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Psychotropic Medication and Drug-Related Alopecia
Psychotropic Medication and Drug-Related Alopecia JULIA
K.
WARNOCK,
M.D., PH.D.
The literature on alopecia as a side effect ofpsychotropic medications is reviewed. Druginduced alopecia usually presents as a diffuse, nonscarring alopecia that is reversible upon withdrawal ofthe drug. Certain psychotropic drugs-such as the beta-blockers,lithium, and anticonvulsants-are most likely to induce a drug-related alopecia. The evaluation and management ofpsychiatric patients with drug-induced alopecia are discussed.
I
n the current psychiatric literature there has been increased awareness of adverse cutaneous manifestations ofpsychotropic medication. 1.2 Alopecia is one such adverse condition characterized by sudden, generalized, or localized hair loss most commonly involving the scalp.3 Druginduced alopecia usually presents as a diffuse, nonscarring alopecia that is reversible upon withdrawal of the drug. Drugs are capable of producing a wide spectrum of alopecia, from flagrant, complete baldness to slight, barely noticed shedding.4 Further, subtle cases of hair loss may be difficult to detect, and it is possible that patients lose small amounts of hair without realizing it. Even if patients do notice hair loss, it may be considered trivial by some physicians and thus go unreported. The incidence rate of drug-related alopecia is difficult to determine accurately because both the numerator and the denominator of the proportion are unknown. The purpose of this article is to review alopecia as a definite, probable, or possible side effect of psychotropic med-
Received November 2, 1989; revised February 14. 1990; accepted March 7. 1990. From the Depanment of Psychiatry, University of Kansas Medical Center. Kansas City. Address reprint requests to Dr. Warnock. University of Kansas Medical Center. Department of Psychiatry. 39th and Rainbow Boulevard. Kansas City. KS 66103. Copyright 1991 The Academy of Psychosomatic Medicine.
e
VOLUME 32· NUMBER 2· SPRING \99\
ication and to make suggestions regarding the evaluation and management of patients who develop psychotropic drug-related alopecia. PSYCHOTROPIC MEDICATION ASSOCIATED WITH DEFINITE HAIR LOSS Beta-Blockers Beta-adrenoceptor antagonists are used with increasing frequency by psychiatrists for a variety of neuropsychiatric conditions, including anxiety disorders, performance anxiety, schizophrenia, aggressive behavior, and akathisia. s Propranolol (Inderal), the first of the beta-blockers to enjoy widespread use, has been well documented as being responsible for hair loss from the scalp6.7 or for parchy, reversible loss of hair from the scalp and body.s More recently introduced beta-blockers are also known to produce hair loss, including metoprolol 9 (Lopressor) and nadolol 'o (Corgard). Many clinicians have seen cases of hair loss secondary to beta-blockers, indicating that the true incidence of hair loss due to these drugs may be much higher than reported in the literature. II The mechanism of hair loss in patients taking beta-blockers is not known, but Stroud II notes that beta-blockers decrease cAMP, which is known to suppress mitosis in \49
_. Drug-Related Alopecia
epidennal cells. Additionally, beta-blockers inhibit catecholamine-induced glycolysis and lipolysis and inhibit the vasodilating effect of catecholamine on peripheral blood vessels. Lithium Lithium is a psychotropic medication occasionally associated with hair loss during treatment. It has been reported that 17% of 99 patients taking lithium developed hairthinning. 