Does coumadin cause hair loss

How to treat hair loss from medication

Drugs that can cause hair loss include:

Blood thinners

Blood thinners, or anticoagulants, can cause hair loss. These include heparin injections and warfarin sodium, which includes the branded drugs:

  • Panwarfin
  • Coumadin
  • Sofarin

Statins

Statins, which are drugs that lower cholesterol, can cause hair loss. These include:

  • Atromid-S (clofibrate)
  • Lopid (gemfibrozil)

Antidepressants

Antidepressants that can cause hair loss include:

  • Prozac (fluoxetine hydrochloride)
  • Paxil (paroxetine)
  • Zoloft (sertraline hydrochloride)
  • Tofranil (imipramine)
  • Janimine (imipramine)
  • Anafranil (clomipramine)
  • Sertraline

Amphetamines

People may take amphetamines for managing attention deficit hyperactivity disorder (ADHD) or treating narcolepsy.

The amphetamine drug Adderall lists alopecia as one of the side effects people may experience.

Anti-gout medications

Allopurinol is a drug that doctors prescribe to lower uric acid levels in people with gout. Brand names of allopurinol include:

  • Zyloprim
  • Lopurin

Beta-blockers for glaucoma

Timolol is a beta-blocker people may use to treat glaucoma. Forms of timolol that may cause hair loss include:

  • Timoptic ocudose
  • Timoptic eye drops
  • Timoptic XC

Beta-blockers for high blood pressure

People taking beta-blockers as a treatment for high blood pressure may experience hair loss as a side effect.

These drugs include:

  • Tenormin (atenolol)
  • Corgard (nadolol)
  • Lopressor (metoprolol)
  • Blocadren (timolol)
  • Inderal or Inderal LA (propranolol)

Hormonal medications

Hormonal medications can treat many different conditions, but can also contribute to hair loss in both males and females.

These drugs include:

  • birth control pills
  • estrogen or progesterone hormone replacement therapy (HRT)
  • testosterone
  • androgenic hormones
  • steroids, including prednisone and anabolic steroids

Anti-inflammatory drugs

Some anti-inflammatory drugs that can cause hair loss include:

  • Naprosyn (naproxen)
  • Anaprox (naproxen)
  • Clinoril (sulindac)
  • Indocin (indomethacin)

Antirheumatic drugs

People taking medication to treat rheumatoid arthritis may experience hair loss. This is because antirheumatic drugs work to fight inflammation by stopping cell growth.

Some drugs target all cells indiscriminately, which means it can affect the cells that produce new hair.

Antirheumatic drugs that may cause hair loss include:

  • Methotrexate, which causes hair loss in 1–3% of users
  • Arava (leflunomide), which causes hair loss in roughly 10% of people who take it

Enbrel (etanercept) and Humira (adalimumab) may also cause hair loss in rare cases. Researchers think this might be because these drugs affect molecules in the body that send messages between cells.

Parkinson’s disease drugs

The drug Levodopa or L-dopa can cause hair loss.

Stomach disorder drugs

Drugs to treat stomach ulcers and digestive issues may cause hair loss. These medications include:

  • Tagamet (cimetidine)
  • Pepcid (famotidine)
  • Zantac (ranitidine)

Other drugs

Other medications that can cause hair loss include:

  • medications for thyroid disorders
  • immunosuppressants
  • chemotherapy
  • antifungals, such as voriconazole
  • some antibiotics
  • anticonvulsants such as Tridone or Trimethadione
  • isotretinoin (Accutane)
  • drugs that contain vitamin A

