**3. Results**

No significant differences of TE serum content in men and women were found between AA patients and control group. The exception was the concentration of copper (Cu) which was statistically significant differences between men and women suffering from AA and matched control (Table 1). In present work in women with hyperandrogenism there are the some trends in TE content in serum than in men. The key disorder was decreased Cu level in frontal zones of scalp hair and serum.


**Table 1.** Trace elements content (mkg/ml) in serum in men and women with AA

In spite of sex decreased Cu concentration in serum were obtained in patients with AA. However, Cu level in women was higher in comparison to men.

Median, 25-th and 75-th percentiles values in women with AA and accompanying other diseases are summarized in Table 2.



\*-P<0,005 (differences between control group and others)

compare the values of quantitative variables. Correlations among variables were studied using

No significant differences of TE serum content in men and women were found between AA patients and control group. The exception was the concentration of copper (Cu) which was statistically significant differences between men and women suffering from AA and matched control (Table 1). In present work in women with hyperandrogenism there are the some trends in TE content in serum than in men. The key disorder was decreased Cu level in frontal zones

> **Men Women AA group, n=40 Control, n=32 AA group, n=97 Control, n=76**

> > **Median**

**Persencile (25-75)**

**Median**

**Persencile (25-75)**

**Persencile (25-75)**

As 0,019 0,015-0,025 0,015 0,008-0,028 0,018 0,007-0,028 0,02 0,01-0,032 Ca 92,3 88,2- 98,5 96,1 91,0-101,0 95,8 90,6-102,4 95,3 89,6-103,3 Co 0,0005 0,0004-0,0006 0,0006 0,0004-0,0007 0,006 0,0005-0,0008 0,0006 0,0005-0,0008 Cu *0,80 0,70-0,85 0,88\* 0,75-1,06 0,85 0,77-0,94 0,99\* 0,90-1,11* Fe 1,3 1,0-1,5 1,4 1,3-1,5 1,3 1,0-1,6 1,2 0,78-1,46 K 183 169-196 187 178-199 170 158-193 178 157-204 Mg 20,7 19,9-21,2 20,7 19,3-22,4 20,3 19,1-21,5 20,8 19,4-22,4 Mn 0,0034 0,0030-0,0038 0,0037 0,0031-0,0048 0,0032 0,0027-0,0039 0,0032 0,0026-0,0043 Mo 0,0008 0,0007-0,0012 0,0009 0,0007-0,0012 0,0009 0,0007-0,0012 0,001 0,0008-0,0014 Ni 0,006 0,005-0,007 0,006 0,005-0,008 0,006 0,005-0,007 0,006 0,005-0,008 Se 0,14 0,13-0,16 0,16 0,13-0,17 0,14 0,13-0,17 0,14 0,13-0,16 Zn 0,89 0,83-1,04 0,91 0,82-1,10 0,81 0,72-0,95 0,83 0,69-1,06

In spite of sex decreased Cu concentration in serum were obtained in patients with AA.

Median, 25-th and 75-th percentiles values in women with AA and accompanying other

the Pearson's coefficient. P ≤ 0.05 was considered significant in all analyses.

340 Pharmacology and Nutritional Intervention in the Treatment of Disease

**3. Results**

**Element**

of scalp hair and serum.

**Persencile (25-75)**

\*-P<0, 01 (differences between control group and AA's group)

diseases are summarized in Table 2.

**Table 1.** Trace elements content (mkg/ml) in serum in men and women with AA

However, Cu level in women was higher in comparison to men.

**Median**

**Median**

\*\*-P<0, 05 (differences between groups with excess of androgens (HA1) and estrogens (HE 1 or 2)).

**Table 2.** TE content and ratio Cu/Mn and Cu/Zn (Median, 25-75th percentiles) in women with AA and associated with different diseases.

When we separated women with AA into subgroups there have obtained differences between control and investigated groups. No significant differences were found between AA patients and control in the majority of TE content in serum. Although the lowest Cu content was observed in group combining AA with other sing of excess of androgens such as hirsutism and acne.

