Trichological Disorders in Organ Transplant Recipients: Case Report and Literature Review

Abstract

Introduction

Kidney transplantation is a life-saving procedure for patients with end-stage renal disease. However, long-term immunosuppressive therapy may lead to adverse effects, including hair disorders.

Case Presentation

We present the case of a 31-year-old patient who developed significant alopecia following kidney transplantation and initiation of tacrolimus-based immunosuppression. The psychological impact of hair loss led the patient to consider discontinuing treatment. Dermatological evaluation revealed features of androgenetic alopecia and telogen effluvium. A change in immunosuppression from tacrolimus to cyclosporine A resulted in marked improvement in hair regrowth and overall well-being. To support this observation, we conducted a targeted literature review, identifying four case reports linking alopecia to immunosuppressive therapy in solid organ transplant recipients.

Conclusion

This case highlights the need for awareness of trichological side effects among transplant clinicians, especially given their potential impact on treatment adherence and patient quality of life. Regular dermatological assessments and individualized management strategies, including the possibility of modifying immunosuppressive regimens, may help reduce these complications.

Established Facts

• Transplant recipients must adapt to numerous side effects associated with posttransplant immunosuppression. Many of these are similar to those commonly observed with immunosuppressive therapies in general, including an increased risk of malignancies and infections. The nature and frequency of these side effects depend on the type of immunosuppressive medication, as well as the duration and dosage of the treatment.

Novel Insights

• While skin cancers related to solid organ transplantation are well-documented in the transplant literature, there is limited information on trichological issues following transplantation. Drug toxicity can contribute to severe hair disorders in organ transplant recipients (OTRs).

Introduction

Nowadays kidney transplantation is the treatment of choice for many patients with end-stage renal disease. Some independent resources have shown that as compared to dialysis, transplantation significantly improves quality of life [1] and increases life expectancy [2].

Transplant recipients must adapt to numerous side effects associated with posttransplant immunosuppression. Many of these align with those commonly observed in the context of immunosuppressive therapies, including an increased risk of malignancies and infections. The nature and frequency of these side effects depend on the type of immunosuppressive medication administered, its duration as well as the dosage. While skin cancers concerning solid organ transplantation are well-documented in transplant literature, information on trichological issues following transplantation is limited. In addition, drug toxicity can contribute to severe hair disorders in organ transplant recipients (OTRs).

Side effects of medications can lead to noncompliance on behalf of the patient, and in some cases them opting to discontinue treatment. Alopecia, often noticed by patients before being diagnosed by doctors, can significantly impact the quality of life [3], especially among women and teenagers. Cases of extensive hair loss in OTRs impact not only psychologically, but may also contribute to the onset of depression. Doctors treating transplant recipients should be able to identify signs of drug-induced hair toxicity in order to reduce these side effects. In most studies on trichological problems in OTRs the particular type of alopecia was not specified and the researchers refrained from providing details on the type and characteristics of hair loss.

Androgenetic alopecia (AGA) or telogen effluvium (TE) can be expected in OTRs. These types of alopecia are likely due to the type and duration of treatment and patients mean age in these groups. It should be noted that among the wider population one of the most common causes of hair loss is AGA which is a genetically determined condition that develops due to an excessive response to androgens [4].

The other type is TE which refers to the excessive loss of hair in the resting (telogen) phase due to factors such as metabolic stress, hormonal fluctuations, or medication use [5]. Another form of alopecia that can be considered in this group of patients, due to the high doses of immunosuppressive drugs, is anagen effluvium. Anagen effluvium is a condition in which anagen-phase hairs experience toxic or inflammatory damage, leading to the fracture of the hair shaft [6]. Another type of nonscarring hair loss is alopecia aerata (AA), which can vary from small patches (<1 cm) to very large ones, and even to complete hair loss on the scalp (alopecia totalis) or loss of hair on the scalp, face, and body (alopecia universalis) [7].

