Rheumatoid arthritis and hair loss can occur together for a number of reasons. However, hair loss is rarely caused directly by rheumatoid arthritis, but rather by factors that coincide with it, such as taking certain medications, stress, and concurrent conditions.
“There are so many possible causes of hair loss [unrelated to rheumatoid arthritis], so we have to rule out other causes too,” says Ashira Blazer, MD, a rheumatologist and Assistant Professor in the Department of Medicine at NYU Grossman School of Medicine. “We all naturally lose hair over time. As we age, that not only can accelerate, but the follicles start to thin so the hairs that come back might be a little thinner.”
But if you’re experiencing out-of-the-ordinary hair loss (large patches or patterns of loss, for example) it could be due to factors related to your RA.
Although hair loss isn’t harmful, it can be devastating. It can change the way you see yourself and hurt your self-confidence.
“There’s no question that hair loss is exceedingly burdensome,” says Adam Friedman, MD, Professor and Chair of Dermatology at George Washington University School of Medicine. “Your hair is your crown and it’s something that tells the world about you.”
But here’s the good news: Hair often grows back and there are many ways to treat hair loss. By talking to your doctor about rheumatoid arthritis and hair loss, you can work together to pinpoint the causes, treatment options, and ways to cope.
Hair Loss: What’s Normal, What’s Not?
You can tell if you’re experiencing out-of-the-ordinary hair loss if you’re spotting strands of hair in places you normally wouldn’t.
“When I’m asking about hair loss that might be pathologic, I say, ‘When you wake up in the morning, do you notice hair on your pillow?’” says Dr. Blazer. “We all lose hair in the shower, or when we brush and comb. It’s really when you’re noticing hair loss where you shouldn’t, or patterns of hair loss, like patches.”
Consider whether amount of hair you’re shedding is more than usual (taking pictures can help you track your hair growth).
“If what you are experiencing is strikingly different from your normal, it is worth asking your doctor about it,” says Carolyn Goh, MD, a dermatologist at UCLA Health Encino. “True patches of hair loss or rashes on the scalp along with the hair loss are often signs of more serious hair loss.”
Common Causes of Hair Loss in Rheumatoid Arthritis
“If it’s something that comes up kind of quickly, that would suggest it’s a medication, especially if it’s a medication that’s recently been changed,” says Max Hamburger, MD, Founder and Executive Chairman of United Rheumatology, a national rheumatology care management organization. “Or it might suggest another illness. Other things can happen to a patient at the same time they have rheumatoid arthritis.”
Here are common reasons people with rheumatoid arthritis may encounter hair loss.
Certain arthritis medications are one of the most common causes of hair loss in people with rheumatoid arthritis, yet it is still not very common to experience hair loss from your medications.
“The most common drug we start with in rheumatoid arthritis is methotrexate, and we’re very familiar with the possibility that this drug can cause thinning of hair,” says Dr. Hamburger. “Many of us will concurrently start [a patient on] folic acid supplements along with methotrexate because that seems to mitigate the hair thinning.”
Methotrexate is a DMARD, or a disease-modifying antirheumatic drug. Some DMARDs affect hair cells.
Study results on how common hair loss related to methotrexate is in rheumatoid arthritis vary widely. In one recent British study of a group of 1,069 RA patients who had started methotrexate and was observed at six months and a year, hair loss was reported in 8 percent of people. A small Polish study (68 people) from 2019 found that hair loss after starting methotrexate occurred in nearly 30 percent of participants. And another study from researchers in India analyzed hair loss in nearly 100 RA patients who just started taking low-dose methotrexate. Researchers compared their rate of hair loss to a control group of patients and found that low-dose methotrexate didn’t seem to cause increased hair loss in RA patients.
Likewise, some CreakyJoints community members report lost hair from methotrexate while others have not. “[I] lost so much hair I can’t look at myself in the mirror,” Elise V. shared on Facebook.
“I had long, thick, stick straight hair my whole life until I started taking methotrexate,” says CreakyJoints community member Lyn C. “I lost so much hair. When I finally failed methotrexate and my hair grew back, it was curly! Nothing that I’ve been on since has made my hair fall out like methotrexate and it’s stayed curly ever since.”
On the other hand, Maria E., who has been on methotrexate since February, says, “my hair has been fine so far.”
Many people associate methotrexate as a type of chemotherapy for cancer (which is well-known to cause hair loss), but keep in mind that receiving methotrexate for arthritis treatment is very different from chemotherapy based on the dose and method of delivery — and is not likely to cause the same type of hair loss. (The dose of methotrexate when used for treating cancer is much bigger than that used for inflammatory arthritis like RA.)
