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ALOPECIA AS A CONSEQUENCE OF TACROLIMUS THERAPY IN RENAL TRANSPLANTATION?

1997; Wolters Kluwer; Volume: 64; Issue: 11 Linguagem: Inglês

10.1097/00007890-199712150-00027

1534-6080

David Talbot, D. Rix, Kamal Abusin, Darius Mirza, Derek Manas,

Dermatologic Treatments and Research

Hirsutism as a consequence of cyclosporine is a well-known association in transplantation. Reversal of this problem by replacing cyclosporine with tacrolimus is one of the accepted indications for drug conversion. However, we report two cases where renal recipients had their immunosuppression changed from tacrolumus to cyclosporine for hair loss. We suspect that although this is the first time this has been recorded, the problem is probably quite common for the reasons described below. In case 1, a 26-year-old man with end-stage renal failure of uncertain etiology received a kidney transplant from an 11-year-old donor. The recipient had had two previous renal transplants, both of which had failed for vascular reasons. The tissue mismatch between donor and recipient was 2-2-0 and the recipient was immunosuppressed with tacrolimus, azathioprine, and prednisolone as part of the tacrolimus versus cyclosporine trial (202). He had initial delayed graft function requiring dialysis for 17 days. In addition, due to his previous vascular thrombosis, he was heparinized and consequently required wound exploration for a retroperitoneal hematoma. At 2 months, peritoneal marsapialization was needed for a lymphocoele. At discharge, he had good graft function with a creatinine level of 134 μmol/L. By 3 months after transplantation, his chief complaint, despite all the complications that he had suffered, was that he seemed to be losing his hair. He had been accustomed to long hair, so his hair loss made a definite impact. This problem became his principle worry to the point that despite all his previous failed grafts, he refused to take more tacrolimus and so was converted to cyclosporine. Since then, he has remained stable and he has a full head of hair 3 years after his transplant. In case 2, a 37-year-old woman with end-stage renal failure secondary to acute glomerulonephritis received a pediatric “en bloc” renal graft. This was obtained from a 2-year-old donor who had died from an intracranial hemorrhage after a tumor resection. The donor-recipient mismatch was 1-0-1 and the transplant was performed without complication. Primary function was obtained and dialysis was not required. Immunosuppression with tacrolimus, azathioprine, and prednisolone was chosen as is usual in our center for these grafts. High levels of tacrolimus were maintained(approximately 20 ng/ml) and she developed a cytomegaloviremia that required treatment with ganciclovir. She had good renal function with a discharge creatinine level of 144 μmol/L. Her chief complaint was hair loss at 3 months. As a consequence, her immunosuppression was changed at 4 months after transplantation from tacrolimus to cyclosporine. She is now 6 months from this conversion and her hair growth is recovering. Although hirsutism as a consequence of cyclosporine is well accepted(1), alopecia has also been described as a complication. This includes alopecia areata (2, 3) and universalis (4). Accelerated male pattern balding is also seen with cyclosporine (5). The mechanism of hirsutism by cyclosporine is uncertain (6), and the drug has been used to treat alopecia, mainly by topical application, which presumably is effective by countering any autoimmune process. In the case of tacrolimus, the literature is somewhat scarce. The Pittsburgh group described the recovery of hair growth after liver transplantation with the use of tacrolimus and attributed this to the reversal of autoimmune alopecia (7). The recovery of health from end-stage liver disease must also have had something to do with it, although some effect on reversal of autoimmune alopecia may occur as tacrolimus has also been used topically to induce hair growth (5). The reduction of hair growth with tacrolimus can be explained by the other immunosuppressive drug used: steroids. These agents have also been discovered to counter “autoimmune” alopecia by topical application(8), but steroids are far more readily accepted as causes of hair loss (9, 10). The hair loss in the cases described here was attributed to the prednisolone. With the limited or negligible effect of tacrolimus on hair growth and absence of cyclosporine, the steroid-induced hair loss went unopposed. Consequently, this side effect became the chief complaint of these patients. Therefore, the normally unwelcome side effect of cyclosporine became the preferred treatment from which both patients have benefitted. David Talbot1 David Rix Kamal Abusin Darius Mirza Derek Manas Renal and Liver Transplant Unit; Freeman Hospital; Newcastle upon Tyne, NE7 7DN, England