12 Another surveyl3 found that 12 of 100 patients attending a lithium clinic complained of hair loss. Hypothyroidism was detected in 3 of the 12 patients, and 2 had regrowth of hair with thyroxine. Other single case reports of alopecia assumed to be caused by lithium are noted. ' 4-'6 Some patients were found to have taken lithium for many years before severe hair loss appeared rather suddenly.17 Another report I 8 involving seven cases noted that lithium produced an increased telogen (resting phase) shedding rate, as evidenced by increased daily shedding counts over a 2-week period. The authors suggested that raised telogen counts equate with a telogen effluvium type of hair loss. There have been two independent reports of lithium-related hair loss that recurred with repeated administration of the drug. 19.20 Because of the reversal design incorporated in these latter reports, they offer the most conclusive demonstration of drug-related alopecia. The mechanism for hair loss with lithium is unknown. Excessive lithium concentrations in the hair 's were detennined not to be a factor. Lithium can cause hypothyroidism, which may account for (or at least contribute to) the observed hair loss. Generally, comprehensive evaluations of cases try to consider this factor 13 and include thyroid function studies in their evaluation. 13-20 PSYCHOTROPIC MEDICAnON ASSOCIATED WITH PROBABLE HAIR LOSS Anticonvulsants The anticonvulsant carbamazepine (Tegretol), a tricyclic compound related to imipramine, 150
is used in psychiatric practice because of its antimanic and antidepressant properties. 21 Carbamazepine has been reported to induce hair loss in an 8-year-old girI. 22 The hair shedding started within a week of drug initiation. It continued for approximately 1month until the drug was discontinued. Within several days after stopping carbamazepine, the molting of hair lessened, and new hair began to grow. There were no residual signs of alopecia after 1 month. Another anticonvulsant, valproic acid or valproate (Depakene, Depakote), has been reported to be effective in the treatment of recurrent major affective and schizoaffective disorders. 23 This drug has been documented to produce transient increases in hair loss in a small percentage ofpatients. 24 •25 TRICYCLIC ANTIDEPRESSANTS Given that tricyclic antidepressants are among the most frequently prescribed drugs in the United States, it is somewhat surprising that so little attention has been paid to alopecia stemming from these drugs. The Physicians' Desk Reference 26 notes alopecia as a side effect for all of the tricyclic antidepressants approved for use in the United States, but case reports of this side effect rarely appear in the literature. II Merrell Dow Pharmaceuticals, makers of desipramine (Norpramin), has received an average of one spontaneous report per year of alopecia since 1964 (J. Roney, July 1989, personal communication). These are likely to be the more severe and clinically significant cases. Mild-to-moderate cases of tricyclic antidepressant-induced alopecia probably remain underreported. Thus, the incidence rate of this side effect remains unknown. Imipramine (Tofranil) has been reported to cause a sudden patch of alopecia 5 x 5 cm on the posterior vertex of the scalp and some loss of hair in the eyebrows of a 36-year-old female. 27 Clinically, the lesion appeared to be an alopecia areata type of hair loss. However, the scalp biopsy did not support this diagnosis. While the biopsy was nondiagnostic, it was consistent with a telogen effluvium. In our own outpatient psychiatric clinic, two PSYCHOSOMATICS
Warnock
recent instances of hair loss believed to be a drug-related side effect of tricyclic antidepressants were spontaneously reported by patients within 2 months of each other and thus prompted the present review. The first case was that of a 35-year-old white female treated with imipramine for panic attacks. Approximately 3 months after the initiation of imipramine, the patient noticed a diffuse hair loss on the scalp. The increased hair loss continued at approximately the same rate for the next 4 months. After a total of 7 months, the imipramine was tapered. Six weeks following discontinuation, the patient reported that her hair loss began to decrease; by 2 months it had returned to the normal daily loss observed before administration of the drug. The second case involved a 9-year-old white female who first complained of hair loss 8 months after treatment with desipramine. The hair loss was diffuse and patchy, localized to the vertex of