Most people start by taking methotrexate via oral pills, but if you’re experiencing hair loss, you may see better results by switching from oral to injectable forms of the drug.
Only a small percent of people will have hair loss related to their DMARDs, says Dr. Blazer. “So I really have to tease out what else is going on, because I don’t want to unnecessarily stop medication that may be helping with rheumatoid arthritis [if that’s not actually the] cause of hair loss.”
Another DMARD that’s used far less commonly nowadays but is also associated with hair loss is leflunomide (Arava).
“It certainly causes hair loss and can cause significant hair loss,” says Dr. Hamburger. “I’ve had some patients bring bags of hair that had fallen out into the office, so it’s been a limiting factor — but leflunomide isn’t used much these days.”
Leflunomide has largely been replaced by biologics for rheumatoid arthritis.
On the other hand, certain medications may actually help with hair loss: Tofacitinib (Xeljanz) is a JAK inhibitor that has been studied as a treatment for alopecia areata, an autoimmune form of hair loss.
In this case, the drug seems to have the benefit of decreasing inflammation in hair follicles in that autoimmune condition. Alopecia areata and rheumatoid arthritis don’t commonly coexist, but it’s still important to note that this rheumatoid arthritis treatment won’t exacerbate hair loss.
JAK inhibitors may be an option for you if you’ve experienced hair thinning from other medications like methotrexate.
“The good news is we have newer medications that are more targeted, don’t necessarily have hair loss as a side effect, like the JAK inhibitors, a class of immune-modulating medications,” says Dr. Friedman.
Other Autoimmune Diseases
Several autoimmune diseases have been linked to hair loss. These can sometimes also affect people with rheumatoid arthritis, which is why it’s important for you and your doctor to work together to figure out what could be causing hair loss.
Alopecia areata is an autoimmune condition that affects about 1.7 percent of the population. It can co-occur with rheumatoid arthritis, although this isn’t common. It develops when the body attacks its own hair follicles, which can lead to hair loss anywhere on the body, per the American Academy of Dermatology (AAD). Periods of hair loss and hair growth are unpredictable with this condition.
Thyroid disease occurs when your thyroid makes too much or too little of important hormones that play key roles throughout your body’s systems, per the Cleveland Clinic. Hashimoto’s thyroiditis is an inherited type of hypothyroidism (where your body makes too little of the important hormones) in which the body’s cells attack the thyroid.
Severe and prolonged thyroid disease can cause hair loss that affects the entire scalp and appears uniformly sparse, per the British Thyroid Foundation.
“The most common disease that I see associated with hair loss in patients with RA is actually the comorbidity of thyroid disease,” says Dr. Hamburger. “So a lot of my [RA patients] have thyroid disease, and they’ve had Hashimoto’s thyroiditis, and often that precedes the diagnosis of RA by a long time.”
Research has shown that people with rheumatoid arthritis are more likely to develop a thyroid condition than the general population, and vice versa. In fact, 14 percent of people with Hashimoto’s thyroiditis had another autoimmune disease, most commonly rheumatoid arthritis, according to a study in the American Journal of Medicine.
Lupus is another autoimmune disease that can sometimes co-occur with rheumatoid arthritis and can cause hair shedding. That’s because lupus can cause widespread inflammation that typically involves your skin, especially on your face and scalp, per the Mayo Clinic. This can cause your hair to gradually thin out or for clumps of hair to fall out.
“A lot of autoimmune diseases overlap with each other,” says Dr. Blazer. “Some people may have lupus and also rheumatoid arthritis. Lupus is a big culprit of hair loss.”
There are three ways stress can be linked to hair loss, according to the Mayo Clinic. Living with a chronic illness like RA can increase stress levels and cause chronic stress.
- Alopecia areata: Severe stress may also play a role in alopecia areata, in which the body’s immune system attacks the hair follicles.
- Telogen effluvium: When you’re highly stressed, it can push your hair follicles into a resting phase. After a few months, all the affected hairs can fall out suddenly when you wash or comb your hair.
- Trichotillomania: This is the irresistible urge to pull out your own hair from your scalp. This can be a way of dealing with unpleasant feelings like stress, tension, or even boredom and loneliness.
Related to telogen effluvium, your stress levels can affect what stage your hair stays in.
