Does Remicade cause hair loss? Infliximab (Remicade and its biosimilars) is a TNF-alpha inhibitor widely used in the UK to treat conditions such as Crohn's disease, rheumatoid arthritis, and plaque psoriasis. Hair loss (alopecia) is listed as an uncommon adverse reaction in the UK Summary of Product Characteristics, affecting an estimated 1 in 100 to 1 in 1,000 patients. However, hair shedding during infliximab treatment is not always caused by the medication itself — co-prescribed drugs, nutritional deficiencies, and the underlying inflammatory condition can all contribute. This article provides a balanced, evidence-based overview to help patients and clinicians make informed decisions.

Hair Loss as a Side Effect of Infliximab (Remicade and Biosimilars)

Alopecia is a recognised uncommon adverse reaction to infliximab, listed in the UK SmPC and reported to the MHRA via the Yellow Card scheme; biosimilars share the same safety profile as the originator.

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Remicade is a brand name for infliximab, a biological medicine classified as a tumour necrosis factor-alpha (TNF-alpha) inhibitor. In UK clinical practice, infliximab is also available as several biosimilar products (including Inflectra, Remsima, and Zessly); these share the same mechanism of action and established safety profile as the originator. Infliximab is used to treat a range of chronic inflammatory conditions, including Crohn's disease, ulcerative colitis, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis. It works by binding to and neutralising TNF-alpha, a protein that drives inflammation in these conditions.

Hair loss (alopecia) is a recognised adverse effect associated with infliximab. The UK Summary of Product Characteristics (SmPC), available via the Electronic Medicines Compendium (EMC), lists alopecia as an uncommon adverse reaction, and the Medicines and Healthcare products Regulatory Agency (MHRA) has received spontaneous reports of hair loss in patients receiving this treatment. Patients who experience a suspected side effect — including hair loss — are encouraged to report it to the MHRA via the Yellow Card scheme at yellowcard.mhra.gov.uk or through the Yellow Card app.

It is important to note that the occurrence of hair loss in a patient taking infliximab does not automatically confirm a causal relationship — many factors can contribute to hair thinning or shedding, and these are discussed below. This article aims to provide a balanced, evidence-based overview of what is currently known, to help patients and healthcare professionals make informed decisions about ongoing treatment.

How Common Is Hair Loss With Infliximab in Clinical Evidence?

The UK SmPC classifies alopecia as uncommon with infliximab, affecting an estimated 1 in 100 to 1 in 1,000 patients; the majority of people receiving infliximab do not experience significant hair loss.

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According to the UK SmPC for infliximab (EMC), alopecia is classified as an 'uncommon' adverse reaction, meaning it is estimated to affect between 1 in 100 and 1 in 1,000 patients. This frequency classification applies to infliximab originator and biosimilar products alike, as biosimilars are required to demonstrate equivalent safety and efficacy to the reference medicine.

Case reports and small observational studies have documented various patterns of hair loss in patients receiving TNF-alpha inhibitors, including infliximab. These include:

• Telogen effluvium — diffuse shedding triggered by physiological stress or systemic illness

• Alopecia areata — patchy, immune-mediated hair loss

• Lichenoid reactions — inflammatory skin changes that can affect the scalp; these are considered rare and are supported primarily by case-report level evidence

• Paradoxical psoriasiform scalp disease — an inflammatory scalp reaction that can occur as a paradoxical response to TNF-alpha inhibition and may contribute to hair changes

Interestingly, there is a paradox in the literature: TNF-alpha inhibitors such as infliximab have been reported to trigger alopecia areata in some patients, despite the fact that TNF-alpha blockade has been explored as a potential treatment for this condition in other contexts. This paradoxical immune response is not fully understood and remains an area of ongoing research.

It is important to emphasise that most evidence for these patterns comes from case reports and pharmacovigilance databases. Whilst valuable for signal detection, such data cannot reliably estimate incidence or establish definitive causality. Large-scale randomised controlled trials have not identified hair loss as a frequent or primary concern with infliximab. The majority of individuals receiving infliximab do not experience significant hair loss.

Why Infliximab May Affect Hair Growth

Blocking TNF-alpha may alter the immune environment of the hair follicle, potentially triggering autoimmune responses such as alopecia areata or paradoxical psoriasiform scalp disease in susceptible individuals.

