Asian Skin Rejuvenation at a glance
- Best Results10-16 months after stopping
- Treatment Recovery4-8 months
- Procedure TimeNA
- Skin SpecialistMedical dermatologist
- Duration of ResultsRegrowth probable
- Back to WorkNA
Accutane- Isotretinoin Induced Hair Loss
Hair loss on Accutane is more common than what is reported in the literature. Early identification & intervention will prevent & in the vast majority of cases reverse hair shedding. In the vast majority of times, hair loss is self-limiting. Correct hair care will reduce chances of hair breakage/loss.
FactsFacts on Accutane Induced Hair Loss
- Skin, nails & hair side effects are experienced by over 80% of people on isotretinoin
- The majority of side effects can be mitigated with a little knowledge
- Hair fragility & thinning can be seen in up to 8% of users
- Tips on how to monitor for hair loss are discussed on this page
- Hair loss on Accutane/Roaccutane is more common in females
- Basic hair care including correct drying, combing & moisturizing can markedly decrease the chances of hair fall
- The majority of Accutane induced hair loss will improve
- It can take up to 10-16 months to recover
How common is hair loss from Accutane/Isotretinoin?
Very, however it is under-reported, the stats are 932 times between 1997 to 2017. Hair loss accounts for 9% of all adverse events from this medication.
The true figure in clinical practice would far exceed the reported cases to the FDA. The majority of cases are female (about 70%) , with males accounting for the rest.
How does hair loss occur on Accutane/Isotretinoin?
This is controversial as new research in 2019/2020 have challenged the notion of Accutane-Accutane induced hair loss.
The general consensus is that isotretinoin is due to telogen effluvium. Namely this drug slows down the growing phase of hair follicles (anagen), with defective anchoring of the hairs in telogen. This accounts for hair shedding.
Recent publications have shown no increase in hair loss on doses up to 0.5 mg per day for up to 3 months duration. Personally, I think that paper is crap, as the majority of patients will be on this medication for up to 6-12 months. The authors should have extended the study to 12 months.
Does Accutane cause permanent hair loss?
The absolute majority of cases are not permanent, however caveats are present- see below -’other factors that contribute to hair loss.’
Hair regrowth will begin at 3-4 months, & it can take 10-16 months for full regrowth. In some cases, stressing about hair loss can lead to telogen effluvium, namely rebound delayed hair loss that occurs months after stress, hence the cycle continues.
Does the dose of Accutane correlate with hair loss?
In the context of evidence-based research, no. The biggest study (as of 2021) does not suggest that being on a whacking big dose of isotretinoin increases the risk.
Many clinical dermatologists (including me) would disagree. Our experience has shown that ‘mini’ doses of Roaccutane/ Accutane anecdotally give less chances of hair fall compared to traditional dosing. Discuss this with your dermatologist.
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How to monitor for hair loss / thinning whilst on Isotretinoin or Accutane?
Though there is no formal method for measuring hair loss whilst on isotretinoin, the following sensible steps may assist patients in monitoring their treatment. Early intervention provides the best outcomes.
- Baseline photography. This gives an objective documentation of hair loss. Photography from the front. Include the frontal hairline, the temples on both sides. Photograph on the sides, then photograph the top. Part the hair in the middle. Take a photo of the part. This gives an objective measurement of hair density.
- Ponytail measurements in females. Tie your hair in a ponytail (if possible), measure the circumference or the diameter. This gives an idea of density.
- Counting the number of hairs lost in a day is not a good indicator of hair loss. Don’t bring a bag of hair to your dermatologist (unless they specifically ask you to – applies to cases of telogen or anagen effluvium). You will lose up to 150 -170 hairs a day, sometime more if your telogen cycle overlaps. If you count hairs, you will miss, or pull out more. This will give you anxiety, that may lead to telogen effluvium, which leads to more hair loss.
*Objective measurements are best. It does not matter how many hairs you shed, it is what the data of serial photos show that counts. If you shed 200 a day, but regenerate 200, your next loss is zero. If you shed 60 but regenerate 10, your next loss is 50.
**If you have hair loss, flag this with your dermatologist early in the treatment. He or she will be keen to look at your photos (& pony tail circumference/diameter). Note: I am a procedural dermatologist. Though I may (seem) versed in medical management, I do not practice medical dermatology. The insights provided are common knowledge to all dermatologists, including your treating physician.
How can hair be different on Accutane- what to look for?
