Teriflunomide and Hair Loss: What to Expect & Coping Tips

When you start Teriflunomide is a disease‑modifying therapy used to treat relapsing forms of multiple sclerosis. It’s sold under the brand name Aubagio and works by slowing down the immune system’s attack on nerve fibers. Many patients wonder why a drug that protects the brain can sometimes make the scalp feel like a desert. The short answer: the medication can interfere with hair‑growth cycles, leading to Hair loss (also known as alopecia) in a subset of users.

How Teriflunomide Works

Teriflunomide blocks the enzyme Dihydroorotate dehydrogenase, which is essential for the creation of pyrimidine nucleotides-building blocks of DNA. By limiting the proliferation of rapidly dividing immune cells, the drug reduces the frequency of MS relapses. This same anti‑proliferative effect can touch other fast‑growing cells, like those in hair follicles, especially during the anagen (growth) phase.

Why Hair Loss Happens

Hair follicles are among the quickest‑renewing parts of the body. When a drug tampers with DNA synthesis, follicles may prematurely enter the catagen (regression) phase and shed hairs. The phenomenon is called Telogen effluvium when it’s a diffuse thinning, and it’s the most common pattern linked to teriflunomide. The reaction isn’t an allergic rash; it’s a metabolic shift that the body can often reverse once the trigger eases.

How Common Is It?

Clinical trial data from the pivotal TEMSO and Teri‑STEP studies show that about 6‑10% of participants reported noticeable hair thinning. Real‑world registries suggest a slightly lower figure, around 4‑7%, because many people experience only mild shedding that goes unnoticed. The risk rises with higher plasma concentrations, which can happen if the liver isn’t clearing the drug efficiently.

What to Expect: Timeline

• Weeks 1‑4: Most patients notice the first signs of thinning, often as a gentle increase in shedding during washing.
• Weeks 5‑12: If the drug’s level remains high, shedding may peak. Some notice patchy thinning, especially around the crown.
• Months 4‑6: For many, the hair cycle stabilises. New growth begins, though the new strands may feel finer.
• Beyond 6 months: Persistent loss beyond this window should prompt a review with your neurologist or dermatologist.

Practical Ways to Reduce Hair Loss

While you can’t completely stop teriflunomide’s impact, several low‑risk strategies can help keep the hair pool healthier:

1. Check liver function regularly. The drug is cleared by the liver; elevated enzymes often signal higher systemic exposure. Adjusting dose or adding cholestyramine (a drug that speeds up teriflunomide elimination) can lower levels.
2. Maintain a balanced diet. Protein, iron, zinc, and omega‑3 fatty acids support keratin production. Foods like lean meat, beans, leafy greens, and fatty fish are excellent choices.
3. Consider a biotin supplement. Biotin (vitaminB7) at 5mg per day has helped many patients improve hair thickness. Discuss dosage with your prescriber to avoid interference with lab tests.
4. Gentle hair care. Avoid tight ponytails, harsh chemicals, and high‑heat styling. A mild sulfate‑free shampoo and occasional scalp massage can stimulate circulation.
5. Stress management. Psychological stress can compound telogen effluvium. Mindfulness, short walks, or light yoga have shown measurable reductions in cortisol‑related hair shedding.
6. Topical minoxidil. A 2% solution applied twice daily can prolong the anagen phase. It’s off‑label for drug‑induced loss but is widely used with good safety data.

When to Seek Medical Help

If you notice any of the following, book an appointment promptly:

• Hair loss exceeding 100hairs per day (roughly more than a half‑palm’s worth during washing).
• Patchy bald spots, especially if they don’t improve after three months.
• Accompanying symptoms like persistent fatigue, jaundice, or unusual bruising - signals that the drug may be affecting the liver or blood counts.
• Pregnancy or planning to become pregnant. Teriflunomide is teratogenic; rapid drug elimination protocols are mandatory.

Your neurologist may lower the dose, switch to an alternative disease‑modifying therapy, or use an accelerated elimination protocol (cholestyramine or activated charcoal). A dermatologist can run a scalp biopsy to differentiate drug‑induced telogen effluvium from other alopecia types.

Bottom Line

Hair loss on teriflunomide is uncomfortable but usually reversible. By monitoring blood work, nurturing nutrition, and using gentle hair‑care habits, most people keep the shedding to a minimum and see new growth within a few months. Keep an open line with your care team-early tweaks can save both strands and confidence.