the scalp. Follow-up of the patient at 2 and 4 months following discontinuation ofthe desipramine indicated normal regrowth of hair in the patches of alopecia. PSYCHOTROPIC MEDICATION POSSIBLY ASSOCIATED WITH HAIR LOSS Other medications used by psychiatrists that may cause hair loss include amphetamines, I I verapamil 28 (a calcium channel-blocking agent first used in the treatment of acutely manic patients in 198229 ), phenothiazines,3O and tranylcypromine (Pamate),J1 a monoamine oxidase (MAO) inhibitor. HAIR PHYSIOLOGY The human hair follicle has two primary phases. The anagen or growth phase lasts approximately 3~ years and encompasses 80%-90% of the scalp follicles. The telogen or resting phase lasts approximately 3 months, after which the club hair is shed as the hair follicle initiates a new growth cycle. 32 Ten to fifteen percent of the scalp follicles are in the telogen phase. Almost 50% of the average 100,000 hairs on the scalp must be lost before clinically detectable thinning occurs. VOLUME 32· NUMBER 2· SPRING 1991
StroUd 11 notes that drug-induced alopecia is becoming more commonly recognized and that most cases of hair loss are due to telogen conversion. However, the mechanism of telogen conversion is poorly understood. Since hair proliferates more actively and has a different keratin and cement than that of the horny layer (stratum corneum), it may be more vulnerable to drugs than normal epidermis. I I As mentioned previously, drug-induced alopecia usually presents as a diffuse nonscarring alopecia. A diffuse hair loss mainly involving the scalp occurs when normal telogen hairs are shed, typically several months after the drug is given. Within 2 to 5 months after discontinuation of the drug, recovery occurs. 32 DIAGNOSIS AND TREATMENT Diagnosis of alopecia secondary to a psychotropic medication can be difficult. The best clinical evidence incriminating a particular drug is recovery of the hair loss with discontinuation of the drug and exacerbation of the alopecia upon reexposure. 11 It is often difficult, however, to get patients to agree to another drug exposure. Other causes of hair loss must be considered before a drug etiology can be concluded; unfortunately, the evaluation of noncicatricial (nonscarring) alopecia may be expensive and time-consuming. The clinician may want to evaluate the patient for history of pregnancy, infection (e.g., tinea, syphilis), endocrine disease, collagen vascular disease, deficiency states (e.g., iron and protein), other drugs (e.g., antimitotic, anticoagulant, birth control pills, antithyroid), recent surgery or fever, traction (e.g., braids, curlers), or trauma (e.g., hot comb). Laboratory data that may be helpful include complete blood count, thyroid function studies, antinuclear antibodies (ANA), ferritin, VDRL, possibly heavy-metal screen (lead, arsenic, and mercury), and scalp biopsy. Fortunately, drug-induced hair loss generally recovers after discontinuation of the drug. Thus, if the hair loss is diffuse, nonscarring, and not clinically impressive (although it may certainly be upsetting to the patient), drug discontinuation is prudent. If hair loss has not decreased 151
Drug-Related Alopecia
within 2 months, a more extensive evaluation may be in order. A clinician has several options when a patient develops psychotropic drug-related alopecia. Obviously, one could select an alternate drug therapy. However, if the patient has a good therapeutic response to a particular psychotropic medication, a physician could safely urge the patient to continue to take the offending agent in mild-to-moderate cases be-
cause it is unlikely that the alopecia will accelerate or lead to frank baldness. 18 There has been no published review of alopecia as a side effect of psychotropic medication. Psychiatrists and clinicians administering these medications will benefit from increased awareness of this potential side effect because it may be a source of noncompliance in some patients.
References I. Warnock JK. Knesevich JW: Adverse cutaneous reactions to anti-depressants. Am J Psychiatry 145:425-430.
