Psychotropic medication and drug-related alopecia

Dissolving microneedles for alopecia treatment

Alopecia is a treatable benign disease, however, approximately 15-30% of women and 50% of men suffer from alopecia, which greatly affects patient's self-esteem and quality of life. Currently, commercial products for alopecia treatment include topical minoxidil solution, oral finasteride tablets and oral baricitinib tablets. However, the barrier of stratum corneum, systemic adverse effects and poor cure rate limit the application of commercial products. Therefore, researchers investigated the mechanism of alopecia, and developed new drugs that could target lactate dehydrogenase-related pathways, remove excessive reactive oxygen in hair follicles, and reduce the escape of hair follicle stem cells, thus injecting new strength into the treatment of alopecia. Moreover, starting from improving drug stratum corneum penetration and reducing side effects, researchers have developed hair loss treatment strategies based on dissolved microneedles (MNs), such as drug powders/microparticles, nanoparticles, biomimetic cell membranes, phototherapy and magnetically responsive soluble microneedles, which show exciting alopecia treatment effects. However, there are still some challenges in the practical application of the current alopecia treatment strategy with soluble microneedles, and further studies are needed to accelerate its clinical translation.

Citalopram-Associated Alopecia: A Case Report and Brief Literature Review

Background:

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatments for various psychiatric disorders. SSRIs offer an improved side effect profile compared to older treatments, which improves patients’ adherence and quality of life.

Case Report:

Here we discuss a case of an uncommon, but a distressing side effect of citalopram. A 76-year old woman was referred to the psychiatry clinic for bizarre behavior. The patient was diagnosed with behavioral variant frontotemporal dementia and was started on citalopram 20 mg and aripiprazole 5 mg daily. At 3.5 months the patient complained of diffuse hair thinning on her scalp. Citalopram was considered the offending agent and was discontinued. Within a few months, the patient regained most of her hair. Although drug-induced alopecia is common among other SSRIs, it is relatively rare with citalopram.

Results and Conclusion:

Early recognition, withdrawal of offending agent, and reassurance to the patient that hair loss is reversible can help alleviate patient distress and avoid relapse.

Risk of valproic acid-related alopecia: A systematic review and meta-analysis

PURPOSE

We systematically reviewed studies to provide current evidence about the incidence and risk of alopecia in patients undergoing valproic acid (VPA) therapy.

METHODS

We retrieved relevant publications and gathered data on alopecia in patients taking VPA and other drugs from prospective studies.

RESULTS

Twenty-five articles met the inclusion criteria, and the overall incidence of alopecia in patients receiving VPA therapy was 11% (95% confidence interval (CI): 0.08-0.13). The pooled risk of alopecia showed a significant difference between patients treated with VPA and all other drugs (odds ratio (OR) 5.02, 95% CI: 3.58-7.03), other epileptic drugs (AEDs) (OR 4.82, 95% CI: 3.32-7.00) and other non-AEDs (OR 5.84, 95% CI: 2.67-12.81). Compared to other drugs, VPA increased the risk of alopecia both in patients with migraine headaches (OR 6.05, 95% CI: 2.89-12.63) and patients with epilepsy (OR 5.29, 95% CI: 3.53-7.92), and the increase risk was reported more frequently in patients with migraine. Both lower doses (OR 4.38, 95% CI: 2.32-8.25) and shorter treatments (OR 4.98, 95% CI: 2.41-10.25) with VPA posed a high risk of alopecia compared to other drugs, as did higher doses and longer treatment times.

CONCLUSIONS

Based on our findings, VPA was significantly associated with a risk of alopecia compared to other drugs, and the risk did not depend on the dose and treatment time.

Severe hair loss associated with psychotropic drugs in psychiatric inpatients-Data from an observational pharmacovigilance program in German-speaking countries

BACKGROUND

The study aimed to investigate severe hair loss related to psychotropic drugs (PDs) by using data from the drug safety programme Arzneimittelsicherheit in der Psychiatrie (AMSP).

METHODS

Data on PD utilization and reports of severe PD-related hair loss were collected in 83 psychiatric hospitals in Austria, Germany and Switzerland during the period 1993-2013.

RESULTS

Out of 432,215 patients under surveillance, 404,009 patients were treated with PDs for the main indications of depression, schizophrenic disorder, neurosis, mania, and organic psychosis. Severe hair loss related to PD treatment was reported in 43 cases (0.01%). The rates of hair loss under antipsychotic drugs were slightly lower than the mean rates of all PDs and antidepressant drugs. Valproic acid was related to the highest risk. In 6 of the 43 cases, hair loss was imputed to multiple drugs, with 4 cases imputed to double drug combinations and 2 cases to triple combinations. Rates of severe hair loss under valproic acid (VPA) and lithium salts were distinctly lower as compared with the overall rates reported in literature. Severe hair loss under PD treatment was reported significantly more often in female patients than in male patients (p < 0.01).

CONCLUSION

The rate of severe PD-related hair loss was very low in the present survey. The large number of patients included in this multicentre study allows for assessment and comparison of hair loss rates related to different PDs and groups of PDs and provides new and supplementary information on PD-related hair loss.

Drugs and hair loss

Hair loss is a common complaint, both in men and women, and use of prescription medications is widespread. When there is a temporal association between the onset of hair loss and commencement of a medication, the medication is commonly thought to have caused the hair loss. However, hair loss and in particular telogen effluvium may occur in response to a number of triggers including fever, hemorrhage, severe illness, stress, and childbirth, and a thorough exclusion of these potential confounders is necessary before the hair loss can be blamed on the medication. Certain medications are known to cause hair loss by a variety of mechanisms including anagen arrest, telogen effluvium, or accentuation of androgenetic alopecia by androgens.

