Medication is a mainstay of treatment for inflammatory arthritis like rheumatoid arthritis. Disease-modifying drugs are usually necessary to help prevent disease progression and manage symptoms. But any time you start a new medication, it’s natural to worry about potential side effects and risks.

One particular concern in our patient community is how arthritis medications may affect hair loss. Your appearance is tied in with your sense of identity and confidence, so hair loss can be especially devastating, adding insult to injury when dealing with a chronic disease.

“One of the medications that we use frequently is [the disease-modifying drug] methotrexate, and hair loss can be a side effect,” says Daytona Beach, Florida rheumatologist and CreakyJoints medical advisor Vinicius Domingues, MD. “I would say at least 5 to 10 percent of patients may experience hair loss. A lot of patients don’t want to take methotrexate because they worry it may affect the way they look.”

“I did worry a lot about [hair loss],” Anne M. told us on Facebook. “At first I was relieved as I thought I wasn’t doing so badly but now after a year, I can see my hair has thinned a lot. It does bother me, but I couldn’t go back to my life prior to treatment.”

However, it’s important to keep in mind that many patients who take arthritis medications will not experience hair loss.

In fact, recent research presented at the annual European Congress of Rheumatology (EULAR 2019) meeting looked at hair loss in a group of nearly 100 rheumatoid arthritis patients who just started taking low-dose methotrexate (more on this drug below) and used a hair-pulling test every few weeks for the first few months to see how their rate of hair loss compared with a control group of patients. The researchers found that low-dose methotrexate did not appear to predispose RA patients to increased hair fall during the study.

If hair loss does occur, you can work with your doctor to figure out how to manage it. “Treatment has to be individualized,” Dr. Domingues says. “[Doctors] have to go above and beyond to help make it better.”

Rheumatologist Ashira Blazer, MD, an assistant professor at NYU Langone Health, says she works with her dermatology colleagues to determine the best way to promote healthy hair growth if her patients experience hair loss. “As a physician, I must be concerned with the concerns of my patients,” she says. “Hair loss is extremely stressful for patients.”

Why Arthritis Medications Can Cause Hair Loss

“The primary group of medications that may cause hair loss would be DMARDs [disease-modifying anti-rheumatic drugs], particularly methotrexate,” says San Francisco rheumatologist Nancy Carteron, MD, who is part of the clinical faculty at the University of California, San Francisco (UCSF).

The way these DMARDs work can put hair cells in the line of fire. “In order to control arthritis, we use medications that limit the growth rate of hyper-active immune cells, which arise from the bone marrow. Apart from bone marrow, hair is the fastest-growing tissue in the body,” says Dr. Blazer. “As one can imagine, using a strategy that limits the growth of fast-replicating tissues may also influence the hair.”

Methotrexate and Hair Loss

Methotrexate (MTX) is commonly used to treat rheumatoid arthritis and some other types of inflammatory arthritis, and even with the risk of hair loss, “this remains the best medication to start with for most RA patients,” Dr. Carteron says.

Although some patients associate methotrexate is associated with chemotherapy for cancer, which notoriously causes complete (if temporary) hair loss, it’s important to note that methotrexate treatment for arthritis is NOT the same as getting chemotherapy to treat cancer.

“The dose and the way methotrexate is delivered for arthritis is very different from standard chemotherapy, and thus is not likely to cause the kind of hair loss that is possible or probable with chemotherapy,” Dr. Carteron says.

When used as chemotherapy, MTX is given in much higher doses and intravenously, she says. “In chemotherapy treatment for cancer, the goal is to kill a majority of the cancer cells, and more healthy cells can be killed during the treatment cycle,” Dr. Carteron says.

In contrast, MTX as an arthritis treatment is at a much lower dose, which means much less drastic side effects. “Methotrexate for RA is given once a week and most often orally with pills, and sometimes by injection. The medication exposure is intermittent, and normal cells have an opportunity to recover, which reduces the odds of experiencing hair loss.”

Unfortunately, Dr. Domingues says it’s hard to tell ahead of time which patients are may be more likely to experience hair loss from methotrexate. “Some thyroid issues can make people more prone to hair loss, so if you have hypothyroidism you’re at increased risk of having hair loss,” he says. Hypothyroidism affects certain hormones that can alter hair follicle growth. Other hormone disorders, such as polycystic ovarian syndrome, can also make hair loss more likely, Dr. Blazer says.

And if your hair is thin to begin with, any hair loss may be more noticeable. “My hair was never thick and it would come out in handfuls,” Karen N. told us on Facebook.

DMARDs and Hair Loss

Other DMARDs, such as leflunomide (Arava), can also cause hair loss through a similar mechanism as methotrexate. Some of the patients we heard from named this drug as responsible for their hair loss problems. “I had hair loss on methotrexate so I switched to leflunomide, and had hair loss worse than the methotrexate so I switched back,” Lindsey S. told us on Facebook.

Other Arthritis Medications and Hair Loss

Other medications for inflammatory arthritis, including biologics, may very infrequently cause hair loss, but this is “much rarer,” says Dr. Domingues. These drugs target specific immune system proteins, so their effects are less far-reaching. “They are more focused and more targeted therapies; therefore their side effects on the hair follicles is not really significant,” Dr. Domingues says. Anecdotally, we didn’t hear from any patients who experienced hair loss from biologic drugs.

Can You Do Anything to Stop or Minimize Hair Loss with Arthritis Drugs?

