Drug-Induced Hair Loss: A Comprehensive Overview

Hair loss, medically termed alopecia, is a common condition with diverse causes ranging from genetics and aging to hormonal imbalances and underlying health issues. Doctors refer to hair loss that occurs as a side effect of medication as drug-induced alopecia. While often temporary, it can significantly impact self-esteem and quality of life. This article delves into the intricate relationship between medications and hair loss, exploring the mechanisms involved, specific drugs implicated, and management strategies.

Understanding the Hair Growth Cycle

Each hair on the human head undergoes an individual life cycle, consisting of three main phases:

• Anagen (Growth Phase): This phase lasts for two to seven years, during which the hair actively grows.
• Catagen (Transition Phase): A short transitional phase lasting a few weeks.
• Telogen (Resting Phase): This phase lasts about three months, during which the hair rests before detaching from the follicle. At the end of the telogen phase, the hair falls out and is replaced by new hair.

Medications can disrupt this natural cycle, leading to hair loss. The effects of drug-induced alopecia often appear within 3 months of an individual starting on a particular medication.

Mechanisms of Drug-Induced Hair Loss

Drugs may affect anagen follicles through 2 main different modalities: (i) by inducing an abrupt cessation of mitotic activity in rapidly dividing hair matrix cells (anagen effluvium) or (ii) by precipitating the follicles into premature rest (telogen effluvium). Medications can trigger hair loss through two primary mechanisms: telogen effluvium and anagen effluvium.

• Telogen Effluvium: This is the most common form of drug-induced hair loss. Telogen effluvium is the most common type of drug-induced hair loss. It usually appears within 2 to 4 months after starting the drug. In telogen effluvium, hair loss becomes evident 2 to 4 months after starting treatment. This condition causes the hair follicles to go into their resting phase (telogen) and fall out too early. People with telogen effluvium usually shed between 30% to 70% more than the normal 100 and 150 hairs a day.
• Anagen Effluvium: This type of hair loss occurs during the anagen phase of the hair cycle, when the hairs are actively growing. In anagen effluvium, hair loss usually occurs within days to weeks of drug administration. It prevents the matrix cells, which produce new hairs, from dividing normally. Anagen effluvium is a prominent adverse effect of antineoplastic agents, which cause acute damage of rapidly dividing hair matrix cells. This type of hair loss usually occurs within a few days to weeks after taking the medication. It's most common in people who are taking chemotherapy drugs for cancer and is often severe, causing people to lose most or all of the hair on their head, as well as their eyebrows, eyelashes, and other body hairs.

Common Medications Associated with Hair Loss

A large number of drugs may interfere with the hair cycle and produce hair loss. Many different types of drugs are thought to cause hair loss. The prevalence and severity of alopecia depend on the drug as well as on individual predisposition. Some drugs produce hair loss in most patients receiving appropriate dosages while other drugs are only occasionally responsible for hair abnormalities.

Read also: Understanding Female Hair Loss: Blood Tests

Here's a breakdown of medication categories and specific drugs linked to hair loss:

Chemotherapy Drugs

Chemotherapy drugs often lead to the anagen effluvium type of hair loss. As these drugs kill cancer cells throughout the body, they also can damage healthy cells, including hair matrix cells. Hair loss can begin within 2 to 4 weeks of starting chemotherapy. The hair typically starts to fall out within two weeks of starting chemotherapy and progresses more rapidly after one to two months, according to the American Cancer Society. Hair loss is more common and severe in patients taking combinations of chemotherapy drugs than in those who take just one drug.

Common chemotherapy drugs associated with hair loss include:

• Dactinomycin
• Cyclophosphamide
• Daunorubicin
• Doxorubicin
• Etoposide
• Docetaxel
• Eribulin
• Ifosfamide
• Idarubicin
• Paclitaxel
• Topotecan
• Irinotecan
• Adriamycin
• Fluorouracil
• Methotrexate
• Nitrosoureas
• Spaclitaxel
• Tamoxifen
• Vinorelbine

Psychiatric Medications

Several psychotropic medications have been associated with hair loss, with valproate derivatives being particularly well-documented culprits.