It should be noted that various etiological factors may predispose OTRs to different types of alopecia. The type and severity of hair loss can be influenced by the cause of organ failure, the type of organ transplanted, the course of the medical procedure, concomitant diseases, the type, doses and duration of immunosuppressive therapy. Tacrolimus (TAC), for example, has been associated with alopecia, particularly in kidney-pancreas transplant recipients [8], while cyclosporine A (CsA) has been linked to hypertrichosis [9–15]. The mechanisms underlying these effects are not fully understood; however, several hypotheses have been proposed, including vascular disruption and autoimmune reactions [8].

Aim

The aim of this article was to present the case of a 31-year-old patient who, after a kidney transplant, sought dermatological consultation due to hair loss for which she was considering discontinuing immunosuppressive medications in an attempt to prevent further hair loss. This article also brings together available information on hair disorders in OTRs undergoing immunosuppression by consolidating data from various published case reports (Table 1).

Table 1.

Case reports in literature

Study	Year	Drug	Transplant organ	Main conclusions
Phillips et al. [16]	2005	CsA	Kidney-pancreas	The development of AA in two kidney-pancreas transplant recipients receiving IS.
Zuk et al. [17]	2011	Daclizumab, sirolimus, and TAC at the time of their first transplantation; however, at the onset of alopecia, all were being treated with a combination of TAC and MMF	Islet	Three cases of alopecia in female islet transplant recipients have been described. In all cases, alopecia developed approximately 7 years after the initial transplant
Okechuku et al. [18]	2015	Steroid, MMF, TAC	Kidney	16-years old female developed anorexia nervosa and alopecia. After switching the immunosuppressive therapy from TAC to CsA, the patient began to regain weight, and the alopecia resolved
González-Guerra et al. [19]	2019	No available information	Kidney	7 of 469 kidney recipients developed AA.
				5 of 7 of them also had another autoimmune disease
				2 of 7 developed AA before transplantation
				It remains unclear whether immunosuppressants prevent the development of AA, promote its resolution, or contribute to its onset.

Case Report

In 2014, the patient was incidentally diagnosed with renal insufficiency and following 11 months of dialysis, underwent kidney transplantation. Initial posttransplant immunosuppression consisted of basiliximab (as an induction), intravenous methylprednisolone, followed by oral prednisone, mycophenolate mofetil (MMF) and TAC. For home treatment, the patient had prescribed oral medicaments: methylprednisolone, TAC an MMF.

Four months after the transplant, she began reporting a significant increase in hair loss. The patient considered disregarding medical recommendations and even discontinuing her immunosuppressive treatment of her own volition, such was the extent of the affect her hair loss had had on her mental well-being.

The dermatological examination revealed that the hair had thinned out significantly at the frontal and temporal area of the scalp which was not noticeable in the occipital region. The pull test was positive, and a subsequent trichoscopy showed follicular miniaturization and yellow dots (Fig. 1). Based on the above findings and clinical history, AGA and TE were diagnosed (Fig. 2).

Fig. 1.

Renal transplant patient less than a year after transplantation. Significant thinning of the hair at the front of the scalp. Trichoscopy showed follicular miniaturization and yellow dots. Androgenetic alopecia (AGA) and telogen effluvium (TE) were diagnosed.

Fig. 2.

Renal transplant patient less than a year after transplantation. Significant thinning of the hair at the front of the scalp. Trichoscopy showed follicular miniaturization and yellow dots. Androgenetic alopecia (AGA) and telogen effluvium (TE) were diagnosed.

A biotin preparation was initiated, followed by a topical solution of minoxidil 5% and a combination product containing estradiol benzoate, prednisolone and salicylic acid topically. At the same time, following the dermatologist's request because of the patient’s alopecia, the transplantologist recommended a change in immunosuppression and a conversion from TAC to CsA was performed. This led to a significant improvement being observed within 2 months, with the hair partially growing back (Fig. 3, 4). This contributed to a noticeable enhancement in the patient’s mood and overall quality of life.

Fig. 3.

Two months after conversion from TAC to CsA.

Fig. 4.

