LETTER
Alopecia Associated with Fluconazole Therapy
Lowell A. Goldsmith, MD
15 July 1996 | Volume 125 Issue 2 | Page 153
TO THE EDITOR:
I read with interest the recent report on reversible alopecia related to fluconazole therapy [1]. Hair shaft and hair sheath structures were not described in the report. After systemic illness, a precipitation of the telogen (resting) phase of the hair cycle often causes hair loss. Alopecia also occurs after fasting, after pregnancy, with hypothyroidism, and with iron deficiency [2]. Telogen hairs can be easily recognized on a hair pull, and the diagnosis can be confirmed by scalp biopsy. Anagen effluvium follows chemotherapy or irradiation, both of which affect the rapidly proliferating cells of the hair matrix. Such hairs can be recognized by their necrotic root sheaths or constricted hair shafts [3]. Constrictions (Pohl-Pinkus marks) analogous to Beau lines in the nails occasionally appear in such hairs because of temporarily decreased growth. Vitamin A and its analogues cause dystrophic anagen hairs that can progress to a usually reversible form of hair loss.
The clinical description of dry skin and dry lips is reminiscent of retinoid toxicity [4]. Liazoral, an imidazole and benzimidazole derivative, inhibits P-450-dependent metabolism and increases endogenous levels of biologically active retinoic acid derivatives [5]. Fluconazole, a triazole, has shown interactions with the P-450 system. I suggest that high-dose fluconazole leads to increased levels of endogenous retinoids and that this factor may explain, at least in part, the reversible hair loss, dry skin, and dry lips associated with fluconazole. This hypothesis can be easily tested by careful dermatologic evaluation of these patients and their retinoid metabolite levels.
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Author and Article Information
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University of Rochester School of Medicine and Dentistry Rochester, NY 14642
1. Pappas PG, Kauffman CA, Perfect J, Johnson PC, McKinsey DS, Bamberger DM, et al. Alopecia associated with fluconazole therapy. Ann Intern Med. 1995; 123:354-7.
2. Fiedler VC, Hafeez A. In: Olsen EA, ed. Disorders of Hair Growth—Diagnosis and Treatment. New York: McGraw-Hill; 1994:241-55.
3. Grossman KL, Kvedar JC. Anagen hair loss. In: Olsen EA, ed. Disorders of Hair Growth—Diagnosis and Treatment. New York: McGraw-Hill; 1994:223-39.
4. Strauss JS, Rapini RP, Shalita AR, Konecky E, Pochi P, Comite H, et al. Isotretinoin therapy for acne: results of a multicenter dose-response study. J Am Acad Dermatol. 1984; 10:490-6.
5. Van Wauwe J, Coene MC, Cools W, Goossens J, Lauwers W, Le Jeune L, et al. Liarozole fumarate inhibits the metabolism of 4-keto-all-transretinoic acid. Biochem Pharmacol. 1994; 47:737-41.[Medline]
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