• Antidepressants: Selective serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft), and tricyclic antidepressants have been linked to hair loss. Certain antidepressants, such as bupropion and imipramine, have also been linked to hair loss.
• Anticonvulsants: According to the authors, the three anticonvulsants most commonly associated with hair loss were: valproic acid (Valproate), lamotrigine (Lamictal), carbamazepine (Tegretol). Valproate is notorious for medication-induced hair loss, with alopecia listed among its most common adverse reactions (occurring in >5% of patients). The proposed mechanism for valproate-induced hair loss includes chelation of zinc and selenium, as well as reduced serum biotinidase activity, which decreases the availability of essential micronutrients required for hair growth. Lamotrigine, used to treat epilepsy and bipolar disorder, has also shown evidence of association with alopecia.
  • If you should take lamotrigine at night if it makes you sleepy and if you are prescribed it once a day. But if it doesn’t make you sleepy or if it tends to keep you awake, then take it first thing in the morning. If you are prescribed lamotrigine twice a day, then space out the dosages as much as you can, which means taking one dose first thing in the morning and one dose at night.
  • Contact your healthcare provider or other emergency medical services right away if you develop a skin rash, blistering or peeling of your skin, hives, painful sores in your mouth or around your eyes or other signs of a drug allergy (such as a fever or swelling of your lymph nodes) while taking lamotrigine. This could signal you are having a serious side effect to lamotrigine which may result in hospitalization or cause death.
• Other Psychiatric Medications: Other psychiatric medications, including antipsychotics.

Cardiovascular Medications

Both traditional anticoagulants and newer direct oral anticoagulants (DOACs) have been implicated in hair loss.

Read also: Oral Minoxidil Treatment

• Antihypertensives: High blood pressure medications (anti-hypertensives), such as beta-blockers, ACE inhibitors, and diuretics. Beta blockers can cause telogen effluvium, though this side effect does not happen often. Medications in this class associated with hair loss include propranolol (Inderal), atenolol (Tenormin), and metoprolol. All ACE inhibitors have also been connected to hair loss as a potential side effect. Angiotensin converting enzyme (ACE) inhibitors.
  • Research has suggested that taking your blood pressure medication at night instead of in the morning can provide better blood pressure control at night without compromising daytime blood pressure control and reduce your overall risk of dying because of cardiovascular disease by 45%.
• Anticoagulants: Blood thinners, including heparin and warfarin (Coumadin). Heparin and warfarin are known to cause alopecia, likely through a telogen effluvium mechanism. The World Health Organization's pharmacovigilance database (VigiBase) has received 405 reports of DOAC-associated alopecia: 143 for rivaroxaban, 215 for dabigatran, 47 for apixaban.
  • She had been prescribed warfarin, an anticoagulation drug (a type of blood thinner), to deal with her clotting issue.

Hormonal Therapies

Hormonal therapies can significantly impact hair growth patterns.

• Birth Control Pills: Many women experience telogen effluvium when starting or discontinuing hormonal contraceptives, as the shift in hormone levels can trigger a synchronized shedding event.
• Hormone Replacement Therapy (HRT)
• Thyroid Medications: Thyroid medications are all known to potentially cause hair loss.

Other Medications

• Acne Medications: Acne medications containing vitamin A (retinoids) have been implicated in hair loss. Excess doses of vitamin A and medications derived from it may cause telogen effluvium. For instance, some acne medications derived from vitamin A, such as isotretinoin (Accutane), may cause hair loss. These medications affect cell growth and differentiation throughout the body, including in hair follicles, potentially leading to premature entry into the telogen phase. Interestingly, however, a combination of topical tretinoin and minoxidil may cause hair growth, but more research is needed.
  • The recommended dietary allowance (RDA) of vitamin A per day is 900 micrograms (mcg) for adult males and 700 mcg for adult females.
• Immune Modulators: Several immunomodulating agents have strong evidence linking them to hair loss. Monoclonal antibodies targeting cytokines, such as tumor necrosis factor-alpha (infliximab) and interleukin 4 (dupilumab). Adalimumab and infliximab, both TNF-alpha inhibitors used to treat autoimmune conditions, have been associated with alopecia in studies with strong levels of evidence.
• Arthritis Medications: For instance, methotrexate may cause hair loss in up to 3% of people with RA. Another DMARD, leflunomide (Arava), may cause hair loss in up to 1 in 10 people.
• Weight Loss Drugs: Weight loss medications, such as Wegovy (semaglutide), can contribute to hair loss through multiple mechanisms. The primary approach to managing medication-induced hair loss is identifying and, when possible, discontinuing the causative agent. This is because dieters who experience hair loss may also have nutrient deficiencies. This could affect hair growth and structure, leading to telogen effluvium.
• Parkinson’s Disease Drugs: Levodopa (Atamet) and other medications for Parkinson’s disease.
• Steroids: Steroids. Anabolic steroids: Synthetic hormones found in steroids can cause a type of hair loss called androgenetic alopecia, a common form of male or female pattern baldness.
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Naproxen (Naprosyn) and other nonsteroidal anti-inflammatory drugs (NSAIDs).
• Antifungal Medications: Antifungal medications, such as fluconazole.
• Colchicine (Colcrys): Colchicine (Colcrys), which doctors use to treat gout, can also sometimes cause the loss of hair in the growing stage.