Many commonly prescribed prescription drugs can cause temporary hair loss, trigger the onset of male and female pattern baldness, and even cause permanent hair loss. Note that the drugs listed here do not include those used in chemotherapy and radiation for cancer treatment.
Your doctor may not mention hair loss as a side effect of some drugs, so don’t forget to do your own research and read the drug manufacturer’s complete warnings. Your pharmacist can provide you with this information even before you fill a prescription.
Many pill and medication guidebooks (sold in bookstores and pharmacies) are also excellent sources of complete information about prescription drugs. If your doctor prescribes any of the following drugs, ask if one that does not have hair loss as a possible side effect can be substituted.
The drugs are listed by category, according to the conditions they treat, then by brand name first, followed by the drug’s generic name in parentheses. In some categories, individual drugs are not listed. For these conditions, you will want to discuss the possibility of hair loss as a side effect of using any of the drugs that treat that particular condition, since many do contribute to hair loss.
Acne

All drugs derived from vitamin A as treatments for acne or other conditions, including:

  • Accutane (isotretinoin)

Blood

Anticoagulants (blood thinners), including:

  • Panwarfin (warfarin sodium)
  • Sofarin (warfarin sodium)
  • Coumadin (warfarin sodium)
  • Heparin injections

Cholesterol

Cholesterol-lowering drugs, including:

  • Atronid-S (clofibrate)
  • Lopid (gemfibrozil)

Convulsions/ Epilepsy

  • Anticonvulsants, including:
  • Tridone (trimethadione)

Depression

  • Antidepression drugs, including:
  • Prozac (fluoxetine hydrochloride)
  • Zoloft (sertraline hydrochloride)
  • Paxil (paroxetine)
  • Anafranil (clomipramine)
  • Janimine (imipramine)
  • Tofranil (imipramine)
  • Tofranil PM (imipramine)
  • Adapin (doxepin)
  • Sinequan (doxepin)
  • Surmontil (trimipramine)
  • Pamelor (nortriptyline)
  • Ventyl (nortriptyline)
  • Elavin (amitriptyline)
  • Endep (amitriptyline)
  • Norpramin (desipramine)
  • Pertofrane (desipramine)
  • Vivactil (protriptyline hydrochloride)
  • Asendin (amoxapine)
  • Haldol ( haloperidol)

Diet

  • Amphetamines

Fungus

  • Antifungals

Glaucoma

The beta-blocker drugs, including:

  • Timoptic Eye Drops (timolol)
  • Timoptic Ocudose (timolol)
  • Timoptic XC (timolol)

Gout

  • Lopurin (allopurinol)
  • Zyloprim (allopurinol)

Heart

Many drugs prescribed for the heart, including those known as the beta blockers, which are also used to treat high blood pressure, and include:

  • Tenormin (atenolol)
  • Lopressor (metoprolol)
  • Corgard (nadolol)
  • Inderal and Inderal LA (propanolol)
  • Blocadren (timolol)

High Blood Pressure

See Above list of beta blockers under “Heart”

Hormonal Conditions

All hormone-containing drugs and drugs prescribed for hormone-related, reproductive, male-specific, and female-specific conditions and situations have the potential to cause hair loss, including:

  • Birth Control Pills
  • Hormone-replacement therapy (HRT) for women (estrogen or progesterone)
  • Male androgenic hormones and all forms of testosterone
  • Anabolic steriods
  • Prednisone and other steroids

Inflammation

Many anti-inflammatory drugs, including those prescribed for localized pain, swelling and injury.

  • Arthritis drugs
  • Nonsteroidal Anti-Inflammatory Drugs including:
  • Naprosyn (naproxen)
  • Anaprox (naproxen)
  • Anaprox DS (naproxen)
  • Indocin (indomethacin)
  • Indocin SR (indomethacin)
  • Clinoril (sulindac)

An anti-inflammatory that is also used as a chemotherapy drug:

  • Methotrexate (MTX)
  • Rheumatex (methotrexate)
  • Folex (methotrexate)

Parkinson’s Disease

  • Levadopa / L-dopa (dopar, larodopa)

Thyroid Disorders

  • Many of the drugs used to treat the thyroid

Ulcer

Many of the drugs used to treat indigestion, stomach difficulties, and ulcers, including over-the-counter dosages and prescription dosages.

