Cited by 855Stress Responses and CortisolAdrenal Hormones and DisordersAnimal Behavior and Welfare Studies

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Stress-related and basic determinants of hair cortisol in humans: A meta-analysis

Stalder, Tobias, Steudte-Schmiedgen, Susann, Alexander, Nina, Klucken, Tim, Vater, Annika, Wichmann, Susann, Kirschbaum, Clemens, Miller, Robert·2017·Psychoneuroendocrinology

DOI 10.1016/j.psyneuen.2016.12.017

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Abstract

The analysis of hair cortisol concentrations (HCC) is a relatively new strategy to measure long-term cumulative cortisol levels, which is increasingly used in psychoneuroendocrinological research. Here, we conduct a first comprehensive meta-analysis of HCC research based on aggregated data from a total of 124 (sub)samples (66 independent studies; total N=10,289). We seek to answer two central questions: (i) Which covariates and basic features of HCC need to be considered in future research? (ii) What are the main determinants of HCC in terms of chronic stress exposure and mental health? Concerning basic characteristics, our findings identify several covariates to be considered (age, sex, hair washing frequency, hair treatment, oral contraceptive use), confirm a decline of HCC from the first to the second proximal 3cm hair segment, and show positive associations between HCC and short-term salivary cortisol measures. Regarding chronic stress, we show that stress-exposed groups on a whole exhibit 22% increased HCC. This long-term cortisol hypersecretion emerges particularly when stress is still ongoing at the time of study (+43% HCC) but is not present in conditions of past/absent stress (-9% HCC, n.s.). We also report evidence for 17%-reduced HCC in anxiety disorders, such as PTSD. Interestingly, no consistent associations with mood disorders and self-reports of perceived stress, depressiveness or social support are found. However, our findings reveal positive associations of HCC with stress-related anthropometric (body mass index, waist-to-hip ratio) and hemodynamic measures (systolic blood pressure). These meta-analytic results are discussed in the light of their practical implications and important areas for future inquiry are outlined.

