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MS treatment and hair loss: what you need to know

Hair loss is not a symptom of MS, but can be a side effect of some MS treatments, and an MS diagnosis could be a contributing factor to stress-related hair loss.

It's normal to lose hair. We lose on average between 50 and 100 hairs a day, often without noticing. Most hair loss doesn't need treatment and is either temporary and it'll grow back or a normal part of getting older, but if you see an increase in hair loss and find your hair is thinning, this may be troubling. 

Hair loss is not a symptom of multiple sclerosis, however hair loss is a side effect of some MS medications or other commonly prescribed medications. A diagnosis of MS could also be a contributing factor to stress-related hair loss. There is no direct evidence that alopecia is more common in patients with MS than in the general population. 

You should consider seeing a physician if:

  • you have sudden hair loss

  • you develop bald patches

  • you're losing hair in clumps

  • your head also itches and burns

  • you're worried about your hair loss

Why is my hair thinning?

It can be difficult to establish the exact cause of hair loss and there are different types - hair falls out in patches, some in particular areas, or you can notice a general thinning of hair all over the head.

1. Genetic hair loss - female or male pattern baldness. 

  • This is the most common form of hair loss and is permanent. 

  • This is due to a family history of hair loss and is unrealted to MS. 

  • This usually temples or the crown of the head in men

  • Often occurs as early as teenage years in men, increasing in likelihood with age

  • This usually happens in 50s or 60s for women or occasionally 30s or 40s. 

  • Hair is lost at the front, top and the crown of the scalp for women.

2. Hair thinning (telogen effluvium) 

The second most common type of hair loss, telogen effluvium occurs when there is a marked increase in hairs shed each day (300). It is characterized by an abrupt onset of diffuse hair loss usually seen 2-3 months after a triggering event. It is usually self-limiting lasting for 6 months, whereas in chronic telogen effluvium it persists beyond 6 months.

Common triggers of telogen effluvium include: 

Hormonal 

  • Pregnancy

  • Postpartum hair loss can be experienced 2 to 4 months after childbirth (40 - 50% of women)

  • Menopause 

  • Discontinuing the use of birth control pills

Physiologic or emotional stress

  • Surgery or general anesthesia

  • Injury

  • Serious illness

  • Severe trauma, a stressful or major life event

Dietary triggers 

  • Severe calorie restriction 

  • Low protein diet 

  • Lack of Omega 3 and 6 

  • Vitamin D deficiency 

  • Iron deficiency 

  • Vitamin B deficiency 

Medication 

  • MS medication

You can find more information about each medication including side effects, risks and benefits in the medication area of the OMS website

Immunosuppressive agents

Hair loss is relatively commonly observed in patients with multiple sclerosis who receive immunosuppressive agents, and is thought to be a consequence of toxicity to the hair follicle.2

These include: 

Another potent anti-cancer drug, this is used to reduce the numbers of T and B cells that can trigger an immune attack. Hair loss is a common side effect. 

Mitoxantrone is a chemotherapy drug also used for some types of cancer and hair loss is a known side effect. This drug can cause you to lose all your hair, however this will usually grow back once your chemotherapy treatment has finished.

Hair loss is a common side effect of Cladribine (Mavenclad), meaning it affects more than 1 in 100 people. 

Other MS medications which can cause hair loss / thinning. 

Common:

More than a third of patients had hair loss in the studies in which this was reported. In one study, more than half the patients experienced hair loss in the first six months of treatment.

Hair loss is a common side effect of Teriflunomide (Aubagio). It is usually mild and temporary and does not require stopping treatment. One study found hair thinning occurred in 10–14% of teriflunomide-treated patients compared to 5% of placebo-treated patients.4

  • HSCT (Haemotopoeitic stem cell transplant) 

An aggressive MS treatment that involves wiping out a patient's immune system with chemotherapy - and then rebuilding it using stem cell transplants. Hair loss is often one of the side effects of the chemotherapy used during this treatment. 

Infrequent - very rare: 

Hair loss is an infrequent side effect of fingolimod (Gilenya). This means it occurs in between 1 in 100 and 1 in 1000 people.

Hair loss appears to be a very rare side effect of Alemtuzumab (Lemtrada). One known case of alopecia universalis has been reported.5

Hair loss is not a reported side effect of Dimethyl-fumarate (Tecfidera, BG-12) however there appears to be some anecdotal occurrences. One case was identified where hair loss occurred three months after starting Tecfidera. Hair re-grew over several months while the treatment was continued.6

Incidence not known: 

  • Glatiramer Acetate (Capoxone)

  • LDN 

  • Natalizumab (Tysabri) 

  • Steroids 

  • Ocrelizumab (Ocrevus) 

It is worth speaking to your neurologist about any medication if it is causing unwanted side effects, particularly if they are serious, but you must weigh up the benefits of a drug and whether it is improving MS symptoms. 


