BH25 Alopecia in a patient undergoing multiple treatments for multiple sclerosis: a rare presentation and case review

Abstract A 33-year-old woman of Mediterranean origin presented to the hair clinic with a history of diffuse hair loss. Her medical background included relapsing–remitting multiple sclerosis (MS), diagnosed in 2014, anorexia, bulimia, transient hypothyroidism and iron deficiency anaemia. She had naturally thick voluminous hair before experiencing hair loss. She was initiated on glatiramer acetate (GA) in 2019. Shortly after starting GA, she began experiencing mild hair shedding, particularly from the vertex of her scalp. GA was then switched to dimethyl fumarate in 2022, which unfortunately led to even greater hair loss. Following this, monthly infusions of natalizumab (eight doses) were administered in 2024. However, her alopecia worsened significantly. Most recently, she was prescribed cladribine, which caused scalp irritation, including burning and itching a week after each course. Examination revealed diffuse, nonscarring hair loss on the scalp, along with mild frontal hairline recession. Two scalp biopsies confirmed nonscarring alopecia with a prominent telogen shift (anagen–telogen ratio of 1 : 3), preservation of sebaceous glands and features of possible early androgenetic alopecia. Blood tests demonstrated normal levels of ferritin, thyroid-stimulating hormone, vitamin B12, folic acid and vitamin D, and a negative antinuclear antibody profile. Her MS treatments were changed exclusively due to alopecia; however, alopecia persisted with each therapy. Notably, the severity of her alopecia appeared to correlate with the effectiveness of her MS treatments. She reported losing clumps of hair when brushing or showering, leading to a noticeable reduction in hair volume. This had an immense effect, leading her to use hair extensions and undergo treatment with platelet-rich plasma and exosome therapy. No hair loss was reported from any other parts of the body. She also denied any additional side-effects from MS medications. Importantly, she was not informed that alopecia could be a potential side-effect associated with these medications. This case reinforces the link between MS medications and hair loss as a significant adverse effect (Porwal MH, Salter A, Patel D, Obeidat AZ. Alopecia in multiple sclerosis patients treated with disease modifying therapies. J Cent Nerv Syst Dis 2022; 14: 11795735221109674). It also underscores the importance of informing patients about this potential side-effect, which can profoundly impact mental health, as seen in our patient’s case [Ross H, Asfour L, Harries MJ. Multiple sclerosis and alopecia areata: drug-induced alopecia areata or coexisting autoimmune phenomena? Br J Dermatol 2023; 188 (Suppl. 4): ljad113.167].