Various clinical conditions can cause hair loss, including scalp diseases, systemic or infectious diseases, toxic agents, hormonal imbalances, and psychiatric disorders. Hair loss in the present patients is likely caused by sertraline, since hair loss appeared after increasing the dose of sertraline and improved after the dose reduction. Information about drug-induced alopecia is sparse and limited to case reports in medical literature. Drug-induced hair loss is more common than what is realized by many clinicians. Few details are available in this context, and hair loss secondary to drug use is often difficult to confirm (
The exact prevalence of hair loss with SSRI treatment has not been determined. In fact, quantifying this prevalence is likely not possible; it is difficult to diagnose hair loss due to drug use because no special method exists to arrive at this diagnosis. The only way to confirm the diagnosis is to stop the medication and observe hair regrowth (
6). For the differential diagnosis, it is necessary to consider trichotillomania, hypothyroidism, hyperthyroidism, hormonal pathologies of the hypothalamic-pituitary-gonadal axis, and iron deficiency. It is also crucial to investigate the potential use by a given patient of other drugs related to hair loss (antihypertensive agents, anticoagulants, anticonvulsants, non-steroidal anti-inflammatory drugs, antiulcer agents) ( 14). For this reason, other conditions associated with hair loss must be rejected during differential diagnosis.
The pathological mechanism of hair loss due to psychotropic drugs has not yet been fully elucidated. The direct toxic effects of psychotropic drugs on the hair follicle matrix must be considered as a possible reason for hair loss in this case (
15). The mechanism of drug-induced hair loss is termed telogen effluvium that involves a premature interruption of growth with early entry of anagen follicles into the resting phase. Hair loss tends to occur within the first 3 months of initiating therapy but may be further delayed ( 3, 4). It has also been shown that human skin can produce serotonin and transform it into melatonin, which has been implicated in hair-growth cycle. Therefore, it is possible that treatments interfering with serotonin homeostasis in the skin may alter the balance between hair growth and hair shedding ( 16). These data suggest a pathophysiological cause of hair loss with the use of antidepressant drugs that has not yet been fully identified ( 4). Given this, it is known that most psychotropic medication causes hair loss in the telogen phase of the hair cycle ( 4). Hair loss observed in patients receiving antidepressant drug treatment potentially relates to personal sensitivity rather than the drug administered ( 5). Although these drugs have an effect on zinc and selenium chelates, several obstacles has faced explaining this effect, namely the inefficiency of zinc and selenium supplements in treatment and the lack of information on the effect of cellular mechanism ( 17). Most drugs cause alopecia likely due to making the hair follicles to enter the resting phase. Therefore, decreasing the dose (or halting treatment completely) could potentially reverse this trend and lead to hair regrowth ( 3, 4).
A variety of serotonin reuptake inhibitors have been shown to cause hair loss, though this side effect is generally rare. The risk of alopecia seems to vary between different SSRIs (
18), and SSRI-induced hair loss is associated with an individual, rather than a drug-specific, sensitivity ( 4). Sertraline can cause hair loss; sertraline and fluoxetine may have different effects on hair loss due to different dopaminergic effects; other SSRIs have been shown to rarely cause hair loss. Sertraline’s relative potency for dopamine reuptake inhibition is one of its points of differentiation from other SSRIs such as fluoxetine ( 19). The different influence exerted by sertraline and fluoxetine on dopamine reuptake inhibition was identified as a possible reason for the side effect of hair loss. In fact, commonly prescribed prescription medications (such as dopaminergic agents) can cause temporary hair loss. In reviewing literature, there have been rarely reports of hair loss after administration of various antidepressant medications, including sertraline ( 12, 19).
