Telogen Effluvuim from NSAIDS: Are they really potential culprits?

NSAID Induced Telogen Effluvium

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used around the world to treat inflammation, fever, and pain. In rare cases (probably less than 1% of users), they may also cause hair loss in the form of a telogen effluvium.

Common over-the-counter NSAIDs include ibuprofen and naproxen. Prescription NSAIDs include: celecoxib (Celebrex), diclofenac (Voltaren), etodolac (Lodine), fenoprofen (Nalfon), indomethacin (Indocin), ketoprofen (Orudis, Oruvail), oxaprozin (Daypro), nabumetone (Relafen), and sulindac (Clinoril). Barter in 1989 reported to the British Medical Journal a young 2 year old who developed hair shedding within 2 months of using naproxen for an arthritis. Hair regrew when naproxen was stopped. The author also shared data on 85 patients with naproxen related hair loss.

Meyer reported hair loss associated with ibuprofen use in an elderly patient which in turn prompted a larger study of ibuprofen related hair loss.

NSAID related hair loss probably occurs in less than 1 -2% of users. Litt’s Drug Manual reports the risk from celocoxib at less than 2 % and diclofenac at 1-3 %. Naproxen is thought to affect 1% of less of all users.

Confidently diagnosing drug related hair loss is challenging. A history of hair loss a) within 2 months of starting a drug, b) cessation of shedding with stoppage of the drug AND c) recurrence of shedding with “rechallenge” (readministration) of the drug provides the best evidence of a potential link between the drug and shedding. Criteria “d” is rarely pursued but involves d) documenting that higher doses of the drug cause higher degrees of shedding. This happens for some but not all drugs.

Diagnosing drug related hair shedding is among the toughest challenges. Many people who think their hair loss is from a drug end up being wrong. A variety of drugs can cause hair shedding other the NSAIDS including beta blockers, lithium, some antidepressants, heparin, retinoids and blood thinners and some blood pressure medications. This list is by no means complete and thousands of drugs are implicated to various degrees.

Reference 

Barter DA. BMJ. 1989.

Meyer HC. JAMA 1979.