1988 2. Biedennan J. Gonzalez E. Bronstein B. et al: Desipramine and cutaneous reactions in pediatric outpatients. J Clin Psychiatry 49:178-183, 1988 3. Mackie RM: Clinical Dermatology: An lIIus/rated Tex/book. New York. Oxford University Press. 1981 4. Brodin MB: Drug-related alopecia. Dermatol Clin 5:571-579.1987 5. Lader M: B-adrenoceptor antagonists in neuropsychiatry: an update. J Clin Psychiatry 49:213-223. 1988 6. Scribner MD: Propranolol therapy (letter). Arch Dermato/I13:1303. 1977 7. Hilder RJ: Propranolol and alopecia. Cutis 24:63--64. 1979 8. Martin CM. Southwick EG. Maibach HI: Propranolol induced alopecia. Am Heart J 86:236-237. 1973 9. GraeberCW. Lapkin RA: Metoprolol and alopecia. Cutis 28:633-634. 1981 10. Shelley ED. Shelley WB: Alopecia and drug eruption of the scalp associated with a new beta-blocker. nadolol. Cutis 35:148-149.1985 II. Stroud 10: Drug-induced alopecia. Seminars in Dermatology 4:29-34. 1985 12. McCreadie RG. Morrison DP: The impact of lithium in southwest Scotland: demographic and clinical findings. Br J Psychiatry 146:70-74. 1985 13. Orwin A: Hair loss following lithium therapy. Br J Dermato/108:503-504. 1983 14. Silvestri A. Santonastaso P. Paggiarin 0: Alopecia areata during lithium therapy: a case report. Gen Hasp Psychiatry 10:46-48. 1988 15. Muniz CE. Salem RB. Director KL: Hair loss in a patient receiving lithium. Psychosomatics 23:312-313.1982 16. Ghadirian AM. LaJinec-Michaud M: Repon of a patient with lithium-related alopecia and psoriasis. J Clin Psychiatry 47:212-213. 1986 17. Yassa R: Hair loss during lithium therapy (letter). Am J Psychiatry 143:943. 1986 18. Dawber R. Mortimer P: Hair loss during lithium treatment. BrJ DermatoI107:124-125, 1982
152
19. Jefferson JW. Griest JH. Diamond RL. et al: Lithium and hair loss. International Drug Therapy Newsletter 14:23, 1979 20. Yassa R, Ananth J: Hair loss in the course of lithium treatment: a report of two cases. Can J Psychiatry 28: 132-133, 1983 21. Ballenger JC. Post RM: Carbamazepine in manic-depressive illness: a new treatment. Am J Psychiatry 137:782-790. 1980 22. Shuper A. Stahl B. Weitz R: Carbamazepine-induced hair loss. Drug Intelligence and Clinical Pharmacy 19:924-925. 1985 23. McElroy SL. Keck PE. Pope HG: Sodium valproate: its use in primary psychiatric disorders. J Clin Psychopharmacol7: 16-24. 1987 24. Laljee HC. Parsonage MJ: Unwanted effects of sodium valproate in the treatment of epilepsy. in The Place of Sodium Valproate in the Treatment of Epilepsy: Royal Society ofMedicine International Congress and Symposium.N030. London.AcademicPress.1980.pp 141-158 25. Lewis JR: Valproic acid (Depakene): a new anticonvulsant agent. JAMA 240:2190-2192. 1978 26. Physicians' Desk Reference, 44th edition. Oradell. NJ, Medical Economics. 1990 27. Baral J, Deakins S: Imipramine-induced alopecia arcatalike lesions (Ietter).lnt J Dermatol26: 198, 1987 28. Rosing DR. Condit JR, Maron BJ, et al: Verapamil therapy: a new approach to the pharmacologic treatment of hypertrophic cardiomyopathy, U1: Effects of longtenn administration. Am J Cordiol 48:545-553, 1981 29. Dubovsky SL. Franks RD, Lifschitz ML. et al: Effectiveness of verapamiJ in the treatment of a manic patient. Am J Psychiatry 139:502-504, 1982 30. Poulsen J: Hair loss, depigmentation of hair, ichthyosis and blepharoconjunctivitis produced by dixyrazine. Acta Derm Venereal (Stockh) 61:85-88. 1981 31. Lesse S: Tranylcypromine (Parnate): a study of 1000 patients with severe agitated depressions. Am J Psychother 32:220-242. 1978 32. Blankenship ML: Drugs and alopecia. Australas J Dermotol24: 100-104. 1983
PSYCHOSOMATICS
K.