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BackgroundResult
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BackgroundMethod
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BackgroundMethod
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BackgroundResultInfluential
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Background
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BackgroundSelf-citation
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Long-term cortisol secretion in attention deficit hyperactivity disorder: roles of sex, comorbidity, and symptom presentation
Pauli‐Pott, U., Skoluda, N., Nater, U. M., Becker, K., Derz, F., Kaspar, E., Kasperzack, D., Kehm, K., Kött, M., Mann, C., et al. (2023) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-023-02180-1 · Cited by 19
“In general population samples, sex differences in HCC are well established, with females showing lower HCC than males [11].”
BackgroundMethod
Stress, physical activity, and resilience resources: Tests of direct and moderation effects in young adults.
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Victims of War: Dehydroepiandrosterone Concentrations in Hair and Their Associations with Trauma Sequelae in Palestinian Adolescents Living in the West Bank
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“Furthermore, it was not possible for us to directly assess body mass index and pubertal status, confining our study to self-reported evidence regarding those two potential confounders of endocrine functioning [60].”
BackgroundSelf-citation
No association between FKBP5 gene methylation and acute and long-term cortisol output
Alexander, N., Kirschbaum, C., Stalder, T., Muehlhan, M., & Vogel, S. (2020) · Translational Psychiatry · doi:10.1038/s41398-020-0846-2 · Cited by 22
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Hair cortisol and other hair analytes decline with storage over a one-year period: A systematic, within-subject investigation
Huthsteiner, K., Finke, J. B., Peters, E. M. J., Klucken, T., & Tobias Stalder, A. (2025) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2025.107593 · Cited by 17
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Morning and evening salivary cortisol levels in patients with chronic widespread pain and those at high risk
Begum, N., Taylor, J. R., Brown, C. A., Rajan, J. N., Keevil, B. G., Pye, E., Rainey, T., & Jones, A. K. P. (2021) · European Journal of Pain · doi:10.1002/ejp.1854 · Cited by 17
“Furthermore, a meta- analysis reporting higher hair cortisol concentrations in chronic stress, identified a positive association between measures of salivary and hair cortisol (Stalder et al., 2017).”
Background
Examination of the acute heart rate and salivary cortisol response to a single bout of walking in urban and green environments: A pilot study
Veitch, J., Timperio, A. F., Salmon, J., Hall, S. J., Abbott, G., Flowers, E. P., & Turner, A. I. (2022) · Urban forestry & urban greening · doi:10.1016/j.ufug.2022.127660 · Cited by 19
Single sample preparation for the simultaneous extraction of drugs, pharmaceuticals, cannabinoids and endogenous steroids in hair
Scholz, C., Baumgartner, M. R., Kræmer, T., & Binz, T. M. (2022) · Analytical Methods · doi:10.1039/d2ay01325h · Cited by 17
A machine learning-integrated stepwise method to discover novel anti-obesity phytochemicals that antagonize the glucocorticoid receptor
Shin, S. H., Hur, G., Kim, N. R., Park, J. H. Y., Lee, K. W., & Yang, H. Y. (2023) · Food & Function · doi:10.1039/d2fo03466b · Cited by 17
Healthy Foundations Study: a randomised controlled trial to evaluate biological embedding of early-life experiences
González, A., Catherine, N. L. A., Boyle, M., Jack, S. M., Atkinson, L. R., Kobor, M. S., Sheehan, D., Tonmyr, L., Waddell, C., & MacMillan, H. L. (2018) · BMJ Open · doi:10.1136/bmjopen-2017-018915 · Cited by 17
“Biological samples: primary outcomes for the HFS Maternal hair cortisol Hair cortisol analysis is emerging as a biomarker for chronic stress because systemic cortisol is understood to be incorporated into the hair shaft during hair growth.(101) To measure maternal physiological stress during pregnancy and early in the…”
Cortisol levels in different tissue samples in posttraumatic stress disorder patients versus controls: a systematic review and meta-analysis protocol
van den Heuvel, L. L., Wright, S. L., Suliman, S., Tobias Stalder, A., Kirschbaum, C., & Seedat, S. (2019) · Systematic Reviews · doi:10.1186/s13643-018-0936-x · Cited by 16
“A recent meta-analysis of hair cortisol studies reported lower hair cortisol levels in patients with anxiety disorders (PTSD and generalised anxiety disorder [GAD]) [17], suggesting that adding newer tissue sampling methods could enhance the understanding of HPA axis function in PTSD.”
BackgroundSelf-citation
Scalp hair cortisol and testosterone levels in patients with sarcoidosis
van Manen, M. J. G., Wester, V. L., van Rossum, E. F. C., van den Toorn, L. M., Dorst, K. Y., de Rijke, Y. B., & Wijsenbeek, M. S. (2019) · PLoS ONE · doi:10.1371/journal.pone.0215763 · Cited by 18
Hair cortisol and dehydroepiandrosterone concentrations: Associations with executive function in early childhood
Hennessey, E. P., Kepinska, O., Haft, S. L., Chan, M., Sunshine, I., Jones, C. L., Hancock, R., & Hoeft, F. (2020) · Biological Psychology · doi:10.1016/j.biopsycho.2020.107946 · Cited by 23
Cortisol trajectory, melancholia, and response to electroconvulsive therapy
Mickey, B. J., Ginsburg, Y., Sitzmann, A. F., Grayhack, C., Sen, S., Kirschbaum, C., Maixner, D. F., & Abelson, J. L. (2018) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2018.05.007 · Cited by 18