**Figure 3.** Content of Cu, Zn and ceruloplasmin (CP) in men and women with AA

Cu concentration in groups with elevated androgens level and with appearance of several marks of androgens abundance was lower than in the whole women group with AA. There were statistically significant differences between Cu level in groups with plenty of androgens and estrogen. In case of being endometriosis or uterine leiomyoma (HE1 and 2) in women Cu concentration in serum have maintained the same than in control, although not decreased in patients with AA. The overflowed androgens in women were conducted the reduction Cu content in serum considerably. The zinc (Zn) level was the lowest in women who combined AA and abdominal obesity. There was variety Zn content in serum in women at ages. In women under 40 year of age either elevated androgens or excess of estrogen the Zn level was getting low as compared to women before 40 year. The ratio Cu/Mn in women HE1 and 2 groups has been elevated significantly in comparison with groups with excess of androgens.

of a numerous growing factors, cytokines, hormones, neurotransmitters, as well as transcrip‐

Copper Deficiency a New Reason of Androgenetic Alopecia?

http://dx.doi.org/10.5772/58416

343

Alopecia areata (AA) is the most common type of alopecia that the onset after puberty in both sexes. AA may affect up to 70 of men and 40% of women [8]. Male and female pattern hair loss are clinically distinct entities but pathogenically indistinguishable. The main role in the onset of AA in men is local disturbances in androgens metabolism which based on genetic predis‐ poses to converse of terminal hair in vellus-like hair. AA is a polygenetic hereditary disease. A low number of CAG repeats in the androgen receptor gene implies increased risk factor for AA; prostate hyperplasia, coronary heart disease. But the role of sex hormones in females is less understood. Same of women suffering from AA are revealed androgens excess with other signs of elevated androgens such as hirsutism, acne, polycystic ovary syndrome. In women

AA in men is due to implicate DNT production by 5 alpha-reductase type 2. The primary precursor of DHT in men is testosterone. The androgen receptor (AR) binding leads to increase production of cytokines such as TGFβ-1 and 2, which promote telogen, thinning and shorten‐ ing hair. There is a low number of AR in occipital hair follicles that hair loss is mostly restricted to the scalp vertex and frontal and temporal areas. The using of a type 2 – selective inhibitor demonstrated the improvements in scalp hair growth in men. On stopping finasteride treatment, the balding process resumed. However, finasteride has been associated with depressive symptoms, persistent sexual side effects (loss of libido and erectile function). In contract to its beneficial effects of finasteride (5 alpha–reductase's inhibitor) in men; it didn't

there is the appearance of AA combining with diffuse hair loss [9].

tion factors and enzymes.

**Figure 4.** Cu content and ratio Cu/Mn in women with AA

There was a tendency to raise the ratio Cu/Mn in women with elevated estrogen level as compared to control. The ratio Cu/Zn was significant lower in women any ages with abundant of androgens than in control. But, in case of abdominal obesity the values of this ratio were higher in comparison with control group.

#### **4. Discussion**

The hair follicle represents a unique, highly regenerative neuroectodermal – mesodermal interaction system. These transformations are controlled by changes in the expression/ activity

**Figure 4.** Cu content and ratio Cu/Mn in women with AA

observed in group combining AA with other sing of excess of androgens such as hirsutism

Cu concentration in groups with elevated androgens level and with appearance of several marks of androgens abundance was lower than in the whole women group with AA. There were statistically significant differences between Cu level in groups with plenty of androgens and estrogen. In case of being endometriosis or uterine leiomyoma (HE1 and 2) in women Cu concentration in serum have maintained the same than in control, although not decreased in patients with AA. The overflowed androgens in women were conducted the reduction Cu content in serum considerably. The zinc (Zn) level was the lowest in women who combined AA and abdominal obesity. There was variety Zn content in serum in women at ages. In women under 40 year of age either elevated androgens or excess of estrogen the Zn level was getting low as compared to women before 40 year. The ratio Cu/Mn in women HE1 and 2 groups has

been elevated significantly in comparison with groups with excess of androgens.