WARNOCK,
M.D., PH.D.
The literature on alopecia as a side effect ofpsychotropic medications is reviewed. Druginduced alopecia usually presents as a diffuse, nonscarring alopecia that is reversible upon withdrawal ofthe drug. Certain psychotropic drugs-such as the beta-blockers,lithium, and anticonvulsants-are most likely to induce a drug-related alopecia. The evaluation and management ofpsychiatric patients with drug-induced alopecia are discussed.
I
n the current psychiatric literature there has been increased awareness of adverse cutaneous manifestations ofpsychotropic medication. 1.2 Alopecia is one such adverse condition characterized by sudden, generalized, or localized hair loss most commonly involving the scalp.3 Druginduced alopecia usually presents as a diffuse, nonscarring alopecia that is reversible upon withdrawal of the drug. Drugs are capable of producing a wide spectrum of alopecia, from flagrant, complete baldness to slight, barely noticed shedding.4 Further, subtle cases of hair loss may be difficult to detect, and it is possible that patients lose small amounts of hair without realizing it. Even if patients do notice hair loss, it may be considered trivial by some physicians and thus go unreported. The incidence rate of drug-related alopecia is difficult to determine accurately because both the numerator and the denominator of the proportion are unknown. The purpose of this article is to review alopecia as a definite, probable, or possible side effect of psychotropic med-
Received November 2, 1989; revised February 14. 1990; accepted March 7. 1990. From the Depanment of Psychiatry, University of Kansas Medical Center. Kansas City. Address reprint requests to Dr. Warnock. University of Kansas Medical Center. Department of Psychiatry. 39th and Rainbow Boulevard. Kansas City. KS 66103. Copyright 1991 The Academy of Psychosomatic Medicine.
e
VOLUME 32· NUMBER 2· SPRING \99\
ication and to make suggestions regarding the evaluation and management of patients who develop psychotropic drug-related alopecia. PSYCHOTROPIC MEDICATION ASSOCIATED WITH DEFINITE HAIR LOSS Beta-Blockers Beta-adrenoceptor antagonists are used with increasing frequency by psychiatrists for a variety of neuropsychiatric conditions, including anxiety disorders, performance anxiety, schizophrenia, aggressive behavior, and akathisia. s Propranolol (Inderal), the first of the beta-blockers to enjoy widespread use, has been well documented as being responsible for hair loss from the scalp6.7 or for parchy, reversible loss of hair from the scalp and body.s More recently introduced beta-blockers are also known to produce hair loss, including metoprolol 9 (Lopressor) and nadolol 'o (Corgard). Many clinicians have seen cases of hair loss secondary to beta-blockers, indicating that the true incidence of hair loss due to these drugs may be much higher than reported in the literature. II The mechanism of hair loss in patients taking beta-blockers is not known, but Stroud II notes that beta-blockers decrease cAMP, which is known to suppress mitosis in \49
_. Drug-Related Alopecia
epidennal cells. Additionally, beta-blockers inhibit catecholamine-induced glycolysis and lipolysis and inhibit the vasodilating effect of catecholamine on peripheral blood vessels. Lithium Lithium is a psychotropic medication occasionally associated with hair loss during treatment. It has been reported that 17% of 99 patients taking lithium developed hairthinning. 