  • Tagamet (cimetidine)
  • Zantac (ranitidine)
  • Pepcid (famotidine)

Reviewed by Paul J. McAndrews, MD

MEDSAFE

Published: 30 May 2016
Revised: 7 February 2017

Early Warning System – Monitoring Communication

Medsafe emphasises that patients should NOT stop using any medicine or medical device subject to a monitoring communication. If you have any concerns with a medicine or medical device you are using, please contact your health professional. A monitoring communication does not mean that the medicine or medical device causes an adverse event.

Rivaroxaban, dabigatran and apixaban and possible risk of hair loss (alopecia) added to the medicines monitoring scheme

30 May 2016

Monitoring finishes 31 December 2016

Medsafe is highlighting a possible risk of hair loss with the use of novel oral anticoagulants (NOACs). The NOACs available in New Zealand are rivaroxaban, dabigatran and apixaban.

In July 2015, the Centre for Adverse Reactions Monitoring (CARM) received a report of hair loss with the use of rivaroxaban. The patient experienced significant and continuously worsening hair loss which was noticed four days after starting rivaroxaban. The patient had no previous history of hair loss.

Review of World Health Organization (WHO) data also suggests that there may be a connection between NOACs and hair loss.

Products Affected

Product name Sponsor
Rivaroxaban
Xarelto Bayer
Dabigatran
Pradaxa Boehringer Ingelheim
Apixaban
Eliquis Pfizer

NOACs are used in a variety of conditions including:

  • Prevention of stroke and systemic embolism.
  • Prevention of venous thromboembolism (VTE).
  • Treatment of deep vein thrombosis (DVT) and/or pulmonary embolism (PE).
  • Prevention of recurrent DVT and/or PE.

Additional Information

Hair loss is not a known side effect of the NOACs rivaroxaban, dabigatran or apixaban. However, it is known to occur with the anticoagulants heparin and warfarin. The exact mechanism for hair loss with heparin and warfarin is unknown but is thought to occur through telogen effluvium. Further information on telogen effluvium is available from the DermNet NZ website.

Hair loss through telogen effluvium can be triggered by a variety of conditions as well as fever, surgery, haemorrhage (bleeding), childbirth and medicines. The effects are usually visible around two to four months after exposure to the trigger.

Patients who experience significant and/or worsening hair loss should continue to take their medicine and seek medical advice.

The overall benefit-risk balance of rivaroxaban, dabigatran and apixaban remains positive.

Advice on how to take this medicine and possible side effects can be found in the consumer medicine information (CMI) and data sheet

Search for consumer medicine information

Search for data sheet information

Regulator Actions

Medsafe is placing this safety concern on the medicines monitoring () scheme to obtain further information on these possible adverse reactions.

Please report any suspected adverse reactions, particularly hair loss, with rivaroxaban, dabigatran and apixaban. Please include information on time to onset of hair loss, the relevant medical history and course of the disease.

Reporting

Consumers and healthcare professionals are encouraged to send reports of suspected adverse reactions to the Centre for Adverse Reactions Monitoring (CARM).

Medsafe cannot give advice about an individual’s medical condition. If you have any concerns about a medicine you are taking Medsafe encourages you to talk to your healthcare professional.

Update to Original Communication

7 February 2017

During the medicines monitoring period (30 May 2016 to 31 December 2016), no further cases were reported to the Centre for Adverse Reactions Monitoring (CARM). The safety concern has been investigated and no link between rivaroxaban, dabigatran and apixaban and hair loss was demonstrated. The balance of the benefits and risks of harm for rivaroxaban, dabigatran and apixaban remains positive and no further action is required at this time.

Medsafe will re-investigate this concern should more information become available.

