1177/039463201202500435
Administrative, technical, or material support: 25. Lassus A, Eskelinen E. A comparative study of a
Drake, Reyes-Hadsall, Martinez, Heinrich, 11. Cho YH, Lee SY, Jeong DW, et al. Effect of new food supplement, ViviScal, with fish extract for
Mostaghimi. pumpkin seed oil on hair growth in men with the treatment of hereditary androgenic alopecia in
Supervision: Huang, Mostaghimi. androgenetic alopecia: a randomized, double-blind, young males. J Int Med Res. 1992;20(6):445-453.
Other: Martinez. placebo-controlled trial. Evid Based Complement doi:10.1177/030006059202000601
Alternat Med. 2014;549721. doi:10.1155/2014/549721 26. Ablon G. A 6-month, randomized,
Conflict of Interest Disclosures: Dr Huang
reported personal fees from Concert and Pfizer 12. Nichols AJ, Hughes OB, Canazza A, Zaiac MN. double-blind, placebo-controlled study evaluating
outside the submitted work; holding patents for An open-label evaluator blinded study of the the ability of a marine complex supplement to
ALTO, BETA, and BELA licensed; and participation efficacy and safety of a new nutritional supplement promote hair growth in men with thinning hair.
in alopecia-related clinical trials by Incyte, Lilly, in androgenetic alopecia: a pilot study. J Clin J Cosmet Dermatol. 2016;15(4):358-366. doi:10.1111/
Concert, and Aclaris, all outside the submitted Aesthet Dermatol. 2017;10(2):52-56. jocd.12265
work. Dr Mostaghimi reported consulting fees from 13. Sattar F, Almas U, Ibrahim NA, et al. Efficacy of 27. Glynis A. A double-blind, placebo-controlled
Pfizer, Concert, Lilly, Hims and Hers, Equillium, oral vitamin D3 therapy in patients suffering from study evaluating the efficacy of an oral supplement
AbbVie, Digital Diagnostics, and Bioniz, and grants diffuse hair loss (telogen effluvium). J Nutr Sci in women with self-perceived thinning hair. J Clin
from Pfizer, all outside the submitted work. Vitaminol (Tokyo). 2021;67(1):68-71. doi:10.3177/ Aesthet Dermatol. 2012;5(11):28-34.
No other disclosures were reported. jnsv.67.68 28. Ablon G, Dayan S. A randomized, double-blind,
Disclaimer: Dr Arash Mostaghimi is an Associate 14. Ead RD. Oral zinc sulphate in alopacia placebo-controlled, multi-center, extension trial
Editor of JAMA Dermatology but was not involved areata-a double blind trial. Br J Dermatol. 1981;104 evaluating the efficacy of a new oral supplement in
in any of the decisions regarding review of the (4):483-484. doi:10.1111/j.1365-2133.1981.tb15323.x women with self-perceived thinning hair. J Clin
manuscript or its acceptance. 15. Siavash M, Tavakoli F, Mokhtari F. Comparing Aesthet Dermatol. 2015;8(12):15-21.
the effects of zinc sulfate, calcium pantothenate, 29. Ablon G. A 3-month, randomized,
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