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Table of Contents 
Year : 2022  |  Volume : 67  |  Issue : 6  |  Page : 815-817
Azathioprine induced anagen effluvium- An uncommon adverse effect of a commonly used drug

1 Senior Consultant Dermatologist, Fortis Hospital, Vasant Kunj, New Delhi, India
2 Department of Dermatology, Asansol District Hospital, Asansol, West Bengal, India
3 Department of Dermatology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India

Date of Web Publication23-Feb-2023

Correspondence Address:
Indrashis Podder
Department of Dermatology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_497_22

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How to cite this article:
Sharma R, Poddar S, Podder I. Azathioprine induced anagen effluvium- An uncommon adverse effect of a commonly used drug. Indian J Dermatol 2022;67:815-7

How to cite this URL:
Sharma R, Poddar S, Podder I. Azathioprine induced anagen effluvium- An uncommon adverse effect of a commonly used drug. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:815-7. Available from:


Azathioprine is a commonly used drug for various dermatological disorders such as pemphigus, vitiligo, lichen planus and alopecia areata.[1] Although bone marrow suppression remains the cardinal adverse effect, anagen effluvium has been reported sporadically, which may be psychologically devastating for the patient.[2],[3],[4] This report describes another uncommon case of azathioprine induced anagen effluvium in an adolescent girl, suffering from cutaneous small vessel vasculitis.

A 17-year-old, otherwise healthy girl, presented with painful reddish lesions over both lower limbs along with episodic high-grade fever for 20 days. She also reported sudden onset hair loss since last 10 days, along with pain in her knee and ankle joints over last week. There was no history of breathlessness, abdominal distention, urinary complaints, ulceration or any systemic involvement. Her drug history included Prednisolone 30-mg PO, once daily and Azathioprine 50-mg PO, twice daily for the last two weeks, prescribed by a general physician.

Dermatological examination revealed multiple asymptomatic, asymmetrically distributed palpable purpuric spots of varying sizes from 2 mm to 1 cm and macular erythema on bilateral lower limbs and buttock [Figure 1]. On scalp examination, we detected non-scarring alopecia without scaling or crusting. Oral mucosa showed blackish discoloration of tongue [Figure 2]. There was increased pigmentation on interphalangeal joints. Systemic examination was normal. We kept our differential as small vessel vasculitis and attributed her hair loss to Azathioprine. Routine blood investigations prior to starting Azathioprine showed Hb of 12.3 gm%, total leucocyte count of 5000/cu mm and platelet count of 220 thousand/cu mm. Current reports showed haemoglobin of 12 gm%, total leucocyte count of 4610/cu mm and platelet count of 200 thousand/cu mm. Hormonal profile was normal. A punch biopsy was taken from the most recent thigh lesion and sent for histopathological examination. Histopathology showed a normal epidermis, capillaries in papillary dermis surrounded by extravasated red blood cells [Figure 3]. Blood vessels showed endothelial cell swelling and perivascular chronic inflammatory cells infiltrate comprising of lymphocytes. No leucocytoclasia, fibrinoid necrosis and intravascular thrombi of vessel wall were seen. Based on ACR criteria, a diagnosis of cutaneous leucocytoclastic vasculitis with azathioprine induced anagen effluvium was made. Azathioprine and steroids were discontinued and patient was started on colchicine 0.5 mg twice daily. Complete hair growth was seen after 2 months of treatment with resolution of skin and mucosal lesions. Repeat hemogram showed parameters within normal limits.
Figure 1: Palpable purpura involving both lower limbs

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Figure 2: (a) Non-scarring alopecia involving entire scalp and blackish discolouration of tongue at baseline, (b) Hair regrowth after 2 months of stopping azathioprine

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Figure 3: Papillary dermis showing dilated capillaries with perivascular lymphocytic infiltration, H&E, 100x

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Anagen effluvium refers to abrupt shedding of hair in the anagen phase due to impaired follicular mitotic activity. Common culprit drugs are chemotherapeutic agents, toxic metals and rarely bismuth, levodopa, colchicine and cyclosporine.[5] Azathioprine is an immunomodulator commonly used in post-organ transplant patients and autoimmune conditions. Being an anti-metabolite drug, it can theoretically impair the follicular metabolic activity. However, very few authors have reported azathioprine induced anagen effluvium, highlighting its rarity. Two authors[2],[4] have reported hair loss after 1 month of initiating azathioprine, while Sonthalia and Daulatabad[3] noted its occurrence after 48 hours. In our case, shedding occurred after 4 days. Likewise, reports have also suggested that anagen effluvium may be considered a cutaneous marker of myelosuppression.[4],[6] It was postulated that pancytopenia resulted in hair shaft damage leading to hair loss. Although our patient did not report any myelosuppression, we are keeping her under observation. As the pathology remained limited to proliferating cells in hair bulb, without affecting the quiescent stem-cells, a complete regrowth occurred in all cases, including our case, within a span of two months following discontinuation of azathioprine.

Azathioprine induced anagen effluvium is an important probable side effect as per WHO-UMC causality scale and should be considered in all patients needing this drug.[7] As per the Hartwig's severity assessment scale, it was a moderate (level 3) reaction.[8] Additionally, those developing hair loss should be monitored for myelosuppression, in cases where drug cannot be withdrawn. This drug may be preferably avoided in younger age-group, and the resultant hair loss can severely impair their quality of life. Our case intends to sensitize dermatologists about this uncommon serious adverse effect of a commonly used drug.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Support- Institutional.

Conflicts of interest

There are no conflicts of interest.

   References Top

Patel AA, Swerlick RA, McCall CO. Azathioprine in dermatology: The past, the present, and the future. J Am Acad Dermatol 2006;55:369-89.  Back to cited text no. 1
Balasubramanian P, Jagadeesan S, Anjaneyan G, Thomas J. An interesting case report of azathioprine-induced anagen effluvium. Indian J Dermatol 2015;60:324.  Back to cited text no. 2
[PUBMED]  [Full text]  
Sonthalia S, Daulatabad D. Azathioprine-associated anagen effluvium. Indian J Dermatol Venereol Leprol 2016;82:322-4.  Back to cited text no. 3
[PUBMED]  [Full text]  
Bhokare AB. Azathioprine-induced alopecia as an early clinical marker of its myelosuppression. Indian J Drugs Dermatol 2017;3:40-1.  Back to cited text no. 4
  [Full text]  
Kanwar AJ, Narang T. Anagen effluvium. Indian J Dermatol Venereol Leprol 2013;79:604-12.  Back to cited text no. 5
[PUBMED]  [Full text]  
Joshi R, Singh S. Plica neuropathica (plica polonica) following azathioprine-induced pancytopenia. Int J Trichology 2010;2:110-2.  Back to cited text no. 6
World Health Organization (WHO)-Uppsala Monitoring Centre. The use of the WHO-UMC system for standardized case causality assessment. Available from:  Back to cited text no. 7
Hartwig SC, Siegel J, Schneider PJ. Preventability and severity assessment in reporting adverse drug reactions. Am J Hosp Pharm 1992;49:2229-32.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3]


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