To understand why infliximab might influence hair growth, it is helpful to consider the biology of the hair follicle. Hair follicles are dynamic, immune-privileged structures that cycle through phases of growth (anagen), regression (catagen), and rest (telogen). TNF-alpha plays a complex role in regulating immune activity within and around the follicle, and disrupting this signalling pathway may have unintended consequences on the hair cycle. The mechanisms described below are hypothetical and are not endorsed by regulatory bodies as definitive explanations.

One proposed hypothesis is that blocking TNF-alpha alters the local immune environment of the hair follicle, potentially triggering an autoimmune response that targets follicular cells. This may help explain the paradoxical induction of alopecia areata observed in some patients on TNF-alpha inhibitors. In alopecia areata, T-lymphocytes mistakenly attack the hair follicle, causing patchy hair loss — a process that TNF-alpha blockade may inadvertently facilitate in susceptible individuals.

A further consideration is paradoxical psoriasiform scalp disease, which has been reported with TNF-alpha inhibitors. This inflammatory scalp reaction can cause scaling, erythema, and associated hair shedding, and should be considered as a differential cause of hair changes in patients receiving infliximab.

Additionally, systemic inflammation itself — the very condition infliximab is used to treat — can cause telogen effluvium. As the body responds to chronic disease, hair follicles may prematurely enter the resting phase, leading to diffuse shedding weeks to months later. This means that hair loss observed during infliximab treatment may, in some cases, be a consequence of the underlying condition rather than the medication.

Clinicians should consider all potential contributing factors before attributing hair loss solely to infliximab, and further research is needed to clarify the precise pathways involved.

Other Medications and Conditions That Can Cause Hair Loss

Methotrexate, azathioprine, and sulfasalazine — commonly co-prescribed with infliximab — are well-established causes of alopecia, as are thyroid dysfunction and iron deficiency anaemia.

When evaluating hair loss in a patient receiving infliximab, it is essential to consider the broader clinical picture. Many patients with inflammatory conditions are prescribed multiple medications simultaneously, and several of these are well-established causes of alopecia.

Medications commonly associated with hair loss include:

• Methotrexate — frequently co-prescribed with infliximab for rheumatoid arthritis and Crohn's disease; hair loss is a well-documented side effect (see BNF monograph for methotrexate)

• Azathioprine and mercaptopurine — immunosuppressants used in inflammatory bowel disease (see BNF monographs)

• Sulfasalazine — used in arthritis and bowel conditions (see BNF monograph)

• Corticosteroids — long-term systemic use may be associated with hair changes in some patients, though this is not a primary listed adverse effect; any concerns should be discussed with a clinician

Underlying conditions that may independently cause hair loss include:

• Thyroid dysfunction (hypothyroidism or hyperthyroidism) — common in patients with autoimmune conditions

• Iron deficiency anaemia — prevalent in Crohn's disease and ulcerative colitis due to malabsorption or chronic blood loss

• Nutritional deficiencies — including zinc and vitamin D; biotin (vitamin B7) deficiency is rare in adults eating a balanced diet, and routine biotin supplementation is not recommended without clinical indication. Importantly, the MHRA has issued a Drug Safety Update warning that high-dose biotin supplements can interfere with a range of laboratory immunoassays, potentially causing misleading test results

• Stress and chronic illness — both physical and psychological stress can precipitate telogen effluvium

Given this complexity, a thorough assessment is necessary before concluding that infliximab is the cause of hair loss. UK primary care dermatology guidance (Primary Care Dermatology Society [PCDS] and British Association of Dermatologists [BAD]) advises that investigations should be guided by clinical suspicion and the pattern of hair loss (for example, diffuse versus patchy; scarring versus non-scarring), rather than applied routinely. Where clinically indicated — for example, in diffuse hair loss — blood tests such as full blood count (FBC), serum ferritin, and thyroid-stimulating hormone (TSH) may be appropriate. NICE Clinical Knowledge Summary (CKS) guidance on alopecia areata similarly recommends investigations based on clinical findings rather than as a routine screen. Identifying and treating a reversible underlying cause may resolve hair loss without any need to alter the infliximab regimen.