Patients on isotretinoin/Roaccutane may notice a deterioration in texture, thickness & hair quality. You may find your hair more difficult to style, more flyovers and frizz. Additionally, you may experience brittle hair that is more susceptible to breakage. These are early signs that may eventually lead to hair thinning.
Reduced sebum (oil) from isotretinoin use may account for some of the changes to hair quality. Your scalp may be dry & flaky as this is a common side effect of isotretinoin.
Will PRP help?
There are no clear cut studies showing the benefits of Platelet Rich Plasma in the context of Accutane induced hair loss. Here are my thoughts-
- Most cases of isotretinoin induced hair loss are self-limiting. This means the vast majority of cases will improve within 6 months. Hence PRP may give a false result.
- A control study is difficult based upon the above. A large number of subjects need to be recruited for a statistically significant interpretation of the results.
- A split scalp study is probably the best. This means half the scalp is treated with PRP injections & the other half not.
- The above will not go through ethics approval (at least here in Australia). Possibly studies from China in the next few years will reveal the results.
- Given the ease of application & the paucity of side effects, the use of PRP would be a sensible option for patients who are experiencing progressive hair fall and/or have plateaued at 4-6 months after ceasing Accutane. A sensible routine is monthly PRP for 3 consecutive months.
Can lasers be of benefit?
Low level laser therapy uses light emitting diodes in the 600-1070nm range. They can work by stimulating the hair follicle. A sensible course of treatment is to have weekly sessions for 10 weeks then reassess.
Lasers including fractional thulium can treat many forms of alopecia, including androgenetic alopecia, alopecia areata & scarring alopecia. They work by stimulation of the hair follicle as well as indirect cytokine release from the epidermis. This laser can also be used to deliver growth factors into the scalp. The use of this wavelength would be sensible as an option for isotretinoin induced hair loss. The recommended number of treatments, as reflected in the studies, ranges from 8 to 12. Sessions are weekly.
Can tablets or lotions be used to treat Roaccutane induced hair loss?
Treatment depends on the diagnosis of hair loss. If the diagnosis is solely due to Accutane induced hair fall, no formal treatment is required, apart from hair care & supportive management. Supplementation with *B complex, folate, zinc, biotin, iron & minerals can be considered.
If there are other factors that contribute to hair loss, directed treatments are often initiated by your treating dermatologist. For example, if there is a contribution from androgenetic alopecia, antihormone medications such as cyproterone acetate, spironolactone, finasteride, dutasteride etc. are prescribed.
What about minoxidil? This is a double-edged sword. Minoxidil can be useful in some cases (male or female pattern hair loss), however it may initially accelerate hair loss by ‘pushing out’ dormant follicles. This can result in rebound hair loss initially. You have to discuss this issue with your dermatologist. Additionally, topical formulations of minoxidil contain propylene glycol & ETOH, both can contribute to increased scalp dryness.
*Vitamin A supplementation is NOT recommended in cases of hair loss. RDi above 10,000 IU may contribute to more hair loss. Remember that Accutane – isotretinoin is a vitamin A derivative.
**Disclaimer: I do not see patients with hair loss. My work is procedural. For advice on hair loss, please consult a medical dermatologist, thank you for your understanding. Dr Davin Lim
What other factors can contribute to Accutane induced hair loss?
Dermatologists think outside the box. In moderate to severe cases of hair loss, we need to exclude or confirm other associated factors that may either contribute to, or are co-incidental with the timeline of Roaccutane use. Your dermatologist will discuss and investigate in more detail. Simple blood tests & hair microscopy can be useful.
One of the most common associated causes is telogen effluvium. This is made worse by stressing about hair loss itself; and so continues the cycle. Telogen effluvium is commonly associated with emotional and/or physical stress. This includes trauma, (emotional & physical), crash dieting, extreme exercise & pregnancy (unlikely if you have been on isotretinoin). The cause of telogen effluvium is shedding of hair within the cycle of telogen (resting phase). This occurs 2-4 months after traumatic circumstances.
Androgenetic alopecia or male/female pattern hair loss is super common. The onset can be in the late teens (around the same time as acne & Accutane prescription). In some cases, mild androgenetic alopecia can compound isotretinoin induced hair loss. In others, Accutane is not the culprit but was coincidentally prescribed during the time of hair loss. ( Said another way, hair loss was inevitable but unfortunately Accutane was prescribed during the same time period of genetically programmed hair fall).