12 Another surveyl3 found that 12 of 100 patients attending a lithium clinic complained of hair loss. Hypothyroidism was detected in 3 of the 12 patients, and 2 had regrowth of hair with thyroxine. Other single case reports of alopecia assumed to be caused by lithium are noted. ' 4-'6 Some patients were found to have taken lithium for many years before severe hair loss appeared rather suddenly.17 Another report I 8 involving seven cases noted that lithium produced an increased telogen (resting phase) shedding rate, as evidenced by increased daily shedding counts over a 2-week period. The authors suggested that raised telogen counts equate with a telogen effluvium type of hair loss. There have been two independent reports of lithium-related hair loss that recurred with repeated administration of the drug. 19.20 Because of the reversal design incorporated in these latter reports, they offer the most conclusive demonstration of drug-related alopecia. The mechanism for hair loss with lithium is unknown. Excessive lithium concentrations in the hair 's were detennined not to be a factor. Lithium can cause hypothyroidism, which may account for (or at least contribute to) the observed hair loss. Generally, comprehensive evaluations of cases try to consider this factor 13 and include thyroid function studies in their evaluation. 13-20 PSYCHOTROPIC MEDICAnON ASSOCIATED WITH PROBABLE HAIR LOSS Anticonvulsants The anticonvulsant carbamazepine (Tegretol), a tricyclic compound related to imipramine, 150
is used in psychiatric practice because of its antimanic and antidepressant properties. 21 Carbamazepine has been reported to induce hair loss in an 8-year-old girI. 22 The hair shedding started within a week of drug initiation. It continued for approximately 1month until the drug was discontinued. Within several days after stopping carbamazepine, the molting of hair lessened, and new hair began to grow. There were no residual signs of alopecia after 1 month. Another anticonvulsant, valproic acid or valproate (Depakene, Depakote), has been reported to be effective in the treatment of recurrent major affective and schizoaffective disorders. 23 This drug has been documented to produce transient increases in hair loss in a small percentage ofpatients. 24 •25 TRICYCLIC ANTIDEPRESSANTS Given that tricyclic antidepressants are among the most frequently prescribed drugs in the United States, it is somewhat surprising that so little attention has been paid to alopecia stemming from these drugs. The Physicians' Desk Reference 26 notes alopecia as a side effect for all of the tricyclic antidepressants approved for use in the United States, but case reports of this side effect rarely appear in the literature. II Merrell Dow Pharmaceuticals, makers of desipramine (Norpramin), has received an average of one spontaneous report per year of alopecia since 1964 (J. Roney, July 1989, personal communication). These are likely to be the more severe and clinically significant cases. Mild-to-moderate cases of tricyclic antidepressant-induced alopecia probably remain underreported. Thus, the incidence rate of this side effect remains unknown. Imipramine (Tofranil) has been reported to cause a sudden patch of alopecia 5 x 5 cm on the posterior vertex of the scalp and some loss of hair in the eyebrows of a 36-year-old female. 27 Clinically, the lesion appeared to be an alopecia areata type of hair loss. However, the scalp biopsy did not support this diagnosis. While the biopsy was nondiagnostic, it was consistent with a telogen effluvium. In our own outpatient psychiatric clinic, two PSYCHOSOMATICS
Warnock
recent instances of hair loss believed to be a drug-related side effect of tricyclic antidepressants were spontaneously reported by patients within 2 months of each other and thus prompted the present review. The first case was that of a 35-year-old white female treated with imipramine for panic attacks. Approximately 3 months after the initiation of imipramine, the patient noticed a diffuse hair loss on the scalp. The increased hair loss continued at approximately the same rate for the next 4 months. After a total of 7 months, the imipramine was tapered. Six weeks following discontinuation, the patient reported that her hair loss began to decrease; by 2 months it had returned to the normal daily loss observed before administration of the drug. The second case involved a 9-year-old white female who first complained of hair loss 8 months after treatment with desipramine. The hair loss was diffuse and patchy, localized to the vertex of the scalp. Follow-up of the patient at 2 and 4 months