“Our hair has two phases — there’s the anagen phase, where the hair is actively growing, and the telogen phase, in which the hair is actually in a resting phase,” says Dr. Blazer. “When you lose hair in the telogen phase, you’re not going to replace it as quickly. Patients who have stress, especially related to chronic illness, may stay in that telogen phase longer. That means when their hairs fall out, they’re not replacing them.”
Stressful events can include rheumatoid arthritis flares, treatment changes, and managing condition side effects or comorbidities, as well as big life event-type stressors that can affect everyone, such as beginning a new job or moving.
These events can also cause you to lose hairs you would normally lose but in a shorter time frame – at rates of 400 to 600 hairs per day versus 100 to 200 during non-stressful times, says Dr. Friedman. This can persist for a few months and then plateau. As long as no other factors are affecting hair growth, the hair will come back, but the process can take a year.
Treatment for Hair Loss
Although hair loss technically doesn’t need to be treated, it can have a significant impact on your self-esteem and confidence — which is reason enough to address it. Plus, hair loss could be indicative of other issues like mineral deficiencies or unknown illnesses.
“Just on its own merits, we don’t need to treat hair thinning, but I don’t want to underestimate the significance of aesthetics,” says Dr. Hamburger. “Our patients suffer enough from damage to their joints, swollen joints, and sometimes weight loss or muscle wasting. They’ve got enough going on with their appearance and their self-image, they certainly don’t need something as important as hair loss to deal with, too.”
Talk to your doctor to find out whether one of the following will help treat your RA-related hair loss.
If a medication like methotrexate is causing your hair to fall out, it’s worth reevaluating if that’s the right therapy for you.
“If there is an offending medication, try to switch the medication,” says Dr. Blazer. “We have so many medications for rheumatoid arthritis, that we really have many options and often we can find something that you can do to increase the hair growth.”
However, stopping medication is not something that should be done without the guidance of your doctor, who will consider your entire medical history.
“If I had a patient on methotrexate who was having prominent hair loss, I’d be looking carefully at their blood counts,” says Dr. Hamburger. “Hair loss would be a sign for me to pay attention to the things I should ideally be paying attention to.”
Hair loss medications
These will typically be used if you’re experiencing male- or female-pattern baldness — patterns of hair loss like thinning on the crown for men or thinning at the part for women. This type of hair thinning is commonly due to genetics and the natural process of aging rather than medications, stress, or underlying conditions.
However, there are some treatments available to treat the hormonal changes that play a role in this type of hair loss.
“From the hormonal perspective, we use several medications, most of them off-label,” says Dr. Friedman. “The only one that’s actually approved is finasteride [Propecia] for male-pattern hair loss. But for women, we use two different medicines that go after hormones — spironolactone and finasteride.”
Spironolactone is a type of diuretic used to treat high blood pressure, but it can block DHT, which is the form of testosterone that can cause the hair follicles to shrink if you’re sensitive to it. It is used for women of childbearing years.
Finasteride is more potent and prevents the production of DHT from testosterone, but it’s not used in women of child-bearing years, says Dr. Friedman.
Minoxidil, or Rogaine, can also be applied to the scalp to stimulate hair growth in adult men and women with certain types of baldness, per the Mayo Clinic.
“Generally speaking, topical minoxidil — which is available over the counter — can be used for hair loss from any cause, including medications or chronic illnesses like rheumatoid arthritis,” says Dr. Goh. “Low-level laser light therapy is another over-the-counter option that is generally safe for hair loss from any cause. Most other treatments for specific types of hair loss would need to be prescribed by a dermatologist.”
Folic acid supplements
“Methotrexate works by interfering with folic acid, and folic acid is very important for the reproduction of some cells, particularly cells that reproduce fairly rapidly,” says Dr. Hamburger. “We know that we can block the adverse effects of methotrexate by supplying folic acid, and if it’s done with the right kind of scheduling, it won’t interfere with the therapeutic effects — but it can mitigate the side effects.”
That said, outside of use with methotrexate, folic acid alone likely won’t be very effective for hair growth.
If you’re deficient in vitamin D, that could also be causing your hair thinning. Studies have shown that people with certain autoimmune diseases like multiple sclerosis or rheumatoid arthritis have vitamin D deficiency, per the AAD. But if your doctor recommends a supplement, don’t expect results overnight.
“Even if you identify the vitamin D deficiency and correct it, it’s going to take a very long time to see the impact of restoring vitamin D levels because hair grows very slowly,” says Dr. Friedman. “It grows about a centimeter a month, so you’re not going to see immediate feedback.”
And beware of supplements that promise you they’ll instantly give you thick locks of hair.