Scalp itch & dryness can lead to scratching with accelerated hair fall. If you experience significant dryness, simple olive oil can be helpful. Your dermatologist may prescribe you an anti-inflammatory lotion to use 2-3 nights per week.
Nutritional disorders are another cause of incidental hair loss. The most common is iron deficiency anemia. B12, biotin, & zinc deficiency are extremely rare.
Rare causes such as lichen planopilaris, discoid lupus, folliculitis de calvans, & trichotillomania can be excluded by your treating dermatologist.
How to prevent hair loss on Accutane / Isotretinoin?
You can take measures to reduce the chances of hair loss on this medication. One of the best ways to monitor hair loss is to take baseline photographs of your scalp prior to starting Accutane. Photograph the hairline (including the temples), sides, & the vertex or crown. You can part the hair in the midline as this gives a good indication of your baseline hair density. Remember, it is normal to lose between 100-150 strands of hair daily, so don’t stress.
- Early communication with your dermatologist is the key. This is the most important step as early hair fall can be mitigated. Your treating dermatologist may reduce the dose of Accutane, or stop it altogether.
- Use a good moisturizer/hair conditioner as hair care is super important. This will keep your hair moisturised & reduce breakages.
- Limit drying your hair with a hair dryer as this can lead to hair shaft fragility.
- Don’t bleach or color or dye your hair whilst on Accutane & for 2 months after stopping this medication. This increases fragility & can accentuate hair loss.
- Brushing techniques include using a wide toothed comb or better still running your fingers through your hair.
- Supplementation with B12, B complexes, Biotin, Iron. This is controversial. There are some reports that suggest isotretinoin can lower vitamin B levels. You can supplement this with foods such as avocado, bananas & broccoli, or simply pop a vitamin tablet.
Disclaimer: I am a procedural dermatologist. I do not manage hair loss medically. Discuss this issue with your treating physician or dermatologist. My work is procedural, namely I cut, inject, laser & peel.
What are other side effects of Accutane - isotretinoin?
Side effects are universally seen on Accutane, hence patients are carefully monitored. The most common side effects include-
- Dry lips & mucous membranes
- Sun sensitivity
- Dry skin & skin fragility including hair fragility
- Ingrown toenails
- Mood changes including depression
- Elevation of liver enzymes & cholesterol
- Joint aches & pains, muscle soreness
The majority of side effects can be mitigated with adjustment of Roaccutane/ Accutane dosage & proper care. Your dermatologist will be able to guide you accordingly.
What may influence your decision to go on to Accutane?
The decision is yours, dermatologists merely guide you. The decision to continue or to cease is in your court.
Here is an insight as to how a dermatologist views who is a suitable candidate for isotretinoin / Accutane / Oratane. This is based upon my thought processes when I used to prescribe Accutane ( I do not prescribe now as my work is entirely procedural). Patient suitability is based upon a risk benefit ratio for that patient. We (I) consider suitability based upon-
- The likelihood of significant acne scarring. Factors such as truncal acne, cystic acne, family history of acne/scars, & picking are considered. The threshold to prescribe is lowered if scarring is an issue.
- Patterns of acne (as reflected by propensity to scar). Some forms of chronic acne, including acne excoriee & adult female jawline hormonal acne are more likely to scar.
- Previous non-pharmacological treatments by the patient. Dermatologists prescribe drugs. Has the patient tried & failed sensible non-pharmacological methods to address their acne. This includes, a super strict acne diet, good makeup practices, acne washes that include BHAs, OTC retinol, niacinamide, & others (see guide in the acne section of this website).
- Has the patient failed treatment with standard pharmacological treatments including adapalene, anti-inflammatory antibiotics, hormonal regulation etc ?
- What is the emotional impact of acne on the patient, balancing the risks vs benefits of prescription? This can get very complex as the patient may be motivated, but not motivated enough to practice non-pharm methods.
- The IQ & intelligence of the patient. This is not discussed much, but face it, everyone lies on a bell curve. Quick cats to the right, not so sharp tools on the left. If one has side effects to isotretinoin, the common sense approach is to stop. For example, if you are noticing changes such as mood swings, hair loss, sore joints etc. the majority of people would cease the medication. Obviously, the job of your treating dermatologist is to point out common side effects.
Disclaimer: I am a procedural dermatologist. I do not manage acne, I am not a pro Accutane lobbyist, nor am I against it. Discuss the treatment with your medical dermatologist.