A total of 27 reports of alopecia were identified in the SWEDIS drug database. As two reports concerned the use of two SSRIs, there were a total of 29 drug-ADR combinations, all but 3 of which were in women (88.9%). The reported rate for alopecia in Sweden was significantly higher with sertraline compared with citalopram, i.e. 20.1 (95% CI 10.7 - 34.4) reports per million patient-years versus 4.5 (95% CI 1.8 - 9.3) reports per million patient-years (
Bourgeois published 2 cases of hair loss due to sertraline. The first case reportedly noticed hair loss approximately 6 weeks after starting sertraline 50 mg. In this case, when sertraline was replaced by paroxetine, hair loss stopped and the hair returned to normal thickness. The second case, a female patient who developed sertraline-related alopecia (150 mg/day), discontinued the drug 2 months after noticing the side effect and switched the treatment to trazodone therapy with no recurrence of hair loss (
19) reported a patient with a major depressive disorder who complained of diffuse scalp hair loss followed by treatment with sertraline. This case is unique because the patient had taken fluoxetine without reporting hair loss both before taking sertraline and after discontinuation. Uzun and colleagues ( 5) reported that hair loss developed in one patient following sertraline use and ceased within around 3 months after sertraline discontinuation. Turkoglu ( 12) reported that extensive hair loss developed with both sertraline and fluoxetine therapy in one case while it then ceased after the patient discontinued these two medications in favor of venlafaxine.
Clinical detection of hair loss is challenging until 25% to 50% of a patient’s hair is lost. Therefore, hair loss is a subjective complaint and it is mostly observed during washing or combing of the hair (
3). Definitively concluding that a given drug causes hair loss presents specific challenges, as no special method exists for arriving at this diagnosis. Rather, discontinuing a drug (or reducing its dose) is often the only way to establish a causal connection to hair loss ( 20). In our case, hair re-grew after the sertraline dose decreased, indicating that hair loss was induced by sertraline. During differential diagnosis, the following should be considered and ruled out: trichotillomania; hypothalamic-pituitary-gonadal axis hormone disorders; hypo/ hyperthyroidism; iron and copper deficiencies; menopause ;and use of oral contraceptives and other drugs that potentially cause hair loss, such as antihypertensive, anticoagulant, anticonvulsive, non-steroid anti-inflammatory, and antiulcer drugs ( 21). Necessary biochemical and endocrinological assays were also conducted on our patient, with the aforementioned considerations excluded along with renal and hepatic insufficiency and hepatitis in the process of differential diagnosis No dermatological illness that could cause hair loss was observed in our case. Observation of hair growth following the rule out of other differential diagnoses and lowering the medication led us to the conclusion that hair loss in our case related to sertraline. In terms of etiology, another interesting point in our case is that, while the majority of reported cases of antidepressant-induced hair loss are in women, our case study was a middle-aged man and it is therefore atypical in terms of gender; in Hedenmalm ( 18) study, all except 3 cases were in women. The previously published case reports on SSRIs and alopecia also predominantly reviewed cases in women ( 7, 9, 11, 22- 25). It is possible that women may be more preoccupied with their hair and more prone to report hair loss to their physicians. Hair loss may also be more noticeable if the hair is long; some men already have a limited amount of hair. Despite these considerations, it is also plausible that women have an increased risk of SSRI-induced alopecia compared with men, even after correcting for the fact that more women than men are treated with SSRIs ( 19).
Drug-induced hair loss generally resolves (with recovery of hair growth) within 2 months after discontinuation of the drug (
3). When an effective psychotherapeutic agent causes alopecia and no appropriate alternative can be provided, the informed patient and clinician should discuss the risks and benefits of continuing, stopping, or changing the dose or medication. Hair loss may be a rare side effect of SSRIs, but it is considered particularly traumatic for both men and women ( 6). Necessary measures must be taken to obviate this side effect when it emerges, including review of the advantages and disadvantages of maintaining treatment with the drug potentially causing the side effect. Significant hair loss should be monitored in treatment because it may lead to bad compliance non-adherence and relapse. Future clinical experience and more research may further clarify drug-induced hair loss and offer new therapeutic recommendations.
Alopecia induced by medications is generally characterized by a diffuse, non-scarring hair loss and its reversibility after stopping drug. Dosage reduction, drug stopping or pursuing therapy with another agent remains the most promising management option (
26). 3.1. Conclusion
Hair loss related to SSRIs is an infrequently observed adverse effect that may be overlooked. We believe that hair loss should also be investigated during control visits in addition to other adverse effects as it may damage the patient’s outer general appearance and negatively affect his or her adherence to management. The cause of this hair loss has not yet been fully elucidated; Researches on larger patient groups that aim to develop the potential mechanism of hair loss are required. Further investigation is needed to determine the scope of this troubling side effect.