Diagnosis of Drug-Induced Alopecia

People who think that they may be experiencing drug-induced alopecia need to consult a healthcare professional. Determining whether a medication is behind hair loss requires “medical detective work”.

When diagnosing drug-induced alopecia, a doctor will take a complete medical history that takes into account the following factors:

• Any new medications that the person is taking, including over-the-counter drugs and supplements
• Any change in medication dosages
• The person’s general health and nutrition status
• Whether the person has had any recent illnesses or surgeries
• Whether there is a family history of hair loss

A doctor may also perform the following tests to assist with the diagnosis:

• Hair pull test and examination: This involves pulling on a small section of the hair to see how many strands come away from the scalp.
• Scalp analysis: The doctor will examine the scalp for signs of flaking, skin discoloration, and hair loss.
• Scalp biopsy: This involves taking skin samples from areas of the scalp where hair loss has occurred and analyzing them. The results can alert the doctor to other possible causes of alopecia.
• Blood tests: These tests can reveal any nutritional or hormonal imbalances that may be causing hair loss.

Management and Treatment

Drug-induced hair loss is usually reversible after interruption of treatment. Most of the time, drug-induced alopecia is reversible. In most cases, hair growth returns to its previous state once you’ve stopped taking a medication that causes hair loss. The best way to treat hair loss from medications is to address the medication causing the problem.

Read also: Anatomy of Eyebrow Muscles

The primary approach to managing medication-induced hair loss is identifying and, when possible, discontinuing the causative agent. However, people should not stop taking a medication without their doctor’s agreement. However, don’t stop taking a drug until speaking with a healthcare professional, as doing so may lead to complications. If you notice hair thinning or hair loss after starting a new medication or modified dosage, speak with a doctor.

The doctor will discuss any alternative treatment options and ensure that a person switches to any new medications safely. They could help modify your current treatment plan, such as by modifying the dosage or suggesting an alternative drug. Adjusting the dosage may also ease symptoms of hair loss.

For most patients, hair regrowth occurs within several months after stopping the medication. The time it takes for the hair to regrow will differ for each person. For example, it can take 2 to 6 months for the hair to begin to grow back after stopping chemotherapy.

Other hair loss treatments are also available, including:

• Topical treatments: A widely used over-the-counter topical medication, minoxidil (Rogaine), can stimulate hair growth and increase its density when applied directly to the scalp.
• Oral treatments: Typically used for male-pattern baldness, finasteride can be prescribed to reduce follicle miniaturization in specific types of hair loss. Learn more about how finasteride treats alopecia.
• Injections: Hair growth can be promoted through injectable forms of minoxidil or platelet-rich plasma (PRP), which uses concentrated platelets from a patient’s blood to enhance hair follicle function and stimulate growth.
• Nutritional support: A diet rich in essential vitamins and minerals is crucial for healthy hair. Supplements such as biotin, zinc and iron can help if there is a deficiency.
• Natural remedies: Such as essential oils, acupuncture, and scalp massage.
• Dietary changes: Such as eating enough protein.
• Hair transplant surgery
• Laser therapy

For ongoing treatments like chemotherapy where hair loss is expected, various scalp cooling techniques may help reduce the severity of hair loss. “Cold capping is the most effective way to prevent chemotherapy-associated hair loss". It involves wearing a cold cap for a set period before and after an infusion, which constricts blood vessels in the scalp. Cooling the scalp reduces blood flow to the hair follicles, making it harder for the chemotherapy drugs to get into the follicular cells. Cooling also reduces biochemical activity, making the hair follicles less susceptible to damage from chemotherapy drugs. One concern with this technique is the risk of cancer recurrence in the scalp, as perhaps this area did not receive the full dose of medication due to cooling vasoconstriction. Know that cold capping is often expensive and usually not covered by insurance. “Many patients choose not to do cold capping because of the time, [expense], [the] discomfort of wearing them and the uncertainty of results". Additionally, topical minoxidil may be prescribed to stimulate hair growth during and after treatment.

After chemotherapy treatment, the hair usually grows back in very quickly, but it may change in texture. In rare cases, the hair will stay thin even after treatment has been stopped. Minoxidil can help regrow hair that is slow to return. There has been success in hair regrowth using low-level laser-based devices. The devices come as hats, helmets, caps, combs, and headbands. The laser technology stimulates the scalp and hair follicles, promoting hair growth and blood flow.

Another product some dermatologists recommend, Nutrafol, is an all-natural supplement that provides nutrients needed for hair growth.

Many people who undergo chemotherapy choose to proudly display their new look. Some chemotherapy patients wear a wig or hat to hide their hair loss until their hair grows back. Remember, if you’re going through a tough health situation, you have every right to be proud of how you’re fighting it. It’s entirely up to you to decide the look you’re most comfortable with.