“First, as highlighted in a recent meta-analysis, several variables can confound hair cortisol measurements -- notably, age, sex, body mass index, oral contraceptives, frequency of hair washing, and hair treatments (Stalder et al., 2017).”
BackgroundInfluentialSelf-citation
Can hair steroids predict pregnancy longevity?
Schonblum, A., Arnon, L., Ravid, E., Salzer, L., Hadar, E., Meizner, I., Wiznitzer, A., Weller, A., & Koren, L. (2018) · Reproductive Biology · doi:10.1016/j.repbio.2018.09.004 · Cited by 17
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Chen, H., Meng, Z., & Luo, J. (2025) · Frontiers in Public Health · doi:10.3389/fpubh.2025.1454992 · Cited by 16
Adverse and traumatic exposures, posttraumatic stress disorder, telomere length, and hair cortisol – Exploring associations in a high-risk sample of young adult residential care leavers
Bürgin, D., Clemens, V., Varghese, N., Eckert, A., Huber, M., Bruttin, E., Boonmann, C., Unternährer, E., O'Donovan, A., & Schmid, M. (2022) · Brain, Behavior, & Immunity - Health · doi:10.1016/j.bbih.2022.100524 · Cited by 14
The association between maternal symptoms of depression and hair glucocorticoids in infants across the perinatal period
Karl, M., Huth, V., Schälicke, S., Müller-Stark, C., Weise, V., Mack, J. T., Kirschbaum, C., Weidner, K., Garthus‐Niegel, S., & Steudte‐Schmiedgen, S. (2022) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2022.105952 · Cited by 17
Self-citation
Cumulative trauma predicts hair cortisol concentrations and symptoms of depression and anxiety in pregnant women—an investigation of community samples from Greece, Spain and Perú
Dobernecker, J., Spyridou, A., Elbert, T. R., Schauer, M., Garthus‐Niegel, S., Ruf‐Leuschner, M., & Schalinski, I. (2023) · Scientific Reports · doi:10.1038/s41598-023-28151-9 · Cited by 17
Stress exposure, hand preference, and hand skill: A deep phenotyping approach
Mundorf, A., Getzmann, S., Gajewski, P. D., Larra, M. F., Wascher, E., & Ocklenburg, S. (2023) · Laterality Asymmetries of Body Brain and Cognition · doi:10.1080/1357650x.2023.2204551 · Cited by 16
“…stress, a meta-analysis spanning 10,289 individuals revealed that several factors such as age, gender, frequency of hair washing, and body mass index influenced hair cortisol concentration but no association was found between hair cortisol and self-reported perceived stress (Stalder et al., 2017).”
Background
Psychoemotional stress as a risk factor for the development of noncommunicable diseases
Ильинична, Г. Л., Balanova, Y. А., Евстифеева, С. Е., Имаева, А. Э., Владимировна, К. А., Kotova, M. B., Maksimov, S. A., Аркадьевна, М. Г., & Shalnova, S. A. (2023) · Russian Journal of Preventive Medicine · doi:10.17116/profmed202326081114 · Cited by 16
Stress Markers, Executive Functioning, and Resilience Among Early Adolescents With Complex Congenital Heart Disease
von Werdt, L., Binz, T. M., Tuura, R., Schmid, A., Naef, N., Rousson, V., Kretschmar, O., Liamlahi, R., Latal, B., & Ehrler, M. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2023.55373 · Cited by 16
Weight stigma as a stressor: A preliminary multi-wave, longitudinal study testing the biobehavioral pathways of the Cyclic Obesity/Weight-Based Stigma (COBWEBS) model.
Lee, K. M., Wang, C., Du, H., Hunger, J., & Tomiyama, A. (2024) · Appetite · doi:10.1016/j.appet.2024.107573 · Cited by 17
“Our null findings for cortisol reflect the mixed literature on hair cortisol at large (Stalder et al., 2017).”
Prenatal and childhood predictors of hair cortisol concentration in mid-childhood and early adolescence
Petimar, J., Rifas‐Shiman, S. L., Hivert, M., Fleisch, A. F., Tiemeier, H. W., & Oken, E. (2020) · PLoS ONE · doi:10.1371/journal.pone.0228769 · Cited by 16
“Hair cortisol concentration (HCC) is a relatively new measure of systemic cortisol concentration and hypothalamic-pituitary-adrenal (HPA) axis activity [1, 2].”
Background
The potential predictive value of salivary cortisol on the occurrence of secondary cognitive impairment after ischemic stroke
Wang, J., Guan, Q., Sheng, Y., Yang, Y., Guo, L., Li, W., Gu, Y., & Han, C. (2020) · Neurosurgical Review · doi:10.1007/s10143-020-01256-9 · Cited by 15
Predicting Hair Cortisol and Cortisone Concentration in Postpartum Women through Repeated Measurements of Perceived Stress
Lang, J., Stickel, S., Gaum, P. M., Habel, U., Bertram, J., Eickhoff, S. B., & Chechko, N. (2021) · Metabolites · doi:10.3390/metabo11120815 · Cited by 16
“Given that the meta-analytic findings indicated different associations of HCC with different strain-exposed subgroups [4], our comparisons involved, in addition to healthy women (ND), women who developed postpartum depression (PPD), which affects up to 11% of mothers [9], and those with postpartum adjustment disorder…”
BackgroundResultInfluential
Determination of thyroid hormones in human hair with online SPE LC–MS/MS: Analytical protocol and application in study of burnout
Gao, W., Penz, M. S., Wekenborg, M., Walther, A., & Kirschbaum, C. (2019) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2019.03.032 · Cited by 16
Self-citation
Effects of psychosocial work characteristics on hair cortisol – findings from a post-trial study
Herr, R. M., Barrech, A., Gündel, H., Lang, J., Quinete, N. S., Angerer, P., & Li, J. (2017) · Stress · doi:10.1080/10253890.2017.1340452 · Cited by 15
“One reason might be that significant HCC elevation requires chronic stress exposure above a certain intensity level to exhaust regulatory capacities of the endocrine system (Stalder et al., 2017).”
BackgroundResultInfluential
Higher hair cortisol levels associated with previous cardiovascular events and cardiovascular risks in a large cross-sectional population study
