Which antihypertensive medication (Angiotensin-Converting Enzyme inhibitor, Angiotensin II Receptor Blocker (ARB), Calcium Channel Blocker (CCB)) causes the least hair loss in a patient with hypertension?

Which Antihypertensive Causes the Least Hair Loss?

Calcium channel blockers (CCBs) and angiotensin receptor blockers (ARBs) cause the least hair loss among first-line antihypertensives, with ARBs being the preferred choice when hair loss is a concern.

Evidence for Hair Loss Risk by Drug Class

ACE Inhibitors - Documented Hair Loss Risk

• Lisinopril has been documented to cause alopecia in case reports, with resolution occurring within 4 weeks after switching to an ARB 1
• Other ACE inhibitors have also been associated with alopecia in previous case reports, though this is not widely recognized 1
• The mechanism appears to be medication-induced, with a probable causality relationship established using the Naranjo Adverse Drug Reaction Probability Scale 1

ARBs - Minimal Hair Loss Risk

• ARBs represent an effective alternative when ACE inhibitor side effects occur, including alopecia 1
• No documented cases of ARB-induced hair loss exist in the available literature 2, 3, 4
• ARBs are specifically indicated for patients experiencing ACE inhibitor side effects, with similar efficacy in blood pressure control 2
• These agents control blood pressure in 40-50% of patients as monotherapy and 60-70% when combined with a thiazide diuretic 2

CCBs - No Hair Loss Association

• No documented association between CCBs and alopecia exists in the literature 5
• CCBs are recommended as first-line therapy by both ACC/AHA and ESC/ESH guidelines 6
• Long-acting dihydropyridine CCBs are particularly recommended for initial therapy 7

Thiazide Diuretics - Insufficient Data

• No specific evidence regarding hair loss with thiazide diuretics was found in the provided literature
• These remain first-line agents per guidelines but lack specific data on alopecia risk 6

Practical Recommendations

For Patients Without Hair Loss

• Select antihypertensive therapy based on standard guideline recommendations: thiazide diuretics, CCBs, ACE inhibitors, or ARBs 6, 7
• Most patients require combination therapy, preferably as single-pill combinations 7, 8

For Patients Developing Hair Loss on ACE Inhibitors

• Switch to an ARB immediately - this is the most evidence-based approach with documented resolution of alopecia 1
• ARBs provide equivalent blood pressure control and cardiovascular protection without the hair loss side effect 2, 3
• Expect resolution within 4 weeks of switching 1

For Patients Concerned About Hair Loss Risk

• Initiate therapy with an ARB or CCB rather than an ACE inhibitor 7
• Combine with a thiazide diuretic if needed for blood pressure control 7, 8
• The combination of ARB plus CCB is a preferred guideline-recommended combination that avoids ACE inhibitor-related hair loss 6, 8

Important Caveats

• Hair loss from ACE inhibitors appears uncommon but is under-recognized by clinicians 1
• Always evaluate other potential causes of alopecia before attributing it to medication
• The combination of two RAS blockers (ACE inhibitor plus ARB) is contraindicated and should never be used 6
• For Black patients, initial therapy should include a CCB or thiazide diuretic regardless, as ACE inhibitors and ARBs are less effective as monotherapy in this population 7, 8