There was a tendency to raise the ratio Cu/Mn in women with elevated estrogen level as compared to control. The ratio Cu/Zn was significant lower in women any ages with abundant of androgens than in control. But, in case of abdominal obesity the values of this ratio were

The hair follicle represents a unique, highly regenerative neuroectodermal – mesodermal interaction system. These transformations are controlled by changes in the expression/ activity

**Figure 3.** Content of Cu, Zn and ceruloplasmin (CP) in men and women with AA

342 Pharmacology and Nutritional Intervention in the Treatment of Disease

higher in comparison with control group.

**4. Discussion**

and acne.

of a numerous growing factors, cytokines, hormones, neurotransmitters, as well as transcrip‐ tion factors and enzymes.

Alopecia areata (AA) is the most common type of alopecia that the onset after puberty in both sexes. AA may affect up to 70 of men and 40% of women [8]. Male and female pattern hair loss are clinically distinct entities but pathogenically indistinguishable. The main role in the onset of AA in men is local disturbances in androgens metabolism which based on genetic predis‐ poses to converse of terminal hair in vellus-like hair. AA is a polygenetic hereditary disease. A low number of CAG repeats in the androgen receptor gene implies increased risk factor for AA; prostate hyperplasia, coronary heart disease. But the role of sex hormones in females is less understood. Same of women suffering from AA are revealed androgens excess with other signs of elevated androgens such as hirsutism, acne, polycystic ovary syndrome. In women there is the appearance of AA combining with diffuse hair loss [9].

AA in men is due to implicate DNT production by 5 alpha-reductase type 2. The primary precursor of DHT in men is testosterone. The androgen receptor (AR) binding leads to increase production of cytokines such as TGFβ-1 and 2, which promote telogen, thinning and shorten‐ ing hair. There is a low number of AR in occipital hair follicles that hair loss is mostly restricted to the scalp vertex and frontal and temporal areas. The using of a type 2 – selective inhibitor demonstrated the improvements in scalp hair growth in men. On stopping finasteride treatment, the balding process resumed. However, finasteride has been associated with depressive symptoms, persistent sexual side effects (loss of libido and erectile function). In contract to its beneficial effects of finasteride (5 alpha–reductase's inhibitor) in men; it didn't improve hair growth in women with AA. These findings suggested that the molecular mechanisms involved in the different metabolic ways in regulations hair growth in women.

We demonstrated the development of AA in women with endometriosis or /and uterine leiomyoma. These diseases have usually revealed of estrogens excess, high activity of aroma‐ tase and decreased level of progesterone. There was a high level of ratio ERβ to ERα against the background of changed ratio progesterone receptor (PRα/PRβ). The onset and develop‐

Copper Deficiency a New Reason of Androgenetic Alopecia?

http://dx.doi.org/10.5772/58416

345

Normal or excess estrogens concentration and deficiency or resistant to progesterone were typical in these women. Cu content in serum and ratio Cu/Mn determined higher than in control. But, Mn level in these groups remains lower to compare with control. These data suggest that the important value in appearance of AA belongs to the relationship between E2 and PR and ratio of their receptors in peripheral tissues. About 15% from all examined women with AA have been detected the cut-off Mn level. Mn is known to impede the female and male reproductive function. In experimental studies the relationship Mn concentration and progesterone level have been shown. There is the high level of Mn-COD in lutein phase of menstrual cycle [14]. Manganese superoxide dismutase (Mn–COD), an antioxidant enzyme in the mitochondria, protects cells by scavenging superoxide radicals. Mn–COD increases by inducing progesterone. Experimental data suggests that Mn down-regulated steroidogenesis in Leydig cells [15]. Mn influences the receptor signaling pathways and contractile machinery of vascular smooth muscle cells [16]. The expression of Mn-COD was significantly increased by 17β–estrogen and testosterone in neutrophil granulocytes in healthy volunteers [17]. In our work we hypothesize that the assignment of low Mn content may reflect depressed value of

ment of AA in this group didn't link to abundant androgens level.

**Figure 5.** Proposed schema of TE dependent androgenetic alopecia

PR, changed ratio PR receptors or cell's resistance to PR.

