What Drugs Cause Alopecia Areata?

The authors of a new study set out to determine drugs implicated in the development of alopecia areata (so-called drug-induced AA). Ezemma et al. performed a systematic review using PubMed to search for all published cases of drug-induced AA.

The authors found sixty-six articles (55 case reports, 9 case series, and two retrospective studies) for their systematic review. These 66 articles included 102 patients. The average age was around 40 years, and approximately half of the patients were female (53.9%).

What drugs are implicated in Drug-Induced AA?

Thirty drugs were found to be associated with the development of drug-induced AA. Monoclonal antibodies caused seventy-six percent of drug-induced AA cases. The TNF-alpha inhibitors and dupilumab comprised most of these cases. Overall, TNF inhibitors were responsible for 47.0% of all patient cases and dupilumab 12.7%.

Adalimumab was the most common TNF inhibitor implicated in drug-induced AA. (18.6% of all cases). Other TNF inhibitors included infliximab (14.7%), etanercept (11.7%), and golimumab (1.9%)

The TOP Causes of Drug-Induced AA

Here is the list of top culprits in drug-induced AA:

1. Adalimumab (18.6% of all published cases) - TNF inhibitor

2. Infliximab (14.7% of all published cases) - TNF inhibitor

3. Dupilumab (12.7% of all published cases) - anti-IL-4/13

4. Etanercept (11.7% of all published cases) - TNF inhibitor

5. Alemtuzumab (5.8% of all published cases) - monoclonal anti-CD52 antibody

6. Hepatitis C therapy (ribavirin, interferon-alpha) (3.9% of all published cases)

7. Cyclosporine (2.9% of all published cases) - calcineurin immunosuppressive agent

8. Belimumab (2.9% of all published cases) - monoclonal AB; inhibitor of B-lymphocyte stimulator (BLyS)

9. Cladribine (1.9% of all published cases) - antimetabolic chemotherapeutic

10. Golimumab (1.9% of all published cases) - TNF inhibitor

11. Haloperidol (1.9% of all published cases) - antipsychotic

12. Pembrolizumab (1.9% of all published cases) - checkpoint inhibitor, anti-PD1

13. Rifampicin (1.9% of all published cases) - antimicrobial

14. Oral retinoid (1.9% of all published cases) - vitamin A derivative

Epidemiology of Drug-Induced AA

Overall, patchy AA was the most common presentation. This was seen in 70.5% of drug-induced AA cases.

The average time to onset of AA was 11.7 months, so this was not always seen immediately.

Interestingly, most patients had no family history of AA (93.1%).

What is the effect of stopping the culprit drug?

Forty-eight patients discontinued the drug thought to cause AA, and nearly all patients had regrowth regardless of additional treatment.

What if patients chose not to stop?

Forty-two patients continued the drug, and most did not have regrowth unless they underwent additional treatment. However, the vast majority (75%) of patients who continued the implicated drug and received treatment had hair regrowth.

Comment

This is interesting and provides some beneficial information. The implicated drugs are similar to those reported in Ravipati et al. (see link) but not the same. The most common drug in Ravipati is the taxanes.

REFERENCE*

Ezemma O et al. Drug-induced alopecia areata: A systematic review. J Am Acad Dermatol. 2024 Jan;90(1):133-134. doi: 10.1016/j.jaad.2023.05.022. Epub 2023 May 18.