PMC

Traditional Anticoagulants and Hair Loss

Traditional anticoagulants are thought to cause hair loss through telogen effluvium, and so alopecia associated with heparins and coumarins may take time to become apparent. In fact, telogen effluvium can frequently go unnoticed, as often hair falling out is due to the re-growth of new hair underneath. Hence, an increase in shedding might not always present as clinically significant alopecia. The latency period between exposure to a drug trigger and increase in hair loss may additionally explain why the phenomenon is under-reported. Finally, there is great interindividual variability in baseline daily hair loss and in density of telogen scalp hair, which dictates whether the increase in rate of loss will lead to cosmetically compromising alopecia . This represents a further complicating factor in determining the extent to which anticoagulants cause an increase in hair loss and alopecia.

A literature search of Embase (1947 to present) and Medline (1946 to present) using terms ‘alopecia’ or ‘hair loss’ in conjunction with ‘heparin’, ‘warfarin’, ‘acenocoumarol’, ‘phenindione’, ‘dalteparin’, ‘enoxaparin’ and ‘tinazparin’ was conducted on the 15 July 2015 and yielded 12 case reports. The first report describes a 2-year-old girl who accidently ingested an unknown amount of the rat poison ‘d-con’, the active ingredient of which is warfarin. Her mother first noticed hair loss 17 days from the accident which peaked at day 21. Her hair started re-growing after 31 days . Accidental warfarin ingestion is also reported by Rook : a 6-year-old boy was noted to lose over 50 % of his hair during a 6-month period when he was often observed to play with soil on a farm which used warfarin as rat poison. Rook also describes a more typical case of a 43-year-old man who complained of severe alopecia 3 months after his heparin treatment for thrombophlebitis. Three different cases of alopecia associated with warfarin use post-valve replacement are reported by Umlas and Herken and one by Al-Ibrahim et al. : a 55-year-old man who complained of an increase in hair shedding 13 years after first taking warfarin, a 65-year-old woman with alopecia appearing 1.5 years into treatment with warfarin and persisting for the duration it is prescribed (14 years), and a 62-year-old woman who only noticed hair loss after 10 years on chronic warfarin therapy; in the latter case, however, the alopecia resolved on discontinuation of anticoagulation and re-appeared on re-challenge . In the case described by Al-Ibrahim et al. the patient presented with alopecia that affected his beard, scalp and moustache 5 years into treatment with warfarin. Two reports were published in the 1990s, a 57-year-old female treated with warfarin for cardiogenic brain embolism and a 49-year-old female, positive for lupus anticoagulant and therefore started on warfarin therapy. Both of them complained of increased hair shedding 2 months into treatment . In recent years there have been only two reports of warfarin-associated alopecia: In 2008 a 70-year-old female anticoagulated for deep vein thrombosis (7 mg/day, no international normalized ratio (INR) target reported) was described to lose patches of previously thick hair soon after commencing treatment . Nakamizo and colleagues describe a 25-year-old man who underwent several cycles of chemotherapy and as a result lost hair all over his body, which then fully regrew 5 months after finishing treatment. He was then treated with warfarin for pulmonary embolism and 1 month into anticoagulant treatment complained of severe diffuse hair loss. The authors speculate that alopecia occurs within 1 month of treatment with warfarin due to an increase in scalp telogen hair post-chemotherapy.

There are three reports of acenocoumarol-associated alopecia published in the literature. In all three cases increase in hair loss is reported within months of starting treatment and it persists for the duration of treatment .