It also might be that hair loss is a side effect of another drug you are taking: 

  • Antidepressants and mood stabilizers  

Depression is a common symptom or comorbidity of MS therefore antidepressants or mood stabilisers may be prescribed. Antidepressants are also often used to treat neuropathic pain syndromes. If you are taking one of these medications, it could be that they are causing the hair loss, this often happens 4-8 weeks after starting the medication. This is not permanent and hair usually recovers up to six months after the medication is discontinued. 

  • Epilepsy medications 

  • Migraine medications

  • Blood pressure medicines 

  • HRT 

  • Blood thinners

  • Acne medications 


Other types of hair loss (unrelated to MS) 

3. Symptom of another medical condition: 

  • Thyroid disease

  • Scalp infections 

  • Other autoimmune disease - e.g.  lupus, Hashimoto’s disease, Graves’ disease, rheumatoid arthritis, alopecia areata (see below). 

4. Alopecia Areata

Alopecia areata (AA) is a common autoimmune disorder that often results in unpredictable hair loss. Hair is lost in patches and occurs because the follicle is affected by inflammation. It is not possible to predict how much hair will be lost. 4 out of 5 affected people will experience complete regrowth within 1 year without treatment. Alopecia universalis is an advanced form of AA when there is a complete loss of hair on the body and alopecia totalis is when there is a complete loss of hair on the scalp - this happens in about 5% of people with AA.

Someone with alopecia areata is slightly more likely than a person without it to develop other autoimmune conditions such as thyroid disease, diabetes, lupus and vitiligo. However there doesn't appear to be a link between AA and MS. 9

5. Trichotillomania 

Trichotillomania, also known as trich, is a hair pulling disorder when someone can't resist the urge to pull out their hair. They may pull out the hair on their head or in other places, such as their eyebrows or eyelashes. This can cause bald patches. 


Ways you can improve hair growth

There aren’t many proven treatments for hair loss but there are some things you can do to improve the health of your hair:

  • Make sure you are gentle with your hair. Avoid harsh treatments or colouring or tight hairstyles. 

  • Take care of your scalp.  Gently massage to increase blood flow and stimulate the scalp. 

  • Keep your hair and scalp moistured - condition your hair regularly. 

  • If you believe your hair loss could be caused by stress, try mindfulness based stress reduction and meditation. This is a key part of the OMS Recovery Program. 

  • If you are being treated with chemotherapy, ask your doctor about a cooling cap. This cap can reduce your risk of losing hair during chemotherapy.

  • Make sure you are eating a balanced diet: 

    • Essential fatty acids, especially omega-3s, play a key role in the health of your skin, hair, and nails. This is a key part of the OMS Recovery Program and can be found in: fatty fish such as salmon, tuna and mackerel, flaxseed oil and some nuts such as walnuts and almonds. 

    • Vitamins B6, B12, and folic acid are important for healthy hair, although they don’t promote hair growth. If you follow a completely vegetarian or vegan diet, you may want to consider taking a B12 Supplement.  Foods with B6 include bananas, potatoes, and spinach. You can get folic acid with plenty of fresh fruits and vegetables, especially citrus fruits and tomatoes. Whole-grain products, beans, and lentils also have it. 

    • Protein is also critical for keeping your hair healthy. The World Health Organisation (WHO) suggests that 0.83 g/kg per day protein is adequate. Fish, cooked green vegetables, avocados, soy products, legumes, whole grains, nuts and seeds are all good sources and are recommended on the OMS Recovery Program. 

    • Trace minerals like iron, magnesium, zinc, and biotin can also affect hair.

  • Get your iron levels tested to check that you are not anaemic. 

  •  Wait and see - most hair loss will stop in time and you will see regrowth. 

Hair loss is not a symptom of MS, but could be related as a side effect of a medication, or due to the stress of an MS diagnosis. The majority of hair loss or thinning is temporary, and does not require treatment.  


References

  1. https://jamanetwork.com/journals/jamaneurology/fullarticle/801063

  2. https://www.sciencedirect.com/topics/neuroscience/glatiramer-acetate 

  3. https://www.ncbi.nlm.nih.gov/pubmed/30830893 

  4. https://link.springer.com/article/10.1007%2Fs40120-018-0107-y 

  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5670499/

  6. https://www.sciencedirect.com/science/article/abs/pii/S2211034816300256 

  7. https://jamanetwork.com/journals/jamaneurology/fullarticle/801063 

  8. https://www.britishskinfoundation.org.uk/alopecia-areata

  9. https://www.jns-journal.com/article/S0022-510X(17)33504-9/abstract

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