Fortunately, if you experience hair loss from your arthritis medication, there is a lot that can be done to minimize or stop it completely. “I have lowered the dose, stretched out the treatment cycle, made sure patients were taking folic acid and other B vitamins, and were eating a balanced anti-inflammatory diet,” Dr. Carteron says. Here are some tips to prevent hair loss that you can try.

1. Take folic acid to help prevent hair loss from methotrexate

Methotrexate also affects the absorption of the B vitamin folic acid, or folate in its natural form, which impacts cell division as well as hair growth. Patients on methotrexate should be taking folic acid at the same time to help mitigate methotrexate side effects, such as nausea. “We can increase the folic acid dose if hair loss is occurring,” says Dr. Domingues. Your doctor may also recommend a different version of folic acid called folinic acid, which is available by prescription. “It’s a little stronger,” says Dr. Domingues.

“I have had hair loss directly as a result of taking methotrexate — the hair loss was immediate — but I added extra folic acid and biotin [another B vitamin], and those helped,” Christina A. told us. Studies have shown taking folic acid doesn’t alter the effectiveness of MTX.

2. Change arthritis drugs or dosages

You may be able to switch to a different type of drug with less risk of hair loss, such as a biologic; or lower the dose of the offending medication while adding in another. “Luckily, there are many options for treating inflammatory arthritis, so management changes can be made in patients experiencing excessive hair loss,” Dr. Blazer says.

In the case of one patient experiencing hair loss, “methotrexate still proved to be the most effective therapy for her RA, even after trying other DMARDs,” Dr. Carteron says. “Therefore, she elected to remain on methotrexate plus a TNF-blocker biologic, but we utilized the lowest possible dose of methotrexate, adjusting it to her disease activity.”

Remember: Don’t stop taking any arthritis medication without first talking to your doctor.

3. Consider other causes of hair loss

If you’re experiencing hair loss and suspect it could be from arthritis medication, you should be evaluated by your doctor to figure out the root (no pun intended) cause of your hair loss. “The medication may be the one thing that you can identify as new or different, but that said, many other common things can cause hair loss, which may be misattributed to medications,” Dr. Blazer says.

“Thyroid problems, anemia, age-related hair loss or thinning, and hair loss associated with pregnancy can all play a role,” Dr. Carteron says. “I investigate other potential causes of hair loss for patients, and help manage them if indicated.” Even stress itself, which not surprisingly can result from a chronic condition, can lead to hair loss.

Having other co-occurring autoimmune conditions, such as lupus and alopecia areata, can also cause hair loss.

“Methotrexate helps my RA. I did stop it for a while when I was getting large bald spots, but it was determined that it wasn’t caused by my meds and I was diagnosed with alopecia areata,” Kris S. shared on FB.

Will Your Hair Grow Back?

Dr. Carteron says that hair can grow back after the cause of hair loss is identified and medications are adjusted as needed.

“With leflunomide I lost a third of the density of my hair, and I was devastated as it fell out so fast,” Sue B. told us on Facebook. “As soon as I stopped it, my hair began to recover.”

Some patients we heard from did say their hair didn’t totally regain its former fullness. “I didn’t stay on methotrexate for long, but my hair just never came back,” Rene Marie B. told us. Others said that their hair took a long time to regrow after stopping methotrexate as it slowly leaves the body. Some who stayed on MTX said the hair thinning eventually stopped.

Unfortunately, it’s hard to know exactly how your medication will affect you until you start it.

Even if your hair does thin, you might be the only one who can tell. “I had extremely thick hair to start with so my hairdresser and I are the only ones who notice,” Cindy B. told us. “I am still on methotrexate because it works and the hair thinning has slowed down.”

Medication side effects can be scary and concerning, but the risks need to be balanced with a medication’s benefits. Dr. Blazer says she reviews the side effects of medications, including hair loss, ahead of time with patients. “This empowers patients to look for the symptom and bring it up to me during our subsequent visits,” she says.

You’re part of the team deciding how to treat your disease, so if you’re not happy with how a drug is affecting you, talk to your doctor.

“It should be shared decision-making, a a conversation — this is never a monologue,” Dr. Domingues says. “It’s always a dialogue of two people, or even more if there are more family members involved, to discuss the ongoing treatment. Doctors and patients share the common goal of trying to make patients better.”

How to Cope with Hair Loss

Keep your hair healthy and as thick as possible while being treated with these tips:

Practice good hair care. Use conditioner and don’t rub your scalp too hard when shampooing or towel-drying. Avoid styling products and heat, and don’t pull your hair back in tight pony tails.

Use a thickening hair growth shampoo. “I found this stuff called Nutri-Ox, a shampoo, conditioner, and scalp spray, and using it my hair has started to regrow,” Sharon C. told us.

With your doctor’s OK, consider medical hair loss treatments. “I committed six months to a hair growth treatment program — thankfully it worked,” Deb S. told us. “I also changed medication. My hair is back in full force, no more wig and I’m still using the growth program.”

Keep a positive outlook. “Methotrexate improved my RA and I am able to walk, so considering the alternative of not taking it and having my hair back, I have learned to live with the thinning,” Mariann V. told us. “I wish it was not so, but so many others have far worse things to deal with!”

Even if hair loss happens, some patients put it in perspective this way: “My hair is still thin but would not stop my meds due to it,” Mary J. told us on Facebook. “Rather have less pain and no hair. No-brainer!”

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