Two months after conversion from TAC to CsA.

In July 2023, owing to advanced failure of the transplanted kidney, it was preemptively retransplanted from an organ donor. Immunosuppression based on prednisone, CsA and MMF remained consistent, and the patient did not report any issues purporting to alopecia at that time or later. However, in September 2023, the kidney was acutely rejected. The patient was successfully treated with pulses of Solu-Medrol, but suffered from recurrent urinary tract infections. Current creatinine level is 2.93 mg/dL. Overview of the case is presented in Table 2.

Table 2.

Overview of described case

6 Oct 2018	I Kidney Tx	Initial immunosuppression Basiliximab i.v. (as an induction) Methylprednisolone i.v., followed by prednisone p.o. Mycophenolate mofetil (MMF) p.o. Tacrolimus (TAC) p.o.
		For home treatment Methylprednisolone (20 –> 12 [mg/d]) p.o. TAC (blood concentration 11 –> 5 [mg/d]) p.o. MMF (1,000 –> 500 [mg/d]) p.o.
20 Feb 2019	Significant increase of hair loss	Androgenetic alopecia (AGA) and telogen effluvium (TE) were diagnosed (Fig. 1)
25 Sep 2019	On dermatologist request, transplantologist changed IS.	Conversion from TAC to CsA (200 –> 125 [mg/d]) was performed
18 Dec 2019	Visible hair regrowth	Continuation of CsA therapy
1 2020	Graft function declined	No change in trichological status
	Creatinine: 3.1 –> 4.37
	Biopsy: tubular epithelial damage
29 Jul 2023	Preemptive re-transplantation	Continuation of CsA therapy
		Stable hair condition

Methods

Table 3 presents a study carried out in April 2025 aimed at finding case reports about hair disorders in immunosuppressed patients. A search of the PubMed database was performed using different variations of primary keywords such as “immunosuppression,” “transplant recipients,” “alopecia,” “hirsutism,” and “hypertrichosis.” The inclusion criteria was case reports concerning the incidence of trichological disorders and immunosuppressive drugs among solid OTRs. A total of 124 potential studies and publications were identified. The selected publications covered the period from 1980 to 2025, with only case reports being chosen. Some of these were not included because of duplications or a lack of information available on trichological disorder. A further two articles were excluded as they described trichodysplasia spinulosa and another three for describing pseudofolliculitis, follicular eruption, or pilomatrix dysplasia. The final set included 4 articles.

Table 3.

Flow diagram of the study

124 articled identified in PubMed	​
↓	Exclusion of articles that are not case reports
15
↓	Exclusion duplicates
11
↓	Exclusion of articles that do not contain information about trichological disorders in abstract, no full text available
9
↓	Exclusion 2 articles about trichodysplasia
7
↓	Exclusion 2 articles about pseudofolliculitis, follicular eruption, or pilomatrix dysplasia
4

Discussion

There is a significant amount of information regarding oncological and infectious complications during immunosuppression in transplant patients. Data on trichological disorders in larger populations of OTRs are sparse, with only a few case reports available in the literature. Without a doubt, the issue of trichological disorders in this group is often underestimated. The trichological disorders are important for transplant recipients, especially for women and teenagers, as they have a significant impact on their quality of life due to social perceptions. Trichological issues may result in patients refraining from adhering to proper immunosuppressive dosing in an attempt to prevent further hair loss.

This case highlights the importance of monitoring and treating the side effects of immunosuppressive medications, which can lead to severe trichological disorders and significantly affect the quality of life in transplant patients. The change in immunosuppression led to a reduction in hair loss, suggesting that TAC was the main risk factor.

Several available studies indicate the involvement of TAC in the development of trichological problems. Zuk et al. [17] described 3 cases of alopecia in women following islet transplantation. TAC was one of the medications used by the patients.

Okechuku et al. [18] also described the case of a 16-year-old female patient who developed adverse effects, including alopecia, 1 month after kidney transplantation. The problem resolved after switching the therapy from TAC to CsA.

