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Alopecia Associated with Fluconazole Therapy
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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.
Lowell A. Goldsmith, MD
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
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