Women with some markers of insulin resistant have increased risk of AA [9]. Several studies have analyzed the relationship between androgenetic alopecia and cardiovascular disease. Women with AGA showed higher significant mean values than non-alopecic women for all the parameters (triglyceridaemia, LDL-C, total cholesterol, total cholesterol/HDL-C and LDL-C/HDL-C) and lower significant HDL-C than controls.

Estrogens are indirect anti-androgens which increase SHMG production by binding to androgens and reducing their bioavailability. The production of estrogens from androgens via aromatase is of the importance in hair follicles. The comparison of scalp biopsies from men and women with AA revealed aromatase levels to be higher in hair follicles from occipital area in comparison to the frontal hair follicles. Furthermore, aromatase levels has found in six times higher in women when compared to men. Recent study has demonstrated that both dermal papilla and outer root sheath expressed aromatase activity. The levels of ER expression and aromatase activity may be modulated by steroid hormones in other tissues it would be important in the hair follicle. Likewise androgens have been reported to alter the ration of ERα to ERβ [2]. The alteration in the ratio of ERα to ERβ in dermal papilla cells could promote E2 signaling via ERβ in preference to ERα.

Since the hair follicles has been shown to express AR, glucocorticoid receptor, ERα, ERβ and progesterone receptors (PRα and PRβ). Both the dermal papilla cells and surrounding epithelial cells express ER. Additional local productions of E2 via conversion from A by aromatase may act in either an autocrine or paracrine manner to control lair growth and differentiation. In experimental studies PR inhibited the synthesis of DHT in dermal papilla by 75%. E2 was less able inhibit its production [6].

However, no direct effects of prolactin on hair growth have been reported [11]. Progesterone acts via PR receptors on cells to induce secretion of paracrine factor that in turn stimulate the expression 17β –hydroxysteroid dehydrogenase type 2 (HSD17β2). HSD17β2 metabolizes E2 to weak estrogenic estrone. The control of hair growth by E2 is much more complex than previously appreciated.

The E2 may modulate hair growth by interfering with androgen metabolism [12]. The estrogenic effects on dermal papilla cells are mediated via ERα.The role of ERβ may be to protect tissues from oxidative stress by inducing battery of antioxidative enzymes. Under hyperestrogenic conditions, the ratio PRβ to PRα is decreased but ratio ERβ to ERα is elevated in endometriosis and uterine leiomyoma. Serum Cu level is known to control by estrogens. Under excess of androgens Cu content in serum was decreased and associated with elevated DHT level which results of 5alpha-reductase type 2 activities. The pathogenic mechanism of AA is case of abundant of androgens doesn't differ in men and women with high androgens level. The development of AA shows up other clinical marks of androgens excess (hirsutism and acne) and reflect the interaction androgens and estrogen metabolism. Both AR and ERα are located into dermal papilla and influenced on hair growth [4]. In some studies have shown there was depressed ratio E2 to androgens [13].

We demonstrated the development of AA in women with endometriosis or /and uterine leiomyoma. These diseases have usually revealed of estrogens excess, high activity of aroma‐ tase and decreased level of progesterone. There was a high level of ratio ERβ to ERα against the background of changed ratio progesterone receptor (PRα/PRβ). The onset and develop‐ ment of AA in this group didn't link to abundant androgens level.

**Figure 5.** Proposed schema of TE dependent androgenetic alopecia

improve hair growth in women with AA. These findings suggested that the molecular mechanisms involved in the different metabolic ways in regulations hair growth in women.