The first report of low molecular weight heparin-associated alopecia was in 2000, where a 9-year-old girl who was treated with dalteparin (100 U/kg) for sinus vein thrombosis noticed extensive hair loss 10 weeks into the treatment. She was on no other medication that could lead to hair loss and it improved 2 weeks after treatment cessation . In 2001, another report was published describing four cases of dalteparin-associated alopecia. Women aged between 59 and 75 year were anticoagulated with dalteparin (80 IU/kg) for prevention of extracorporeal clotting in haemodialysis. They noticed “hair coming out in handfuls” between 6 weeks and 3 months from starting treatment. When the anticoagulation regimen was changed to citrate, hair loss stopped and in one patient that was re-challenged with dalteparin, it re-appeared . Tinzaparin has also been linked to diffuse alopecia in a 66-year-old man who had been on enoxaparin for 9 months and then was switched to tinzaparin for 3 months for prevention of extracorporeal blood clotting. Interestingly, hair loss only occurred with tinzaparin and not enoxaparin. A biopsy of the alopecia area showed “atrophic hair follicle in the papillary dermis and widened follicles filled with keratin fragments” . Wang and colleagues , however, describe three cases of females (aged 22–52 years) treated with enoxaparin (1 mg/kg twice a day) and then with warfarin for sinus vein thrombosis who noticed a significant increase in hair loss 3 weeks after commencing treatment with enoxaparin. Dermatologists were consulted and diagnosed telogen effluvium. Interestingly, alopecia ceased during treatment with warfarin (INR target of 2). All three cases were rated 6 on the Naranjo Adverse Drug Reaction (ADR) probability score and therefore enoxaparin was deemed to be the cause of the alopecia .

The published case reports suggest that alopecia is reversible on cessation of treatment and reappears on re-challenge . For warfarin, hair loss is reported to begin after 3 months of treatment, but the time range of onset reported is wide: 2 months to 13 years. Similarly, with heparins, the time of onset is wide, with the average time of onset similar to that reported with warfarin. Despite the fact that spontaneously shed hair was not examined in any of the reported cases, the timing and presentation of hair loss strongly suggests telogen effluvium to be the mechanism.

Age and gender do not affect susceptibility to anticoagulant-induced telogen effluvium . However, there are more published reports in women. This is possibly because of men attributing hair loss to male-pattern baldness. Additionally, females might aggravate the shedding of the resting hair resulting from telogen effluvium by frequent grooming, and therefore increase the rate of loss to a level that produces obvious alopecia.

There is a lack of unanimity over the influence of dose and treatment duration with anticoagulants and the relationship with alopecia. Case reports that implicate oral coumarins in causing telogen effluvium state the dose of the drug that the patients were prescribed, but only two specify the range at which the INR was maintained . Two cases of alopecia were as a result of poisoning with warfarin .

For heparins, where the dose has been reported it was either given at therapeutic levels or at low doses for preventing coagulation in the extracorporeal circuit (Table 1). In a study where three groups of patients were given different doses of heparin, heparin and oral anticoagulant, or heparin with an oral anticoagulant, a direct relationship between dose and incidence of hair loss was established . In contrast, in another study a different heparin was given to a total of 240 patients, and alopecia was not apparently related to the total dose received .

The specific mechanism behind anticoagulant hair loss caused by anticoagulants is unknown. Most studies simply imply that telogen effluvium is part of the process. Some groups have tried to elucidate the specific mechanism; Kligman took a biopsy of the scalp of patients who experienced alopecia after heparin exposure. Microscopic examination demonstrated that the capillaries of the dermis were variably distended with blood and there was an inconsistent, peculiar focal degeneration of collagen bundles in the vicinity of vessels of the follicular connective sheath. Flesch proposed that the hair entering the resting phase prematurely could be provoked by slow strangling of the hair root and injury to the connective tissue papilla. Currently there is uncertainty whether or not the aforementioned change in the vasculature of the scalp is the possible cause of the injury and therefore instrumental in the course of telogen effluvium.

Heparin is also known to possess antimitotic activity, to increase the cohesion of the dermal–epidermal junction in rats and to suppress the proliferation of epithelial bulb in vitro . All these modalities could mediate alopecia, and none is exclusive of the other.

It’s normal to lose a bit of hair every day, but if you notice excessive hair loss or balding, the medications you are taking could be to blame.