Tricot et al. [8] described that vasoconstriction caused by TAC can also lead to hair loss resulting from impaired microcirculation in hair follicles. One of the side effects of TAC is endothelial damage, which may lead to disturbances in the blood flow. However, more studies are required to understand the mechanism of alopecia caused by TAC.

The underlying cause of alopecia does not seem to be due to an autoimmune response. Tricot et al. [8] demonstrated no association between alopecia and an increased incidence of acute graft rejection. Moreover, Shapiro et al. reported that alopecia resolved after reducing the TAC dose [20].

González-Guerra et al. [19] investigated the relationship between AA and solid organ transplantation. It remains unclear whether immunosuppressive drugs prevent the development of AA, promote its resolution, or contribute to its onset.

Philips et al. [16] also reported the development of AA in two kidney-pancreas transplant recipients receiving immunosuppressive therapy, which included CsA. The higher incidence of alopecia among female patients could indicate a disruption in sex hormone balance. Nevertheless Gebhart et al. [21] showed a rapid resolution of hair loss without hormonal therapy, which challenges this theory.

When diagnosing alopecia in transplant patients, it is important to consider their entire clinical spectrum. This includes the underlying disease related to renal failure, endocrinological disorders and other preoperative issues such as previous trichological conditions, a history of immunosuppressive drug use, the course of the medical procedure itself in addition to the postoperative period, immunosuppressive and other drugs currently being administered. A full diagnosis requires a series of biochemical tests (Table 4) as well as a dermatological examination, including a pull test and trichoscopic examination. A trichoscopy should be applied to all OTRs as it helps in the early detection of trichological problems, as well as recommending a classification and establishing a diagnosis of alopecia type. Consideration can also be given to performing a trichogram.

Table 4.

Suggested laboratory tests in OTRs reporting trichological disorders

Basic laboratory tests:

CBC (complete blood count)

AlAT (alanine aminotransferase)

AspAT (aspartate aminotransferase)

Creatinine

Uric acid

Hormonal laboratory tests:

TSH (thyroid stimulating hormone)

Free thyroxine

Free triiodothyronine

Free testosterone

Androstenedione

Estrogen

Prolactin

Additional laboratory tests:

Vitamin D3

Ferritin

Iron

Vitamin B12

Dehydroepiandrosterone sulfate

VDRL – Veneral Disease Research Laboratory Test Qualitatively

Antinuclear antibodies

In cases of trichological changes related to immunosuppressive medications, a conversion of immunosuppression should be considered in consultation with the transplant specialist. In cases of mixed types of alopecia, multidirectional treatment is required.

Regular monitoring and early intervention can help prevent or mitigate the progression of trichological problems in OTRs. Such practices should be part of routine examinations of transplant patients by dermatologists specializing in transplant dermatology. Broader studies are needed to evaluate the spectrum of trichological problems in OTRs, which would aid in developing more targeted and effective treatment strategies.

Conclusions

Regular trichological evaluations should equally be routine for transplant patients. When diagnosing alopecia in transplant patients, it is vital to consider the patient’s entire clinical spectrum. A full diagnosis requires a series of biochemical tests, a dermatological examination including a pull test and trichoscopic examination. In cases of trichological changes related to immunosuppressive medications, a conversion of immunosuppression should be considered in consultation with the transplant specialist.

The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000551649).

Statement of Ethics

Ethical approval was not required for this study in accordance with local and national guidelines, as this is a retrospective case report. Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This study was supported by Medical University of Gdansk, 01-10025/0008256.

Author Contributions

Conceptualization: E.K. and B.I.W. Methodology, formal analysis, investigation, and data curation: E.K., A.D.Ś., B.I.W. Supervision: A.D.Ś. Writing – original draft: E.K. Writing – review and editing: A.D.Ś. and B.I.W.

Funding Statement

This study was supported by Medical University of Gdansk, 01-10025/0008256.

Data Availability Statement

All data generated or analyzed during this study are included in this published article. Further inquiries can be directed to corresponding author.