following discontinuation ofthe desipramine indicated normal regrowth of hair in the patches of alopecia. PSYCHOTROPIC MEDICATION POSSIBLY ASSOCIATED WITH HAIR LOSS Other medications used by psychiatrists that may cause hair loss include amphetamines, I I verapamil 28 (a calcium channel-blocking agent first used in the treatment of acutely manic patients in 198229 ), phenothiazines,3O and tranylcypromine (Pamate),J1 a monoamine oxidase (MAO) inhibitor. HAIR PHYSIOLOGY The human hair follicle has two primary phases. The anagen or growth phase lasts approximately 3~ years and encompasses 80%-90% of the scalp follicles. The telogen or resting phase lasts approximately 3 months, after which the club hair is shed as the hair follicle initiates a new growth cycle. 32 Ten to fifteen percent of the scalp follicles are in the telogen phase. Almost 50% of the average 100,000 hairs on the scalp must be lost before clinically detectable thinning occurs. VOLUME 32· NUMBER 2· SPRING 1991
StroUd 11 notes that drug-induced alopecia is becoming more commonly recognized and that most cases of hair loss are due to telogen conversion. However, the mechanism of telogen conversion is poorly understood. Since hair proliferates more actively and has a different keratin and cement than that of the horny layer (stratum corneum), it may be more vulnerable to drugs than normal epidermis. I I As mentioned previously, drug-induced alopecia usually presents as a diffuse nonscarring alopecia. A diffuse hair loss mainly involving the scalp occurs when normal telogen hairs are shed, typically several months after the drug is given. Within 2 to 5 months after discontinuation of the drug, recovery occurs. 32 DIAGNOSIS AND TREATMENT Diagnosis of alopecia secondary to a psychotropic medication can be difficult. The best clinical evidence incriminating a particular drug is recovery of the hair loss with discontinuation of the drug and exacerbation of the alopecia upon reexposure. 11 It is often difficult, however, to get patients to agree to another drug exposure. Other causes of hair loss must be considered before a drug etiology can be concluded; unfortunately, the evaluation of noncicatricial (nonscarring) alopecia may be expensive and time-consuming. The clinician may want to evaluate the patient for history of pregnancy, infection (e.g., tinea, syphilis), endocrine disease, collagen vascular disease, deficiency states (e.g., iron and protein), other drugs (e.g., antimitotic, anticoagulant, birth control pills, antithyroid), recent surgery or fever, traction (e.g., braids, curlers), or trauma (e.g., hot comb). Laboratory data that may be helpful include complete blood count, thyroid function studies, antinuclear antibodies (ANA), ferritin, VDRL, possibly heavy-metal screen (lead, arsenic, and mercury), and scalp biopsy. Fortunately, drug-induced hair loss generally recovers after discontinuation of the drug. Thus, if the hair loss is diffuse, nonscarring, and not clinically impressive (although it may certainly be upsetting to the patient), drug discontinuation is prudent. If hair loss has not decreased 151
Drug-Related Alopecia
within 2 months, a more extensive evaluation may be in order. A clinician has several options when a patient develops psychotropic drug-related alopecia. Obviously, one could select an alternate drug therapy. However, if the patient has a good therapeutic response to a particular psychotropic medication, a physician could safely urge the patient to continue to take the offending agent in mild-to-moderate cases be-
cause it is unlikely that the alopecia will accelerate or lead to frank baldness. 18 There has been no published review of alopecia as a side effect of psychotropic medication. Psychiatrists and clinicians administering these medications will benefit from increased awareness of this potential side effect because it may be a source of noncompliance in some patients.
References I. Warnock JK. Knesevich JW: Adverse cutaneous reactions to anti-depressants. Am J Psychiatry 145:425-430.
