Treating Alopecia Caused by Renal Disease

Chronic kidney disease (CKD) can cause dysfunction in organs well outside the renal system. The skin is one of the organs most commonly affected.

CKD is a “chronic inflammatory state, which means it has broad systemic effects,” Uday Nori, MD, clinical professor of medicine and transplant nephrologist, the Ohio State University Wexner Medical Center, Columbus, Ohio, told Medscape Medical News. “This means that manifestations of kidney disease have an inflammatory effect on an array of organs, including the skin, and many patients do complain about alopecia.”

Roughly 50%-100% of people whose CKD has progressed to end-stage renal disease (ESRD) have one or more associated cutaneous changes. Cutaneous manifestations often begin at disease onset and continue through its progression until the terminal stage and/or after initiation of dialysis.

“CKD, and especially ESRD, can have many cutaneous manifestations affecting the skin, hair, and nails,” Leslie Robinson-Bostom, MD, professor of dermatology and director of the Division of Dermatopathology at Warren Alpert Medical School of Brown University, Providence, Rhode Island, told Medscape Medical News.

The disease affects 8%-16% of the world’s population. In the United States alone, an estimated 14% of people (about 35.5 million) have CKD, and more than 808,000 are living with ESRD. Early recognition of CKD’s skin manifestations can alleviate suffering and decrease morbidity in this large population.

Hair Has a Life Cycle

Alopecia affects almost 10% of patients receiving dialysis for ESRD, although hair changes have been reported in an estimated 25%-38% of patients receiving dialysis.

The condition is defined as “the absence or loss of hair in an area where it is expected to be present,” and it can be “localized or diffuse, temporary or permanent.”

The life cycle of hair consists of four phases: Anagen, the active growing phase; catagen, a transitional period; telogen, a resting phase; and exogen, the hair loss stage.

Normally, about 90% of hair should be in the anagen phase, Robinson-Bostom explained. But in a person with a chronic illness, such as CKD, or experiencing an acute event, up to 30% of hair can cycle into the exogen phase, with hair from the telogen phase being shed.

The most common type of kidney disease–related alopecia is telogen effluvium, the excessive shedding of resting/telogen hair after some insult, such as metabolic stress, anemia, certain medications, or surgery. Sometimes, the insult will “trigger the hair to stop growing and involute,” according to Robinson-Bostom. “CKD is one of a variety of conditions and comorbidities that can cause insult to the system and trigger telogen effluvium and subsequent shedding of hair.”

There are different types of alopecia associated with CKD. Androgenic (or “male-pattern”) alopecia (AGA) is mediated by 5-alpha-reductase and dihydrotestosterone, leading to miniaturization of hair follicles and the shortening of successive anagen cycles. Alopecia areata, an autoimmune condition, can also occur comorbidly with CKD.

Although the origin of alopecia areata, a “common chronic tissue-specific autoimmune disease,” is not renal, it is associated with a higher risk of developing CKD. The condition is characterized by focal areas of hair loss, usually on the scalp, eyebrows, beard, and moustache areas. One study found that patients with alopecia areata had a significantly higher odds ratio for developing CKD.

Causes of Alopecia in Kidney Disease

Kidney disease can cause a variety of complications that can lead to telogen effluvium and result in alopecia. Among them are iron deficiency, anemia, reduced sebum production, abnormal parathyroid hormone levels, uremia, and elevated stress.

Medications commonly used in the setting of CKD, including heparin, certain antihypertensives (eg, beta-blockers), certain lipid-lowering agents, and recombinant human erythropoietin to treat CKD-related anemia may also be associated with hair loss.

Certain specific diseases that cause kidney disease also can cause alopecia, Nori said. For example, systemic lupus erythematosus is the most commonly reported rheumatologic cause of ESRD and is independently associated with alopecia, particularly alopecia areata, he said. “It can also cause nonscarring and scarring alopecia, called discoid lupus erythematosus,” Robinson-Bostom added.

Treating Kidney-Related Alopecia

Unfortunately, there is no therapy specifically for alopecia associated with CKD or ESRD, Robinson-Bostom said. But addressing the possible causes of the alopecia (eg, anemia or iron deficiency) might be helpful. Discontinuing an offending medication or substituting it with an alternative also could address the problem.

A case report described a 66-year-old patient who developed alopecia while being treated with anticoagulation therapy to prevent extracorporeal blood clotting during dialysis. The agent tinzaparin — a low–molecular weight heparin (LMWH) — appeared to have caused the alopecia, which reversed completely when enoxaparin, another LMWH, was substituted.

Some medications that treat hair loss can be helpful for patients experiencing alopecia related to CKD, Robinson- Bostom said. These include topical and oral minoxidil, originally developed as an antihypertensive, and spironolactone, a treatment for female-pattern hair loss.

Nori recommends biotin ( also known as vitamin B7 or vitamin H) to his patients with kidney disease and alopecia. “Although its utility isn’t proven for helping CKD-related alopecia, some of our patients have reported some improvements,” he said. “We also encourage our patients to eat a balanced diet and to take vitamin and mineral supplements, which will benefit many systemic effects of CKD, including alopecia.”

Robinson-Bostom recommends herbal supplements, including Nutrafol and Viviscal. A systematic review of 30 studies found high-quality evidence suggesting promising potential effectiveness of several dietary/herbal supplements (Table). Adverse effects were “rare and mild” for all the therapies evaluated in the review.

Table. Herbal Supplements for Alopecia

Lower-quality evidence was found for the probiotics kimchi and cheonggukjang , vitamin D3, and Forti5 (a formula consisting of green tea extract, omega 3 and omega 6 fatty acids, cholecalciferol, melatonin, and beta-sitosterol).

It is important to remember that these therapies were not evaluated specifically for alopecia related to renal disease, and that their ingredients should be carefully reviewed by the treating nephrologist to make sure there are no kidney-related contraindications, Robinson-Bostom advised. For example, Pantogar is a product sometimes used for alopecia. It contains several ingredients, including keratin. But keratin, which is found in some hair products, has been linked to a higher risk for acute kidney injury.

The 5-alpha-reductase inhibitors finasteride and dutasteride are often used to treat AGA, but they should be avoided in the setting of renal disease because they can cause kidney dysfunction. Low-level laser light therapy is a promising intervention, but it can result in dry skin and pruritis, which are already problematic in many patients with renal disease.

Robinson-Bostom noted that some patients with CKD- and ESRD-related alopecia also have a zinc deficiency and might benefit from zinc supplementation if blood tests corroborate the deficiency.

A multidisciplinary approach is optimal for treating patients with renal disease and dermatologic issues, including alopecia, Robinson-Bostom said.

“I advise nephrologists to have a good working relationship with their local dermatologists because it takes a team effort to address the renal aspects, while also bearing in mind the cutaneous manifestations that have such an enormous and devastating effect on the quality of life of our patients,” she said.

Nori agreed, noting that he refers his patients with cutaneous manifestations of CKD to dermatologists for further evaluation and treatment if the measures he recommends are insufficient.

Robinson-Bostom and Nori declared no relevant financial relationships.

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape Medical News and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).