When to Speak to Your Doctor or Specialist

Patients should contact their GP or specialist if they notice progressive hair thinning, patchy loss, or scalp changes, and must not stop infliximab without medical advice due to the risk of disease flare.

Patients who notice hair loss whilst receiving infliximab should not discontinue their treatment without first consulting their specialist. Stopping a biological medicine abruptly can lead to a flare of the underlying condition and may affect the ability to restart the same treatment in the future due to the development of anti-drug antibodies.

You should contact your GP or specialist if you experience:

• Noticeable or progressive hair thinning or shedding

• Patchy bald areas on the scalp or elsewhere on the body

• Hair loss accompanied by scalp redness, scaling, or soreness

• Hair loss alongside other new symptoms such as fatigue, weight changes, or skin rashes

• Significant distress or impact on quality of life related to hair changes

Seek prompt medical assessment if you develop:

• Severe scalp pain, tenderness, or swelling

• Pustules or crusting on the scalp

• Fever or feeling systemically unwell alongside scalp changes

These features may suggest a more urgent condition such as a scalp infection or scarring alopecia, which requires timely evaluation. If you are unable to reach your usual care team and feel acutely unwell, contact NHS 111 for advice.

Your specialist — whether a gastroenterologist, rheumatologist, or dermatologist — can review your medication history, arrange appropriate investigations, and refer you to a dermatologist if needed. A dermatologist can perform a scalp examination, trichoscopy, or occasionally a scalp biopsy to determine the type and cause of hair loss.

It is also worth raising hair loss concerns at your next scheduled infusion appointment or outpatient review, even if the change seems minor. Early assessment allows for timely identification of treatable causes and ensures that any decision about continuing, adjusting, or switching treatment is made collaboratively and with full clinical information.

If you believe your hair loss may be related to infliximab or another medicine, you can report this directly to the MHRA via the Yellow Card scheme at yellowcard.mhra.gov.uk.

Managing Hair Loss During Infliximab Treatment

Management depends on the identified cause; treating reversible factors such as nutritional deficiencies often restores hair growth, while switching biologics or specific dermatological treatments may be considered where infliximab is implicated.

The management of hair loss in patients receiving infliximab depends entirely on the identified cause. A personalised approach, guided by a multidisciplinary team, is recommended.

If the hair loss is related to a nutritional deficiency or comorbidity: Addressing the underlying cause — for example, treating iron deficiency anaemia or correcting thyroid dysfunction — often leads to significant hair regrowth over several months. Dietary optimisation and supplementation should only be undertaken where clinically indicated and guided by blood test results. Routine supplementation with biotin is not advised without confirmed deficiency, given its rarity in adults and the MHRA warning regarding interference with laboratory immunoassays.

If the hair loss is attributed to a co-prescribed medication: Your specialist may consider adjusting the dose or switching to an alternative agent, where clinically appropriate and safe to do so. This decision must always be balanced against the risk of disease flare.

If infliximab itself is suspected: In cases where infliximab is considered the most likely cause, the clinical team will weigh the benefits of continued treatment against the impact of hair loss. In many cases, the benefits of disease control outweigh the risk of alopecia, particularly when hair loss is mild. Switching to an alternative biologic — such as another TNF-alpha inhibitor or a different class of biological therapy — may be considered in consultation with the patient. Any such switch should follow disease-specific NICE Technology Appraisals and be agreed through multidisciplinary team review.

If a specific dermatological diagnosis is made: Evidence-based treatments are available for certain types of hair loss. For example, topical or intralesional corticosteroids are used in the management of alopecia areata, in line with British Association of Dermatologists (BAD) guidance. Paradoxical psoriasiform scalp disease may require specific topical treatments. Your dermatologist will advise on the most appropriate approach based on your diagnosis.

If you are considering over-the-counter treatments such as topical minoxidil, discuss this with your clinician first to ensure suitability alongside your current medications and condition.

General supportive measures include:

• Gentle hair care practices to minimise mechanical stress

• Avoiding heat styling and harsh chemical treatments

• Psychological support or referral to a counsellor if hair loss is causing significant distress

• Signposting to patient support organisations such as Alopecia UK

With appropriate investigation and management, many patients find that hair loss is either reversible or manageable without compromising their treatment for the underlying condition. Further information on hair loss is available on the NHS website (NHS: Hair loss).

Frequently Asked Questions