1988 2. Biedennan J. Gonzalez E. Bronstein B. et al: Desipramine and cutaneous reactions in pediatric outpatients. J Clin Psychiatry 49:178-183, 1988 3. Mackie RM: Clinical Dermatology: An lIIus/rated Tex/book. New York. Oxford University Press. 1981 4. Brodin MB: Drug-related alopecia. Dermatol Clin 5:571-579.1987 5. Lader M: B-adrenoceptor antagonists in neuropsychiatry: an update. J Clin Psychiatry 49:213-223. 1988 6. Scribner MD: Propranolol therapy (letter). Arch Dermato/I13:1303. 1977 7. Hilder RJ: Propranolol and alopecia. Cutis 24:63--64. 1979 8. Martin CM. Southwick EG. Maibach HI: Propranolol induced alopecia. Am Heart J 86:236-237. 1973 9. GraeberCW. Lapkin RA: Metoprolol and alopecia. Cutis 28:633-634. 1981 10. Shelley ED. Shelley WB: Alopecia and drug eruption of the scalp associated with a new beta-blocker. nadolol. Cutis 35:148-149.1985 II. Stroud 10: Drug-induced alopecia. Seminars in Dermatology 4:29-34. 1985 12. McCreadie RG. Morrison DP: The impact of lithium in southwest Scotland: demographic and clinical findings. Br J Psychiatry 146:70-74. 1985 13. Orwin A: Hair loss following lithium therapy. Br J Dermato/108:503-504. 1983 14. Silvestri A. Santonastaso P. Paggiarin 0: Alopecia areata during lithium therapy: a case report. Gen Hasp Psychiatry 10:46-48. 1988 15. Muniz CE. Salem RB. Director KL: Hair loss in a patient receiving lithium. Psychosomatics 23:312-313.1982 16. Ghadirian AM. LaJinec-Michaud M: Repon of a patient with lithium-related alopecia and psoriasis. J Clin Psychiatry 47:212-213. 1986 17. Yassa R: Hair loss during lithium therapy (letter). Am J Psychiatry 143:943. 1986 18. Dawber R. Mortimer P: Hair loss during lithium treatment. BrJ DermatoI107:124-125, 1982
152
19. Jefferson JW. Griest JH. Diamond RL. et al: Lithium and hair loss. International Drug Therapy Newsletter 14:23, 1979 20. Yassa R, Ananth J: Hair loss in the course of lithium treatment: a report of two cases. Can J Psychiatry 28: 132-133, 1983 21. Ballenger JC. Post RM: Carbamazepine in manic-depressive illness: a new treatment. Am J Psychiatry 137:782-790. 1980 22. Shuper A. Stahl B. Weitz R: Carbamazepine-induced hair loss. Drug Intelligence and Clinical Pharmacy 19:924-925. 1985 23. McElroy SL. Keck PE. Pope HG: Sodium valproate: its use in primary psychiatric disorders. J Clin Psychopharmacol7: 16-24. 1987 24. Laljee HC. Parsonage MJ: Unwanted effects of sodium valproate in the treatment of epilepsy. in The Place of Sodium Valproate in the Treatment of Epilepsy: Royal Society ofMedicine International Congress and Symposium.N030. London.AcademicPress.1980.pp 141-158 25. Lewis JR: Valproic acid (Depakene): a new anticonvulsant agent. JAMA 240:2190-2192. 1978 26. Physicians' Desk Reference, 44th edition. Oradell. NJ, Medical Economics. 1990 27. Baral J, Deakins S: Imipramine-induced alopecia arcatalike lesions (Ietter).lnt J Dermatol26: 198, 1987 28. Rosing DR. Condit JR, Maron BJ, et al: Verapamil therapy: a new approach to the pharmacologic treatment of hypertrophic cardiomyopathy, U1: Effects of longtenn administration. Am J Cordiol 48:545-553, 1981 29. Dubovsky SL. Franks RD, Lifschitz ML. et al: Effectiveness of verapamiJ in the treatment of a manic patient. Am J Psychiatry 139:502-504, 1982 30. Poulsen J: Hair loss, depigmentation of hair, ichthyosis and blepharoconjunctivitis produced by dixyrazine. Acta Derm Venereal (Stockh) 61:85-88. 1981 31. Lesse S: Tranylcypromine (Parnate): a study of 1000 patients with severe agitated depressions. Am J Psychother 32:220-242. 1978 32. Blankenship ML: Drugs and alopecia. Australas J Dermotol24: 100-104. 1983
PSYCHOSOMATICS