Adverse cutaneous reactions to antipsychotics

Antipsychotic agents are known to cause adverse cutaneous reactions in approximately 5% of the individuals for whom they are prescribed. The majority of adverse cutaneous events are benign and easily treated, and do not place the patient at a serious health risk. However, these adverse events may impact on compliance so discussing strategies with the patient to avoid potential adverse cutaneous effects will improve compliance. The most frequently reported cutaneous adverse effects of antipsychotic medications include: exanthematous eruptions, skin pigmentation changes, photosensitivity, urticaria and pruritus. Only a small percentage of adverse cutaneous reactions are life threatening. The most important step in minimizing morbidity is prompt recognition of severe drug reactions with withdrawal of the causative medication. If a skin eruption occurs in an outpatient setting, it is generally advisable to discontinue the drug and to consider switching to another class of agent. If the reaction is mild, and the therapeutic benefits far exceed the risks of the symptomatic treatment, then the antipsychotic agent may be continued.

Adverse cutaneous reactions to antidepressants

Antidepressants are among the most widely prescribed medications in the United States. Adverse cutaneous drug reactions (ACDRs) associated with drugs are common, with possibly higher rates associated with psychotropic medications. While the vast majority of ACDRs are benign and easily treated, serious and life- threatening ACDRs, such as those associated with antidepressants, do rarely occur. ACDRs to antidepressants are diagnosed primarily on the basis of the patient's history. A clinician who is aware of these common and potentially serious adverse events will help avoid their continuation or recurrence. There are certain characteristics that place an individual at higher risk for an ACDR such as female gender, increasing age, African-American ethnicity, use of multiple medications and presence of a serious illness. If a cutaneous reaction occurs in an outpatient setting, it is advisable to discontinue the offending antidepressant and substitute it with one from another class. Treatment of the ACDR should be symptomatic if the patient shows no other significant signs of reaction. If other signs are present, however, a dermatology consultation should be obtained. Since the diagnosis of ACDRs is often tentative, and the exanthema is likely to be benign, the physician treating a patient with a mood or anxiety disorder must weigh the risk of developing these potential problems against the possibility of relapse of the psychiatric disorder should the medication be discontinued.

Alopecia due to psychotropic medications

OBJECTIVE

To review the literature and describe the incidence and nature of psychotropic drug-related alopecia to assist clinicians in their therapeutic decisions when this adverse event occurs.

DATA SOURCES

A MEDLINE search (December 1966-March 1998), using each drug name and the keywords alopecia or hair loss, was conducted. A database from the Clarke Institute of Psychiatry in Toronto was also searched. Additional English-language articles were identified through the bibliography of the reviewed literature. Certain pharmaceutical companies were also consulted.

STUDY SELECTION

All published case reports and review articles were considered for study evaluation.

DATA EXTRACTION

When possible, details regarding psychotropic drug therapy, development of alopecia, and clinical outcomes were collected for each case.

DATA SYNTHESIS

Hair loss from the scalp, eyebrows, and pubic area was identified as a possible, yet uncommon, adverse effect of most psychotropic medications. There are few effective management options for alopecia; however, resolution was achieved on discontinuation of the offending drug in almost all of the cases reported. Alopecia was perceived to be an undesirable effect by most patients, often resulting in poor compliance and hence therapeutic failures.

CONCLUSIONS

Due to the self-limiting nature of mild to moderate hair loss with psychotropic medications, clinicians should consider continuing therapy if there is a good clinical response and the patient agrees with this decision. If severe alopecia occurs, it is recommended to discontinue the medication and pursue therapy with another agent. This is to ensure positive therapeutic outcomes and improved patient compliance.

Lithium therapy associated with hidradenitis suppurativa: case report and a review of the dermatologic side effects of lithium

Lithium is frequently used in the management of several psychiatric disorders including acute mania, bipolar (manic-depressive) disorder, and recurrent depression. We describe a patient in whom hidradenitis suppurativa developed while the patient was receiving lithium. The cutaneous side effects of lithium are reviewed. The most frequent are psoriasis, acneiform lesions, folliculitis, alopecia, and a maculopapular/macular eruption. Many of these side effects respond less readily to conventional therapy while the patient is receiving lithium.

Alopecia areata associated with haloperidol

A patient with a 7-year history of depression relapsed after self-discontinuation of antidepressant drugs. He was admitted to our hospital and re-administered amoxapine 150 mg. p.o. per day, and further given haloperidol 5 mg i.m. or p.o. per day because he was suicidal and excited. One month later, an area of alopecia was found on the back of his head. Immediately, he received dermatological treatment. The psychotropic drugs were continued, but the hair loss was unchanged after one month. So, haloperidol alone was discontinued. One week later, the hair loss had stopped and a month later alopecia had virtually disappeared. We suggest that alopecia areata is associated with haloperidol.

Alopecia and mood stabilizers: two case reports

Two cases of alopecia observed during treatment with lithium and valproate are described, and the recent literature on this subject is reviewed. Our clinical observations confirm earlier reports. These toxic alopecias are characterized by a diffuse but rarely total hair loss. After stopping medication, the hair grows back generally and completely. Two cases of toxic alopecia are presented where hair grew back following a substitution of lithium by valproate in the first case and after stopping valproate in the second. The evaluation and therapeutic attitude in the presence of alopecia in patients needing mood stabilizers are also discussed.