Illicit Substances and Hair Loss

Both prescription and illicit substances have been linked to hair loss. Drugs can disrupt the natural hair growth cycle, leading to conditions like telogen effluvium, a type of temporary hair loss often triggered by stress or trauma.

Some drugs that can contribute to hair loss include:

• Amphetamines: These stimulants can constrict blood vessels, reducing blood flow to the hair follicles and potentially causing hair loss.
• Cocaine: Similar to amphetamines, cocaine use can restrict blood flow to the scalp, leading to hair thinning and loss.
• Opioids: Chronic opioid use can disrupt hormone levels and interfere with hair growth cycles.

If you’re experiencing drug-induced hair loss, seeking treatment for addiction is the first step towards getting your health back and reversing the hair loss.

The Impact of Addiction and Mental Health

Addiction itself is a chronic disease that has its origins in environmental stressors. Science is slowly recognizing that the mind and the body are intrinsically connected. Stress is physical and thus affects the entire functioning of the body, from heart health to hair growth. Stress releases hormones like cortisol, which can disrupt the hair growth cycle and lead to temporary hair loss.

Hair loss due to addiction is generally a result of lifestyle factors that commonly accompany addiction, such as poor nutrition, lack of sleep, and inadequate hygiene. Mental health conditions like depression and anxiety are often associated and diagnosed alongside addiction. These conditions can independently contribute to hair loss. Similar to the stress caused by addiction, these mental health disorders can disrupt the hair growth cycle and trigger telogen effluvium.

The most effective way to prevent hair loss related to addiction is to seek professional help for the addiction itself. Addressing the underlying addiction can help reduce stress, improve overall health, and potentially reverse some of the damage caused to the hair follicles.

Preventing Hair Loss in Addiction Recovery

In line with that, focusing on a healthy lifestyle can support hair health. This includes:

• Eating a balanced diet: Ensure your diet includes essential nutrients like protein, iron, and vitamins that promote hair growth.
• Getting enough sleep: Seven to nine hours of quality sleep each night allows your body to repair and regenerate.
• Managing stress: Engage in exercise, meditation, or spending time in nature.
• Avoiding harsh hair treatments: Minimize the use of heat styling tools, chemical treatments, and tight hairstyles that can damage hair.

By working on your overall physical and mental health, you create the best conditions for hair growth and lessen the risk of addiction and hair thinning.

Addiction's Impact on the Body

Addiction can have a profound impact on various aspects of health, including hair health. The effects of addiction on both physical and mental health are wide-ranging. In addition to hair loss, addiction can impact various organs and systems in the body, including:

• Brain: Drugs can alter brain chemistry, leading to impaired judgment, memory problems, and mood disorders.
• Heart: Addiction affects the heart, increasing the risk of heart disease, stroke, and high blood pressure.
• Liver: Substance abuse can lead to liver damage or failure.
• Lungs: Smoking and inhaling drugs can cause respiratory problems, including chronic bronchitis and lung cancer.
• Immune system: Addiction can weaken the immune system, making individuals more susceptible to infections.

In addition, addiction can alter hormonal balance, leading to sexual dysfunction and menstrual irregularities. Recognizing that addiction is a complex disease that affects the entire body, and seeking professional help is essential for comprehensive recovery.

Drug-induced hair loss is often reversible once the substance abuse is addressed and a healthy lifestyle is adopted. However, the extent of hair regrowth can vary depending on the type and duration of drug use, as well as other individual factors.

Some potential treatments for drug-induced hair loss include:

• Medications: Medications such as minoxidil and finasteride may help stimulate hair growth.
• Hair transplantation: Severe hair loss may necessitate hair transplant surgery.
• Lifestyle changes: A healthy lifestyle with a balanced diet, stress management, and proper hair care can support regrowth.

Seeking Help for Addiction

If you or someone you know is struggling with addiction and concerned about hair loss or other health effects, seeking professional help is vital. Addiction treatment programs offer comprehensive care that addresses both the physical and psychological aspects of addiction.

Treatment options include:

• Detoxification: The medically supervised detox process helps individuals safely withdraw from substances and manage withdrawal symptoms.
• Therapy: Individual counseling and group therapy can help individuals understand the root causes of their addiction, develop coping mechanisms, and prevent relapse.
• Medication-assisted treatment: Certain treatment medications can help reduce cravings and manage withdrawal symptoms, making it easier to stay sober.
• Support groups: Connecting with others in recovery support groups can provide valuable support and encouragement.

Addiction is a treatable disease, and seeking help is a sign of strength. By addressing the addiction, you can improve your overall health and well-being, including the health of your hair.

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