What other acne treatments are available apart from Accutane?
Dermatologists utilize many anti-acne treatments, depending on the severity of acne, the impact it has on your life as well as individual factors.
The most important concept to grasp is that you should try everything sanely possible to place your acne under control (or better still, remission). This includes a strict anti-acne diet, good skin practices (make up etc) as well as simple over the counter products like retinol, salicylic acid washes, niacinamide, benzoyl peroxide & even zinc supplementations. Give yourself 6 to 8 weeks to control your acne (take baseline photos as a guide).
Next step: See your GP. Treatments include topical retinoids like adapalene, trifarotene, & tretinoin. Option for antibiotics & in females the OCP.
Next step: medical dermatologists. My colleagues prescribe medications, not fairy dust, so be prepared. It is highly recommended to try all the other fluff before seeing a dermo because chances are, they will not prescribe you tea tree oil, witch hazel or give you a gluten free diet to follow. Sensible options include high strength salicylic acid peels, low level lasers with phototherapy, higher strength topical retinoids, anti-hormones & other medications. Our aim is to treat your acne in the fastest, safest possible way. Be guided by your dermatologist.
Disclaimer: I am a procedural dermatologist. I do not prescribe acne medications, nor do I get involved in your management. My job involves surgery, lasers, scary peels & complex injectables. For acne management, please see one of my nurses or my medical colleagues.
Who to see for Accutane induced hair loss?
Discuss this with your treating dermatologist as they have your records. Dermatologists are all knowledgeable in the management of disorders of the skin, hair & nails.
If you would like a second opinion, book a consultation with my colleagues at Clinic Cutis.
Disclaimer: I am a procedural dermatologist. I do not treat hair loss medically. My job involves surgery, lasers, scary peels & complex injectables. For medical management of hair loss, please see one of my medical colleagues. Thank you, Davin Lim.
Davin’s Viewpoint- Accutane Induced Hair Loss
It happens. It is more common than what is reported in the literature. It is unfortunate. It is distressing. It is self-limiting in most cases. It is co-incidental in some. It can be somewhat preventable in many cases (with early detection & intervention).
Isotretinoin induced hair loss usually occurs in young adults. In the majority of times it is self-limiting, namely hair growth will return once the medication is ceased. It can take up to 6-12 or beyond to gain normal growth & density. In some rare cases, the hair does not return back to the normal density. This is usually due to other factors such as incidental (or rather concurrent) androgenetic alopecia. This especially applies to males. If this is the case, early intervention with medical management for male pattern baldness should be initiated. The diagnosis can be confirmed with a family history of AGA & with an examination (bitemporal recession, vertex thinning, miniaturization of hair follicles). In females, it can be more complex. Other conditions such as telogen effluvium or iron deficiency should be considered. Be guided by your dermatologist.
A sensible method of monitoring for hair loss is not to count hairs lost on a daily basis (this will lead to more anxiety & OCD), as one typically loses up to 150 to 170 strands a day! A sane method is baseline photos prior to, or at the start of Accutane- Isotretinoin therapy. Photos should include the frontal hairline including bitemporal areas, sides, & the crown or vertex. Part the hair in the midline as this will give an idea of baseline hair density. For females, the diameter or circumference of the ponytail is a very accurate measurement of hair density (which is proportional to hair loss/hair fall).
If you notice an objective measurement of hair loss, stop your isotretinoin & discuss this with your medical dermatologist. There are other methods to help with your acne including LLLT, PDT, & other medical options.
Intervention with PRP, low level lasers & thulium fractional lasers are novel treatments for other forms of hair loss including androgenic alopecia, alopecia areata, & other hair disorders. Whilst they are not proven to help with hair loss from isotretinoin, given the banal nature of these interventions, it may be sensible to start early. This especially applies to cases of incidental male/female pattern hair loss. In most cases supportive management is recommended; namely time, good hair care (avoid dye, avoid colours, correct grooming-combing techniques, avoid excessive drying). A hair supplement that includes vitamin B complexes, zinc, iron, & biotin can be useful for the feelgood factor.
*Disclaimer: I do not treat medical conditions such as hair loss. This includes Accutane induced hair loss/thinning. Your management should be supervised by your treating dermatologist. I do not treat acne. My elective practicing skill sets are procedural, namely I cut, laser, peel & inject. For medical management, please book an appointment with my colleagues @cliniccutis
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