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Tuesday, December 12, 2006

The Use of Sulfasalazine in Alopecia Areata

Amy J. McMichael, MD
Associate Professor, Director of Hair Disorders Clinic, Department of Dermatology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.

Sulfasalazine is an anti-inflammatory medication first used to treat rheumatoid arthritis. It also has been used to treat inflammatory bowel disease, seronegative arthropathies, and psoriasis.[1] Sulfasalazine, a compound of sulfapyridine and 5-aminosalicylic acid, works as both an immunomodulator and an immunosuppressant medication. It inhibits inflammatory cell chemotaxis and cytokine and antibody production.

The most common side effects are nausea, vomiting, anorexia, dyspepsia, malaise, and headaches. These side effects become especially problematic at doses higher than 3 g per day. Taking the medication with food or using enteric-coated tablets can help minimize gastrointestinal side effects. Rare side effects include fever, rash, hepatitis, pancreatitis, pneumonitis, and agranulocytosis. Liver function tests and complete blood counts should be monitored closely for the first 3 months, then every 3-6 months thereafter. Because sulfasalazine inhibits folate absorption, folate supplementation is recommended. Finally, patients with allergies to sulfa should not be started on sulfasalazine.

Sulfasalazine is not a first-line therapy, but it has been used to treat alopecia areata. The literature is primarily anecdotal, and it is important to remember that this drug has not been approved by the US Food and Drug Administration for use in alopecia areata. Patients must be made aware of this prior to starting sulfasalazine. A retrospective chart review performed by Ellis and colleagues[2] showed that 7 (23%) of 30 patients with alopecia areata treated with sulfasalazine for 3 months achieved cosmetically acceptable regrowth. Doses ranged from 1 to 4 g per day. Eleven patients discontinued the medication due to side effects, mainly gastrointestinal distress.

Although sulfasalazine is not commonly used to treat alopecia areata, the low incidence of severe side effects makes it a reasonable choice for patients who have failed multiple agents and are able to tolerate the side effects. It is typically started at 500 mg per day and increased up to 3 to 4 g per day as tolerated. An adequate trial of at least 4 months on 3 g per day should be tried before discontinuing the drug. In terms of dosing schedules for teenagers, there are no regimens that are different from those in adults, although you may consider starting at a lower initial dose.

Posted 01/01/2003


  1. Ellis CN, Brown MF, Voorhees JJ. Sulfasalazine for alopecia areata. J Am Acad Dermatol. 2002;46:541-544.
  2. Wolf JM, Lashner BA. Inflammatory bowel disease: sorting out the treatment options. Cleve Clin J Med. 2002;69:621-631.