GLP-1 receptor agonists (RA) have taken the healthcare industry and the public by storm. You can’t deny their popularity and expanding utility beyond diabetes and weight loss. We’ve gotten to know some the skin side effects appreciated with GLP-1s including the most famous “Ozempic face” but hair loss has also taken center stage. Restoring health and losing weight seems like a great idea for most, but the threat of hair loss might steer people away from GLP-1s.
The reality is that we are still learning about hair loss seen with GLP-1s. What we do know is that about 15% of patients on a GLP-1 will experience hair loss. A recent study presented at a dermatology conference in Paris this past fall suggested that GLP-1 RA use may independently increase the risk of certain types of hair loss, particularly telogen effluvium and androgenic alopecia (female or male pattern hair loss). Some studies have shown differences in the risk of hair loss depending on the type GLP-1 medication. On the other hand, tirzepatide has also been shown to potentially improve scarring alopecia. This is what I mean by emerging evidence and our journey to learn more about alopecia and GLP-1s. It’s just the beginning.
So what do we know? Typically, GLP-1 hair loss is characterized by diffuse shedding across the entire scalp, a condition known as telogen effluvium (TE). TE usually occurs 2-3 months after starting a GLP-1 or a dose increase, and results when a stressor pushes hair follicles from their active growth phase (anagen) into their resting phase (telogen). TE classically presents with patients noticing more hair in the shower or on their brush. You may also have a positive “ponytail test”, a clinical sign I use with my patients. This means when you gather your hair as if you were going to put it up in a ponytail, you notice there’s less hair to grab than there was before. Although imperfect and subjective, it’s helpful for patients and clinicians to get an idea of hair loss volume especially if they have a thick hair to begin with. It validates their concerns, particularly when the thinning isn’t obvious.
GLP-1 telogen effluvium is likely due to rapid weight loss and less likely the medication itself. It can also be the result of nutrient deficiency. Because of the appetite suppression and trend to sometimes follow restrictive diets, many GLP-1 users don’t get adequate nutrition. The good news is that TE seen with GLP-1s typically improves on its own for most. On average, TE resolves in 3-9 months. However, some patients can develop chronic telogen effluvium and evidence is mounting that GLP-1s may identify those with a predisposition for androgenetic alopecia. The thought is that TE can serve as a telogen elevator and might trigger androgenetic alopecia in those who are genetically predisposed.
So if you’ve decided to start a GLP-1, there are a few things you can do to help prevent TE associated hair loss. First, take a low and slow approach to your weight loss. That often means titrating your dose up slowly that your weight loss is more gradual in onset. In addition to dosing slowly, be mindful of your diet. Don’t follow aggressive calorie restrictions, consider a multivitamin and be sure to consume enough protein and a balanced diet. And my favorite—scalp massage. Regular scalp massage has been known to trigger hair growth by stimulating blood flow around follicles. Now the gray area–If you are genetically predisposed to androgenetic alopecia, you might be at increased risk for developing it while on a GLP-1. While we don’t have a test yet to determine who is at risk, it is something to consider. The good news is that we have treatments to treat androgenetic alopecia from minoxidil to regenerative techniques. And while none of wants hair loss, if a GLP-1 is medically necessarily to maximize your health, it’s important to have a hair loss evaluation so it isn’t a deterrent from compliance.
Trotter’s Take: TE seen with GLP-1s is a possible side effect, but if it lasts longer than 6 months, then an evaluation for an underlying cause or androgenetic alopecia is warranted.