Here are 11 drugs that have been known to cause excessive hair loss as a side effect.

1) Cholesterol-lowering medications — atorvastatin and simvastatin

Atorvastatin (Lipitor) and simvastatin (Zocor) belong to a group of cholesterol-lowering medications known as “statins”. Have hair loss is a reported side effect of both drugs. The newer statin, rosuvastatin (Crestor), luckily does not have this risk.

2) Anticoagulant — warfarin

The anticoagulant, warfarin (Coumadin), is a commonly used blood thinner that has been reported to cause hair loss.

3) Blood pressure medications — captopril and lisinopril

ACE inhibitors are a class of medications used to treat high blood pressure. They include the medicines, captopril and lisinopril. Both of the drugs have been known to cause hair loss—but only in around 1% of patients taking them.

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4) Psoriasis treatment — acitretin

Acitretin (Soriatane) is a pill used for the treatment of psoriasis and has a well-known adverse effect of hair loss.

5) Anti-arrhythmia drug — amiodarone

Amiodarone (Cordarone or Pacerone) is used in patients with heart rhythm problems known as arrhythmias, and has a rare—but reported—side effect of hair loss.

6) Anticonvulsant — divalproex

Anticonvulsant divalproex (Depakote) is used for seizure disorders, bipolar disorder and for migraine prevention, and can lead to hair loss.

7) Antacid — cimetidine

Cimetidine (Tagamet) is an over-the-counter acid reducer used for GERD and acid reflux. Hair loss has been reported (though infrequently) in people taking it.

8) Gout medication — colchicine

Colchicine is a medication used to treat acute gout attacks. It carries a very small risk of hair loss.

9) Steroids — testosterone and progesterone

Hair loss is reported in people taking the hormones testosterone and/or progesterone. Medications containing progesterone, like Depo-Provera (medroxyprogesterone) injections, Provera, and Prometrium have a well-recorded history of causing hair loss in some people.

10) Acne treatments — isotretinion

Absorica and Accutane are used to treat severe acne and contain the active ingredient, isotretinoin. Hair loss is a well-known adverse reaction for both medications.

11) Antifungal — ketoconazole

Ketoconazole is an oral antifungal pill that can cause hair loss.

– – –

In addition to these medications, other well-known causes of hair loss include poor diet, major illness or surgeries, psychological stress, significant weight loss, chronic iron deficiency, thyroid disorders, and childbirth.

Dr O.

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  • Alopecia from drugs

    What is alopecia from drugs?

    Alopecia from drugs is a usually reversible nonscarring diffuse hair loss that occurs within days to weeks of starting a new medication or changing the dose.

    Who gets drug-induced alopecia?

    The development of hair loss and severity depend both on the drug and individual predisposition. Some drugs cause hair loss in most patients receiving an appropriate dose. Other drugs are only occasionally responsible for hair loss.

    There are two types of drug-induced hair loss:

    • Anagen effluvium – the shedding of actively growing hairs
    • Telogen effluvium – the shedding of resting, or bulb hairs

    Anagen effluvium

    Anagen effluvium is usually due to chemotherapy drugs and rarely with gold, colchicine or poisoning with arsenic, bismuth, thallium or boric acid.

    Telogen effluvium

    Telogen effluvium is the mechanism of virtually all other medication-induced hair loss. The list of possible drug causes is very long and includes:

    • Anti-coagulants — heparin, warfarin and possibly newer anticoagulants such as rivaroxaban, dabigatran and apixaban
    • Anti-hypertensives — beta-blockers, ACE inhibitors
    • hormones — oral contraceptive pill (during/after/changing), hormone replacement therapy, androgens
    • Anticonvulsants — valproic acid 12–28% (dose-dependent), carbamazepine up to 6%, phenytoin
    • Mood stabilisers and antidepressants — most, such as lithium 12–19%
    • Others — cimetidine, retinoids (acitretin > isotretinoin), antithyroid drugs, cholesterol-lowering drugs, interferons, anti-infective agents, amphetamines, nonsteroidal anti-inflammatory drugs (NSAIDs), bromocriptine, levodopa, some antipsychotics and anti-anxiety drugs, rarely tricyclic antidepressants such as amitriptyline.

