Methotrexate hair loss in rheumatoid arthritis: what the trials show

Also searched as: methotrexate hair lossmethotrexate hair thinning rheumatoid arthritisMTX hair loss

A meta-analysis of randomized trials of weekly low-dose methotrexate with folic or folinic acid estimated alopecia at 1.0%–4.9%; in a UK cohort of 1,069 people with early RA, alcohol use was linked to higher odds of alopecia.

No consistent week-by-week window is published for this, so it is not on the calculator.

The timeline

Stage	When (typically)	What's happening
Typical drug-shed onset	2–4 months after a start or dose change	DermNet: with telogen effluvium from drugs, hair loss usually becomes evident after 2–4 months. [DermNet]

Low dose vs chemo dose

	Weekly low dose (RA, psoriasis)	High-dose chemotherapy
How often	1.0%–4.9% alopecia in RCTs [Arthritis]	Anagen hair loss is common with chemotherapy [DermNet]
Mechanism	Usually telogen shedding [DermNet]	Growing hairs stop [DermNet]

Who noticed it more in the UK study

Mucocutaneous side effects overall affected 26.0% of 1,069 patients over the first year [Rheumatology].
Women had higher odds of mucocutaneous effects, and alcohol use was linked to alopecia [Rheumatology].
The trials in the meta-analysis all co-prescribed folic or folinic acid [Arthritis].

Normal vs. warning signs

Commonly normal

Mild diffuse thinning
No patches

Warning signs — get checked

Patches or smooth bald spots
Scalp pain, redness, burning or scaling
Loss of eyebrows, eyelashes or body hair
Mouth ulcers, fever or unusual bruising — contact your rheumatology team

Find a trichologist →

What may help

Never stop or change a prescribed medicine on your own — raise hair changes with your prescriber, who can weigh them against why you take it.
Ask your rheumatologist whether your folic acid plan is right for you.
Note when thinning started relative to dose changes.

Related triggers

Medications

Telogen club hair

Frequently asked questions

How common is methotrexate hair loss?

Randomized trials put alopecia at 1.0%–4.9% on weekly low-dose methotrexate.

Does folic acid help methotrexate hair loss?

The trials in the meta-analysis all used folic or folinic acid; whether to change your dose is a question for your rheumatologist.

When does methotrexate hair loss start?

Drug-related shedding usually becomes evident 2–4 months after a start or dose change, per DermNet.

Sources

Arthritis Care & Research, 2020. Low-Dose Methotrexate and Mucocutaneous Adverse Events: Systematic Review and Meta-Analysis of RCTs
Rheumatology (Oxford), 2022. Rates and predictors of methotrexate-related adverse events in early rheumatoid arthritis (RAMS, n=1069)
DermNet. Alopecia from drugs