Women with some markers of insulin resistant have increased risk of AA [9]. Several studies have analyzed the relationship between androgenetic alopecia and cardiovascular disease. Women with AGA showed higher significant mean values than non-alopecic women for all the parameters (triglyceridaemia, LDL-C, total cholesterol, total cholesterol/HDL-C and LDL-

Estrogens are indirect anti-androgens which increase SHMG production by binding to androgens and reducing their bioavailability. The production of estrogens from androgens via aromatase is of the importance in hair follicles. The comparison of scalp biopsies from men and women with AA revealed aromatase levels to be higher in hair follicles from occipital area in comparison to the frontal hair follicles. Furthermore, aromatase levels has found in six times higher in women when compared to men. Recent study has demonstrated that both dermal papilla and outer root sheath expressed aromatase activity. The levels of ER expression and aromatase activity may be modulated by steroid hormones in other tissues it would be important in the hair follicle. Likewise androgens have been reported to alter the ration of ERα to ERβ [2]. The alteration in the ratio of ERα to ERβ in dermal papilla cells could promote

Since the hair follicles has been shown to express AR, glucocorticoid receptor, ERα, ERβ and progesterone receptors (PRα and PRβ). Both the dermal papilla cells and surrounding epithelial cells express ER. Additional local productions of E2 via conversion from A by aromatase may act in either an autocrine or paracrine manner to control lair growth and differentiation. In experimental studies PR inhibited the synthesis of DHT in dermal papilla

However, no direct effects of prolactin on hair growth have been reported [11]. Progesterone acts via PR receptors on cells to induce secretion of paracrine factor that in turn stimulate the expression 17β –hydroxysteroid dehydrogenase type 2 (HSD17β2). HSD17β2 metabolizes E2 to weak estrogenic estrone. The control of hair growth by E2 is much more complex than

The E2 may modulate hair growth by interfering with androgen metabolism [12]. The estrogenic effects on dermal papilla cells are mediated via ERα.The role of ERβ may be to protect tissues from oxidative stress by inducing battery of antioxidative enzymes. Under hyperestrogenic conditions, the ratio PRβ to PRα is decreased but ratio ERβ to ERα is elevated in endometriosis and uterine leiomyoma. Serum Cu level is known to control by estrogens. Under excess of androgens Cu content in serum was decreased and associated with elevated DHT level which results of 5alpha-reductase type 2 activities. The pathogenic mechanism of AA is case of abundant of androgens doesn't differ in men and women with high androgens level. The development of AA shows up other clinical marks of androgens excess (hirsutism and acne) and reflect the interaction androgens and estrogen metabolism. Both AR and ERα are located into dermal papilla and influenced on hair growth [4]. In some studies have shown

C/HDL-C) and lower significant HDL-C than controls.

344 Pharmacology and Nutritional Intervention in the Treatment of Disease

E2 signaling via ERβ in preference to ERα.

by 75%. E2 was less able inhibit its production [6].

there was depressed ratio E2 to androgens [13].

previously appreciated.

Normal or excess estrogens concentration and deficiency or resistant to progesterone were typical in these women. Cu content in serum and ratio Cu/Mn determined higher than in control. But, Mn level in these groups remains lower to compare with control. These data suggest that the important value in appearance of AA belongs to the relationship between E2 and PR and ratio of their receptors in peripheral tissues. About 15% from all examined women with AA have been detected the cut-off Mn level. Mn is known to impede the female and male reproductive function. In experimental studies the relationship Mn concentration and progesterone level have been shown. There is the high level of Mn-COD in lutein phase of menstrual cycle [14]. Manganese superoxide dismutase (Mn–COD), an antioxidant enzyme in the mitochondria, protects cells by scavenging superoxide radicals. Mn–COD increases by inducing progesterone. Experimental data suggests that Mn down-regulated steroidogenesis in Leydig cells [15]. Mn influences the receptor signaling pathways and contractile machinery of vascular smooth muscle cells [16]. The expression of Mn-COD was significantly increased by 17β–estrogen and testosterone in neutrophil granulocytes in healthy volunteers [17]. In our work we hypothesize that the assignment of low Mn content may reflect depressed value of PR, changed ratio PR receptors or cell's resistance to PR.

In women serum ferritin levels may also be assessed to determine hair loss. Appreciating the importance of iron as a factor in hair loss may be important in the therapy in a variety of etiologically distinct forms of hair loss. According to obtained findings there was no statistical difference in iron content between control and experimental groups [18].

