Hair Loss in Isotretinoin Users: Is it All Just a Telogen Effluvium?

Hair loss in the form of a telogen effluvium is a side effect of isotretinoin. It is somewhat debated as to how common this side effect truly is. The percentage of patients that report hair loss after isotretinoin treatment ranges from 0.28% to 12.0% depending on the exact study.

In previous article, I reviewed a nice study showing that about 3.2 % of those using isotretinoin at low doses can have shedding with istreotinoin. This rises to about 5.7 % in those using high doses of isotretinoin.

 Tran et al 2022

A newly published retrospective study reported on the development of alopecia in patients on isotretinoin therapy.  Authors wanted to answer two main questions:

a) what types of hair loss occur in patients who say they have hair loss while taking isotretinoin and

b) how do patients who develop hair loss while on isotretinoin differ from patients who do not develop hair loss on isotretinoin?

To do so, the authors performed a retrospective analysis of patients diagnosed with hair loss of various kinds between 2013 and 2018.  Patients were excluded if they had used isotretinoin before their hair loss started. Patients who developed hair loss following receipt of isotretinoin were further compared to other patients in the same time period who were prescribed isotretinoin and were not diagnosed with hair loss.

There were 6330 patients identified with some kind of hair loss over this 2013-2018 period. Of these 6330 patients,  48 had been prescribed isotretinoin at some time between these years. Of these 48 patients, hair loss occurred concurrently or within 2 years after taking isotretinoin in 19 patients (39.6%).

The mean age of these 19 patients was 27 and half were male and half were female. There were 4 main diagnoses in patients who said they used isotretinoin and had hair loss. These were telogen effluvium (10/19 or 52.6%), androgenetic alopecia (5/19, 26.3%), lichen planopilaris (3/19 or 15.8%) and alopecia areata (2/10 or 10.5 %).

Given that AA prevalence may be around 0.2 %, AGA prevalence around 12-36 % in this particular group and lichen planopilaris around 0.05 % maximum estimate, this would suggest an overrepresentation of LPP in patients treated with isotretinoin - and possibly alopecia areata.

Patients with Hair Loss from Isotretinoin are Older and Used the Medication Longer and Had a Higher Total Dose

The 19 patients in whom hair loss occurred during or after isotretinoin were further compared to 413 patients who did not have any sort of hair loss after isotretinoin therapy. Diagnosis, age, sex, total cumulative dose, and duration of treatment were examined. Overall, compared to patients on isotretinoin without hair loss, patients who developed hair loss were older, had higher cumulative isotretinoin dose, and longer duration of treatment (P = 0.008, P = 0.004, and P < 0.001, respectively).

Overall, I think this study is interesting.

This paper does not set out to determine how common hair loss is from isotretinoin. We don’t have a sense in this study how many used isotretinoin and did or did not develop hair loss. That’s been covered in other studies - and the number runs somewhere around 0.28 to 12 %.

 The fact that hair loss becomes more of an issue the longer and longer one uses isotretinoin and the more medication one uses, there is a suggestion that isotretinoin probably drives more than just a TE. There are patients who use istretinoin and develop hair loss issues long after a TE would be expected to have taken place. Isotretinoin could possibly drive AGA and possibly lichen planopilaris and possibly AA. More studies are needed to prove this.

REFERENCE

Tran PT et al. Characteristics of Patients with Hair Loss after Isotretinoin Treatment: A Retrospective Review Study.Int J Trichology. 2022 Jul-Aug;14(4):125-127.