Faresjö, Å., Theodorsson, E., Stomby, A., Quist, H., Jones, M. P., Östgren, C. J., Dahlqvist, P. M., & Faresjö, T. (2024) · BMC Cardiovascular Disorders · doi:10.1186/s12872-024-04221-2 · Cited by 15
“Although HCC tends to increase with aging [14], there were no significant age differences in HCC for this middle-aged cohort.”
Background
Effects of person-environment fit of gender-role orientation on burnout, engagement and hair steroids as stress biomarkers among women
Wacker, E., Fischer, A., & Schorlemmer, J. (2021) · Journal of Occupational Medicine and Toxicology · doi:10.1186/s12995-021-00303-5 · Cited by 17
Effects of social tolerance on stress: hair cortisol concentrations in the tolerant Tonkean macaques (Macaca tonkeana) and the despotic long-tailed macaques (Macaca fascicularis)
Sadoughi, B., Lacroix, L., Berbesque, J. C., Meunier, H., & Lehmann, J. (2021) · Stress · doi:10.1080/10253890.2021.1998443 · Cited by 19
“We also included the interaction of z.age and sex to explore sex-specific changes of cortisol with age (Stalder et al., 2017).”
BackgroundMethod
Profiling steroid and thyroid hormones with hair analysis in a cohort of women aged 25 to 45 years old
Peng, F., Palazzi, P., Mezzache, S., Bourokba, N., Sœur, J., & Appenzeller, B. M. R. (2022) · European Journal of Endocrinology · doi:10.1530/eje-22-0081 · Cited by 15
Maternal stress and hair cortisol among pregnant women following hurricane Florence
Howells, M. E., Wander, K., Rivera, L., Arfouni, C., Benhelal, O., Galeano, M. A. O., Schultz, L., Flock, N., & Dancause, K. N. (2022) · American Journal of Human Biology · doi:10.1002/ajhb.23847 · Cited by 15
“…collected and fairly easily—it is important to note that retention of cortisol within hair may be affected by behavioral factors like hair washing (Rippe et al., 2016; Stalder et al., 2017) and environmental factors like sun exposure (Wester et al., 2016) which are unaccounted for in our analyses.”
Background
Determinants of hair cortisol in preschool children and their mothers: A Brazilian birth cohort study
Martins, R. C., Tovo‐Rodrigues, L., Oliveira, I. O., Blumenberg, C., Bertoldi, A. D., da Silveira, M. F., Domingues, M. R., Silveira, M. P. T., González, A., & Murray, J. (2023) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2023.106027 · Cited by 15
“The overwhelming majority of studies using hair cortisol as a marker of chronic stress have been conducted in high-income countries, while 84% of the global population live in low- and middle-income countries, including many of the world’s communities most vulnerable to stress, and characterized by highly unequal livi…”
Influential
Stress specifically deteriorates working memory in peripheral neuropathic pain and fibromyalgia
Jacobsen, H. B., Brun, A., Stubhaug, A., & Rème, S. E. (2023) · Brain Communications · doi:10.1093/braincomms/fcad194 · Cited by 15
“Cortisol in hair could thus provide a more reliable approach, as it is a retrospective long-term biomarker of chronic stress.(22) Four previous studies have assessed hair cortisol concentrations (HCC) in chronic pain.”
Background
Evaluating Mixtures of Urinary Phthalate Metabolites and Serum Per-/Polyfluoroalkyl Substances in Relation to Adolescent Hair Cortisol: The HOME Study
Sears, C. G., Liu, Y., Lanphear, B. P., Buckley, J. P., Meyer, J. S., Xu, Y. Y., Chen, A., Yolton, K. A., & Braun, J. M. (2023) · American Journal of Epidemiology · doi:10.1093/aje/kwad198 · Cited by 14
Sex-specific association of hair cortisol concentration with stress-related psychological factors in healthy young adults
Kim, W. J., Park, K., Park, J. T., Seo, E., An, S. K., Park, H. Y., & Lee, E. M. (2021) · Biology of Sex Differences · doi:10.1186/s13293-021-00399-8 · Cited by 15
Higher hair cortisol concentrations associated with shorter leukocyte telomere length in high-risk young adults
Bürgin, D., Varghese, N., Eckert, A., Clemens, V., Unternäehrer, E., Boonmann, C., O’Donovan, A., & Schmid, M. (2022) · Scientific Reports · doi:10.1038/s41598-022-14905-4 · Cited by 13
Hair glucocorticoids during pregnancy in the context of trauma exposure and their predictive value for the development of childbirth-related posttraumatic stress disorder symptoms
Steudte‐Schmiedgen, S., Schälicke, S., Bergunde, L., Karl, M., Weise, V., Junge‐Hoffmeister, J., Schumacher, S., von Soest, T., Weidner, K., Kirschbaum, C., et al. (2022) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2022.105973 · Cited by 15
Self-citation
Serotonin transporter gene methylation predicts long-term cortisol concentrations in hair
Alexander, N., Illius, S., Tobias Stalder, A., Wankerl, M., Muehlhan, M., & Kirschbaum, C. (2019) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2019.03.033 · Cited by 15
Self-citation
Using Hair Cortisol to Examine the Role of Stress in Children's Health Inequalities at 3 Years
Bryson, H., Mensah, F. K., Goldfeld, S. R., & Price, A. M. H. (2019) · Academic Pediatrics · doi:10.1016/j.acap.2019.05.008 · Cited by 15
Childhood hair cortisol concentration and early teen cardiometabolic outcomes
Petimar, J., Rifas‐Shiman, S. L., Hivert, M., Fleisch, A. F., Tiemeier, H. W., & Oken, E. (2019) · Pediatric Obesity · doi:10.1111/ijpo.12592 · Cited by 15
“However, the intra‐assay %CV was less than 10% in other studies using this method.(25) Last, we lacked information on hair colour, texture, and frequency of washing, and so could not standardize HCC to these variables.”
Correlates of Mental Health in Adolescents and Young Adults with Cerebral Palsy: A Cross-Sectional Analysis of the MyStory Project
Gorter, J. W., Fehlings, D., Ferro, M. A., Gonzalez, A., Green, A. D., Hopmans, S. N., McCauley, D., Palisano, R. J., Rosenbaum, P., Speller, B., et al. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11113060 · Cited by 14