[2] Thornton M.J. et al. The modulation of aromatase and estrogen receptor alpha in cul‐ tured human dermal papilla cells by dexamethasone: a novel mechanism for selec‐ tive action of estrogen via estrogen receptor beta? //J. Investigative

Copper Deficiency a New Reason of Androgenetic Alopecia?

http://dx.doi.org/10.5772/58416

347

[3] Ohnemus U. et al. The Hair Follicle as an Estrogen Target and Source. // Endocrine

[4] Hoffmann R. Enzymology of the hair follicle. //European J. Dermatology.-2001.-Vol.

[5] Hoffmann R. et al. 17alpha-estradiol induces aromatase activity in intact human ana‐

[6] Niiyama S, Happle R, Hoffmann R. //Influence of estrogens on the androgen metabo‐ lism in different subunits of human hair follicles. //Eur. J. Dermatol. – 2001.-Vol.11.-

[7] Chevronnay G.H.P. et al. Regulation of matrix metalloproteinases activity studied in human endometrium as a paradigm of cyclic tissue breakdown and regeneration. //

[8] Kevin J. et al. Promising therapies for treating and /or preventing androgenic alope‐

[9] Arias-Santiago S. et al. A comparative study of dyslipidaemia in men and women with androgenic alopecia. //Acta Derm. Venereol.-2010.-Vol. 90.-P. 485-487.

[10] Niiyama R., Happle R. and Hoffmann R. Influence of estrogens on the androgen me‐ tabolism in different subunits of human hair follicles. //Eur. J. Dermatol.-2001.-Vol.

[11] Craven A.J. et al. Prolactin signaling influences the timing mechanism of the hair fol‐ licle: analysis of hair growth cycles in prolactin receptor knockout mice. //Endocri‐

[12] Ohnemus U. et al. Hair cycle control by estrogens: catagen induction via estrogen re‐ ceptor (ER)-α is checked by ER-β signaling. //Endocrinology.-2005.-Vol. 146.-N. 3.-P.

[13] Matthew D. et al. Extra-adrenal glucocorticoids and mineralocorticoids: evidence for local synthesis, regulation and function. //Am. J. Physiol. Endocrinol. Metab.-2011.-

[14] Sugino N. et al. Superoxide dismutase expression in the human corpus luteum dur‐ ing the menstrual cycle and in early pregnancy. //Mol. Hum. Reprod. – 2000. – Vol. 6.

gen hair follicles ex vivo. //Exp. Dermatol. – 2002.-Vol.11.-N.4.-P. 376-380.

Biochim. Biophys. Acta.-2012.-Vol. 1824.-N. 1.-P. 146-156.

cia. //Skin Therapy Lett.-2012.-Vol. 17.-N. 6.-P.1-4.

nology.-2001.-Vol. 142.-N. 6.-P. 2533-2539.

Dermatology.-2006.-Vol. 126.-P. 2010-2018.

Reviews.-2006.-Vol. 27.-N. 6.-P. 677-706.

11.-N. 4.-P. 296-300.

N.3.-P. 195-198.

11.-N.3.-P. 195-198.

1214-1225.

Vol. 301.-P. 11-24.

– N. 1. – P. 19-25.


**Table 3.** The difference of the onset and development of AA under excess of androgen or estrogen.

In this hypothetic scenario, there were two groups' women with AA. One of them has been registered excess of A in serum (Table 3). The other demonstrated normal level of A but had the alteration of estrogen and progesterone contents in blood. A lot of hormones, growth's factors take part in development of AA. Many diseases have followed by AA. Typically, the excess of A in blood in both men and women with AA have been revealed. Surprisingly, in women with hyperestrogenic condition the onset of AA have shown. The comparable with control level of A has been demonstrated in this group. Therefore, the ratio of ERα to ERß in follicular dermal papilla cells may be important. The alteration of estrogen, progesterone and androgen receptors has the key of metabolic disturbances in dermal papilla cells and outer root sheath. That is why the typical approaches for treatment of AA which include in using hormonal replacement therapy, inhibitors of DHT production and others were not fruitful.

### **Author details**

Margarita G. Skalnaya\*

Address all correspondence to: skalnaya@yandex.ru

Center for Biotic Medicine, Moscow, Russia