    Telogen effluvium may also occur as a result of a serious drug eruption such as Stevens-Johnson syndrome / toxic epidermal necrolysis or drug hypersensitivity syndrome, in which case hair falls out a few weeks to months after the acute illness and slowly regrows again.

    What are the clinical features of drug-induced alopecia?

    Hair loss due to medications is usually diffuse and nonscarring. The hair loss may be ‘patterned’ as seen in male-pattern or androgenetic alopecia or female-pattern alopecia. The scalp is the most common site affected, but all body hair including eyebrows and eyelashes may be lost with chemotherapy.

    Anagen effluvium hair loss may become obvious within days to weeks of starting chemotherapy, whereas with telogen effluvium the hair loss usually becomes evident after 2–4 months.

    In a study of women having chemotherapy for breast cancer, the average time between starting chemotherapy and hair loss was 4–5 weeks but occurred in some as early as two weeks. The hair loss was maximal in the second cycle with more than 1000 hairs/day being lost in severe cases. Even with chemotherapy, the degree of hair loss can vary between no noticeable effect through to severe rapid, extensive loss, even on the same drugs and regimes.

    How is the diagnosis made?

    The only way to confirm suspected drug-induced hair loss is to cease the possible drug for at least three months and observe regrowth. However, the diagnostic steps below may be necessary.

    1. History

    A detailed drug history should be taken in all patients presenting with diffuse nonscarring hair loss, concentrating on the three months before the hair loss was noted. This should include all new medications, any changes in dosages, and also over-the-counter supplements. This list must include chemotherapy, the oral contraceptive pill and hormone replacement therapy. Other causes of diffuse hair loss should also be asked about, such as general health, recent illness or surgery and dietary history. The family history for patterned (androgenetic) hair loss should be noted.

    2. Examination

    Examination of the scalp should assess the degree and pattern of hair loss, the presence of redness or scaling of the scalp and the length, diameter and breakage of hair shafts.

    3. Hair pull test

    The hair pull test involves gentle pulling of a cluster of hairs from the base to the tip. Normally only 1-2 hairs come out. In hair shedding conditions, 10-15 hairs may pull out. The pulled hairs can be examined under the microscope for anagen or telogen bulbs, fractures and tapering.

    4. Scalp biopsy

    A skin biopsy from an area where the hair is thin may be required to exclude other causes of diffuse hair loss.

    5. Blood tests

    If the explanation for hair loss is obscure, it is usual to perform at least blood count, iron studies and thyroid function tests.

    Treatment of drug-induced alopecia

    Usually, the only treatment required for drug-induced hair loss is to cease the causative drug if it is possible to do so. Once that drug has been ceased, hair shedding settles, although this may take up to 6 months. Evidence of hair regrowth is usually seen within 3–6 months but can take 12–18 months to recover cosmetically.

    The most effective treatment to reduce hair loss from chemotherapy to date has been cooling the patient’s head to reduce the blood flow around hair follicles. Hair cooling devices are worn for 30 minutes before infusion of the causative drug, during the infusion, and for 90 minutes afterwards.

    Topical calcipotriol was not effective in a trial of breast cancer patients undergoing chemotherapy. In mice, topical minoxidil and topical ciclosporin stimulated regrowth after cyclophosphamide.

    Proposed mechanisms

    1. Inhibition of cell division or death of hair matrix cells by chemotherapy drugs leads to a tapering of the hair shaft (which can cause the hair shaft to break if severe) and so-called anagen effluvium.
    2. Pushing the hair follicles into an early resting phase (from anagen to telogen) results in telogen effluvium.

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