Authors: Stalder, T., Steudte-Schmiedgen, S., Alexander, N., Klucken, T., Vater, A., Wichmann, S., Kirschbaum, C., & Miller, R.
Affiliations: Universität Hamburg (DE)
University of Siegen (DE)
Technische Universität Dresden (DE)
MSB Medical School Berlin (DE)
ORCID: Alexander, Nina
Klucken, Tim
Kirschbaum, Clemens
Miller, Robert
Venue: Psychoneuroendocrinology
Publisher: Elsevier BV
Published: 2017-03
Volume: 77
Pages: 261-274
ISSN: 0306-4530 (ISSN-L)
DOI: 10.1016/j.psyneuen.2016.12.017
OpenAlex: W2512922965
Semantic Scholar: 78b482bd463a2e29e2aae66b9cf8e24a66b06fe6
Cited by: 855
References: 154
Citations by year: 2026: 83 · 2025: 100 · 2024: 123 · 2023: 101 · 2022: 88 · 2021: 111 · 2020: 95 · 2019: 74 · 2018: 56 · 2017: 23
FWCI: 5.97
Type: journal article
Language: en
Open access: closed
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
Locations: Psychoneuroendocrinology (publishedVersion)
PubMed (publishedVersion)
Funders: German Research Foundation (1213/5-1, 940/2)
Topics: Life Sciences › Neuroscience › Behavioral Neuroscience › Stress Responses and Cortisol
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
Life Sciences › Agricultural and Biological Sciences › Animal Science and Zoology › Animal Behavior and Welfare Studies
Keywords: hair cortisol, chronic stress, cortisol hypersecretion, salivary cortisol, anxiety disorders, post-traumatic stress disorder, mood disorders, perceived stress, body mass index, waist-to-hip ratio, systolic blood pressure, hair treatment, oral contraceptive use
MeSH terms: Hair, Hemodynamics, Humans, Hydrocortisone, Stress, Psychological

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Stress-related and basic determinants of hair cortisol in humans: A meta-analysis

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