A new review has been published highlighting different studies’ findings on the use of various alopecia therapies among breastfeeding mothers, with a detailed discussion provided on each medication’s transference to breast milk, blood serum levels in infants, potential adverse events among neonates, and other clinical considerations.1
These data were all authored by a team of investigators, led by Carli D. Needle, an MD candidate at The Ronald O. Perelman Department of Dermatology at New York University’s Grossman School of Medicine. Needle et al noted that alopecia areata, androgenetic alopecia (AGA), and cicatricial alopecia can each lead to negative physical symptoms and notable psychological distress among patients and women in particular.2
“Given the limited research in this area and the importance of avoiding interruptions in alopecia treatment, this review aims to help guide clinicians in choosing safe and appropriate hair loss therapies for women during lactation,” Needle and coauthors wrote.1
Design and Findings
The trial investigators carried out their literature searches using the Scopus, PubMed, and Web of Science databases. Searches were done only in English. Existing safety databases such as the Drugs and Lactation Database (LactMed) and the United States Food and Drug Administration (FDA) Drug Database were also used by the team, and any primary literature cited by these databases was further examined when accessible. Terms included the medication names and classes assessed by this review, as well as “lactation” and “breastfeeding.” Searches were done from November 2024 – December 2024.
The investigators noted the increasing systemic and topical medication use in alopecia treatment. The hair regrowth medication minoxidil is generally classified as low-risk during lactation, with oral being documented in breastfeeding mothers without complications. Nevertheless, because of possible transmission through skin contact or milk, cautious utilization of minoxidil is still being advised, especially in premature infants or neonates.
Needle and coauthors highlighted that Janus kinase inhibitors (JAKi), which reduce inflammation by targeting T-cell signaling pathways, are among some of the most effective. Approved JAKis for alopecia areata include baricitinib, deuruxolitinib, and ritlecitinib. As a result of their small molecular size, JAK inhibitors can pass into breast milk, contributing to concerns about infant exposure.
Tofacitinib appears in human breast milk within hours of ingestion, leading to current guidelines to avoid breastfeeding while implementing it. For other JAKis, such as baricitinib and ritlecitinib, lactation safety data are limited, though pharmacokinetic modeling suggests drug levels fall below clinical significance within several half-lives. Given uncertainty, those using such drugs are typically advised to pause breastfeeding during active JAKi use.
Needle and colleagues pointed to a variety of other research, noting different recommendations based on the drugs available for alopecia. Methotrexate, for example, only enters breast milk in small amounts but its active metabolite can linger in neonatal tissues as a result of immature infant kidney function. Even low levels of exposure is linked to potential developmental toxicity, so methotrexate is contraindicated during breastfeeding.
Other data highlighted by the investigative team included diphencyprone (DPCP), a topical option often used in alopecia areata that also acts as a contact allergen, triggering localized immune responses to encourage hair regrowth. Despite noted minimal systemic absorbtion, rare reports of DPCP entering circulation do exist. The lack of robust data, the team suggest, suggests a need for caution until further research is available.
The investigators further highlighted azathioprine that is now applied in autoimmune dermatologic conditions, noting that most experts recommend waiting a few hours after dosing before breastfeeding to allow peak concentrations of the medication to subside. They further pointed to cyclosporine, adding that variable transmission into breast milk has been observed with the drug and largely depends on the formulation. Generally, cyclosporine is considered compatible with breastfeeding, though infants should be monitored for potential adverse effects.
The Excimer laser, a narrow-band ultraviolet B (NB-UVB) therapy used to manage autoimmune scalp conditions, was noted as effective and generally safe, though folate supplementation was highlighted as necessary for consideration in postpartum mothers given this treatment. Needle et al pointed to data suggesting poor absorbtion of topical vitamin D analogues like calcipotriene during lactation, but noted that oral vitamin D is safe up to 10,000 IU daily, and supplementation in the mother may benefit infants given low levels of breast milk vitamin D.
For androgenetic alopecia, spironolactone is an anti-androgen agent that appears in breast milk only in trace amounts and has not been linked to infant harm. In a similar vein, topical clascoterone was shown to have lower systemic absorption, though safety during lactation was noted as not well established. Other findings in the review suggest that progestin-only pills, particularly drospirenone, have no adverse effects among breastfed infants when introduced after 6 weeks postpartum.
Other topical treatments like ketoconazole 2% shampoo, often implemented in scalp inflammation, were noted as safe resulting from their negligible levels of systemic absorption. Low-level laser therapy (LLLT), frequently utilized in hair regrowth procedures, is also regarded as safe during lactation due to its noninvasive nature and lack of drug interaction. Platelet-rich plasma (PRP) was shown by the investigators’ review to pose minimal risk for breastfed infants. Some natural or plant-based therapies, including saw palmetto and rosemary oil, had less data and were not recommended.
For scarring (cicatricial) alopecias, topical tacrolimus is considered to be safe due to limited systemic absorption, though available data suggests direct contact with the infant skin should be avoided. Hydroxychloroquine was noted by Needle et al as being excreted in small amounts into breast milk, though it has not been linked to harms among infants. The antibiotic doxycycline was shown by the team to generally be safe for short-term use during lactation.
They highlighted that mycophenolate mofetil is not considered safe during breastfeeding given the high transfer into milk and risks linked to its use such as infections or developmental delays. Pioglitazone, a metabolic agent, is also shown to have produced harmful effects in animal studies and should be avoided. The investigators did, however, highlight the safety of low-dose naltrexone, sometimes used off-label for inflammatory conditions, which has shown minimal transmission into milk.
Clindamycin and rifampicin, both antibiotics used for inflammatory scalp conditions, are compatible with breastfeeding. However, Needle and coauthors did note that infants should be monitored for any GI symptoms. Retinoids like isotretinoin and acitretin were noted as being contraindicated given their high risk of toxicity and birth defects. In contrast, topical retinoids were shown to be likely safe.
The review also highlighted tumor necrosis factor (TNF) inhibitors such as adalimumab, primarily utilized in resistant inflammatory alopecias, which data suggest do appear in breast milk at very low levels. The protein molecules are broken down in an infant’s gut and are not absorbed systemically, making them compatible with breastfeeding.
“Although breastfeeding confers well-established health benefits, some individuals may choose to prioritize treatment for alopecia over continued breastfeeding, especially when effective therapies are not fully validated as compatible with lactation,” they wrote.1 “It is therefore crucial for providers to understand the risk of systemic absorption…in order to make informed decisions and safe recommendations to breastfeeding patients.”
References
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CD Needle, AL Brinks, CA Kearney, et al. “Alopecia Treatments in Breastfeeding: Safety and Clinical Considerations,” International Journal of Dermatology (2025): 1–20, https://doi.org/10.1111/ijd.17940.
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N Hunt and S McHale. “The Psychological Impact of Alopecia,” BMJ 331, no. 7522 (2005): 951–953, https://doi.org/10.1136/bmj.331.7522.951.