“Most of the hair supplements that are out there are pretty bogus,” says Dr. Friedman. “And don’t watch your hair grow — it’s going to be at least a year or two until you really appreciate a difference.”
Controlling your stress levels and living an overall healthy lifestyle is important for your hair. “Anything you can do to mitigate stress may help,” says Dr. Friedman. “Things like meditation, yoga, and exercise will help decrease the feeling of angst.”
Eating a vitamin-rich and protein-rich diet, getting enough sleep, and even hydration are also important for your hair health.
“Hydration is really important for your body’s self-regulation in general,” says Dr. Blazer. “I want to make sure you’re in as healthful of a state as possible. Hair follicles thrive when you have healthy blood flow to the scalp. Being well hydrated will help feed nutrients to the follicle and help it grow.”
And remember, if something isn’t good for your overall health, your hair won’t love it either.
“Doing things that are generally bad for you will be bad for your hair,” says Dr. Friedman. Think: eating an unhealthy diet, not getting enough sleep, or drinking or doing drugs.
Keep your hair styling in moderation — think curling, straightening, or blow drying your hair — to protect it from damage. And if you do style your hair, fortify it with conditioner.
“When somebody says to me their hair doesn’t grow beyond a certain length, it’s not that their hair stops growing, but rather that it just breaks off from damage,” says Dr. Friedman.
Here are more common habits that can further hair damage, per the AAD:
- Rubbing shampoo into the length of your hair. Instead, gently massage your scalp with shampoo and let it run through your hair when you rinse.
- Rubbing your hair with a towel. Wrap it to let it absorb the water instead.
- Brushing your wet hair. If you have straight hair, let it dry a bit before gently combing with a wide-tooth comb. If you have textured hair or tight curls, always comb hair while it’s damp with a wide-tooth comb.
- Pulling your hair back tightly. Wear it loosely instead.
As you deal with rheumatoid arthritis and hair loss, keep in mind that your doctor is there to help. There are many causes of hair loss and rheumatoid arthritis (and related factors) may or may not the primary reason for yours. Talk to your doctor about your symptoms and treatments so you can work together to figure out what’s going on.
10 Hair-Care Habits That Can Damage Your Hair. American Academy of Dermatology Association. August 13, 2021. https://www.aad.org/public/everyday-care/hair-scalp-care/hair/habits-that-damage-hair.
Boelaert K, et al. Prevalence and relative risk of other autoimmune diseases in subjects with autoimmune thyroid disease. American Journal of Medicine. February 2010. doi: https://doi.org/10.1016/j.amjmed.2009.06.030.
Can stress cause hair loss? Mayo Clinic. April 5, 2019. https://www.mayoclinic.org/healthy-lifestyle/stress-management/expert-answers/stress-and-hair-loss/faq-20057820.
Hair loss and thyroid disorders. British Thyroid Foundation. August 13, 2021. https://www.btf-thyroid.org/hair-loss-and-thyroid-disorders.
Hair Loss Types: Alopecia Areata Overview. American Academy of Dermatology Association. August 13, 2021. https://www.aad.org/public/diseases/hair-loss/types/alopecia.
Interview with Adam Friedman, MD, professor and Chair of Dermatology at George Washington University School of Medicine.
Interview with Ashira Blazer, MD, a rheumatologist and Assistant Professor in the Department of Medicine at NYU Grossman School of Medicine.
Interview with Carolyn Goh, MD, a dermatologist at UCLA Health Encino.
Interview with Max Hamburger, MD, Founder and Executive chairman of United Rheumatology.
Kandpal R. Alopecia universalis in a case of rheumatoid arthritis after treatment with etanercept. International Journal of Trichology. July 2019. doi: https://doi.org/10.4103/ijt.ijt_22_19.
Łukasik A, et al. The influence of methotrexate on hair loss while using immunomodulatory doses. Polski Merkuriusz Lekarski. February 28, 2019. https://pubmed.ncbi.nlm.nih.gov/30830893/.
Lupus: Can it cause hair loss? Mayo Clinic. November 24, 2020. https://www.mayoclinic.org/diseases-conditions/lupus/expert-answers/lupus/faq-20058400.
Minoxidil (Topical Route). Mayo Clinic. August 13, 2021. https://www.mayoclinic.org/drugs-supplements/minoxidil-topical-route/side-effects/drg-20068750?p=1.
Thyroid Disease. Cleveland Clinic. April 19, 2020. https://my.clevelandclinic.org/health/diseases/8541-thyroid-disease.