International Journal of Trichology

: 2019  |  Volume : 11  |  Issue : 3  |  Page : 140--141

Autistic-undisciplined - Practice what you preach!

D Hugh Rushton1, Dominique J J Van Neste2,  
1 School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
2 Brussels Hair Clinic, Brussels; Skinterface, Tournai, Belgium

Correspondence Address:
Dr. D Hugh Rushton
School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth

How to cite this article:
Rushton D H, Van Neste DJ. Autistic-undisciplined - Practice what you preach!.Int J Trichol 2019;11:140-141

How to cite this URL:
Rushton D H, Van Neste DJ. Autistic-undisciplined - Practice what you preach!. Int J Trichol [serial online] 2019 [cited 2022 Dec 8 ];11:140-141
Available from:

Full Text


We read the Commentary, “Autistic-undisciplined thinking in the practice of medical Trichology (Trueb et al. 2019, 11;1:1-7)” with some concern. While exhaustive documentation together with unbiased preconceived ideas remains open for discussion, the use of terms such as “autistic” and “abuse” is unnecessary and could be perceived as pejorative.

We do agree with the view that while the evidence is incomplete, one should adopt a principle of uncertainty and keep an open mind. There are many issues with this paper and one example illustrates our apprehensions.

 Abuse in Iron Supplementation

The authors conclude, “By approaching the hair loss patient in a methodical way…an individualized treatment plan can be designed. For this process…to make enumerations so complete, and reviews so general, so that nothing is omitted.” The authors concentrate on the narrowness of thinking based on a single study.[1] This retrospective, poorly designed investigation exhibited scientific bias, and how the peer review missed these confounders is difficult to justify. They studied 418 subjects complaining of hair loss, with 181 evaluated in the statistical analysis and employed a telogen value of >15% to define telogen effluvium (TE). However, Figure 3[1] presented a significant number of subjects with a telogen value <15%. By their own criteria, these individuals did not have TE and should have been excluded.

Turning to their conclusion, “nothing is omitted.” We would point the authors to the following papers. Deloche et al.[2] investigated 5110 women and concluded that low iron store represents a risk factor for hair loss in nonmenopausal women. Du et al.[3] demonstrated that up-regulation of hepcidin caused the “Mask Mouse” to be iron deficient, anemic, lose body hair, and females to be infertile. However, supplementation with additional iron resolved all symptoms, including complete hair regrowth in both female and male mice. Given that hepcidin is unique to all mammals in controlling iron uptake and of fundamental importance in iron and hair loss regulation. Why were these papers ignored?

Iron deficiency is widespread in females and a significant confounder. The gold standard to set reference ranges would be to compare bone marrow iron staining with serum ferritin concentrations. We doubt the author's validated their serum ferritin reference range against bone marrow iron staining. More likely they compared serum ferritin values with a serum ferritin reference range derived from a supposedly 'normal' population. This is only acceptable if the sampled populations contained no iron deficient individuals. Puolakka found serum ferritin concentrations of 52 μg/L associated with absence of bone marrow iron staining.[4] The lower serum ferritin reference range in healthy female controls, without hair loss confirmed with the unit area trichogram, was 40 μg/l. This parameter is also the lower concentration found in control men without hair loss (Rushton PhD Thesis, 1988). Furthermore, veterinary medicine employs the same lower reference ranges for hemoglobin (Hb) for male and female mammals.[5] There is no objective evidence to support a sexual dimorphism for Hb or ferritin in humans.

The authors might wish to reflect on the possibility that hair follicle hepcidin upregulation diverts iron from nonessential tissues to the vital tissues in some women.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Bregy A, Trueb RM. No association between serum ferritin levels & 10 microg/l and hair loss activity in women. Dermatology 2008;217:1-6.
2Deloche C, Bastien P, Chadoutaud S, Galan P, Bertrais S, Hercberg S, et al. Low iron stores: A risk factor for excessive hair loss in non-menopausal women. Eur J Dermatol 2007;17:507-12.
3Du X, She E, Gelbart T, Truksa J, Lee P, Xia Y, et al. The serine protease TMPRSS6 is required to sense iron deficiency. Science 2008;320:1088-92.
4Puolakka J. Serum ferritin in the evaluation of iron status in young healthy women. Acta Obstet Gynecol Scand Suppl 1980;95:35-41.
5Rushton DH, Dover R, Sainsbury AW, Norris MJ, Gilkes JJ, Ramsay ID, et al. Why should women have lower reference limits for haemoglobin and ferritin concentrations than men? BMJ 2001;322:1355-7.