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Chemotherapy-induced alopecia

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Chemotherapy-induced alopecia is a distressing side effect common to certain treatment regimens in oncology. Unfortunately, chemotherapy-induced alopecia is an often overlooked or minor factor among our current research priorities and thus advances in amelioration have been minimal. This review offers a comprehensive examination of the clinically relevant basic science, clinical research, and current management options for chemotherapy-induced alopecia. We emphasize that hair loss secondary to chemotherapy is not as random or nonspecific in patterns or extent of disease, as one would initially perceive. Patient support and education information and templates are provided to facilitate patient treatment.

Section snippets

Hair biology

The hair follicle is a highly organized structure within the skin. At the base of every hair follicle there is a structure called the papilla that consists of a collection of rapidly dividing matrix cells that forms an outward moving hair shaft from the dermis. In human beings, all hair follicle formation is complete at birth and the total number of terminal hair follicles on the scalp is approximately 100,000.2 After birth, hair growth involves lifelong continuous cycling through 4 stages as

Pathogenesis of CIA

Cytotoxic chemotherapy agents target dividing cells and as a result the highly proliferative hair matrix cells are an unintended target.4 Because affected hairs are those that are in the proliferative anagen phase, CIA is referred to as anagen effluvium.5

Studies of cyclophosphamide-induced alopecia in human beings and in mice have formed the basis for our current understanding of the pathogenesis of CIA. Early work in human beings demonstrated that cyclophosphamide administration leads to two

Clinical features of CIA

Alopecia from the cytotoxic effects of chemotherapy depends on the specific agent, the dose and duration of therapy, the route by which it is administered, and the response of the individual. Certain classes of chemotherapy agents are known to cause alopecia more readily. The typical agents include alkylating agents, anthracyclines, antibiotics, antimetabolites, vinca alkaloids, and taxanes (Table I). Although several studies have classified or tabulated chemotherapeutic agents based on

The experience of hair loss in patients with cancer

Across the literature, hair loss consistently ranks among the most troublesome and traumatic aspects of chemotherapy (Fig 2).36, 37 Almost 90% of patients with early-stage breast cancer considered perioperative chemotherapy to be the most burdensome aspect of their treatment course because of the alopecia.38 Some women have found hair loss to be more difficult to cope with than the loss of a breast.39, 40 Others have considered refusing treatment because of anticipated alopecia.40, 41 These

Physical interventions

Scalp cooling methods, in the form of ice packs, cooling caps, and caps connected to cooling devices (Penguin Cold Caps, Medical Specialties of California, London, UK), were introduced in the 1970s as a treatment for CIA.45 Scalp hypothermia is postulated to work by several mechanisms. It stimulates local vasoconstriction, thus decreasing the amount of chemotherapeutic agent reaching the follicle. The colder temperature also slows cellular uptake and reduces the overall intrafollicular

Practical applications to patient care

Given our current understanding of the human hair cycle and the state of experimental interventions, clinicians treating CIA must be proactive and supportive toward patients. An overall multidisciplinary approach is recommended. We have summarized our recommendations in Table IV and provided a patient education handout (Table V) with related Internet sites. Our institution offers several other factors to ameliorate patient distress. In particular, easy access to social workers and psychiatrists

References (71)

  • G.M. Kiebert et al.

    Effect of peri-operative chemotherapy on the quality of life of patients with early breast cancer

    Eur J Cancer

    (1990)
  • S. Rosman

    Cancer and stigma: experience of patients with chemotherapy-induced alopecia

    Patient Educ Couns

    (2004)
  • P. Katsimbri et al.

    Prevention of chemotherapy-induced alopecia using an effective scalp cooling system

    Eur J Cancer

    (2000)
  • E.G. Grevelman et al.

    Prevention of chemotherapy-induced hair loss by scalp cooling

    Ann Oncol

    (2005)
  • S.A. Forsberg

    Scalp cooling therapy and cytotoxic treatment

    Lancet

    (2001)
  • M. Duvic et al.

    A randomized trial of minoxidil in chemotherapy-induced alopecia

    J Am Acad Dermatol

    (1996)
  • R. Rodriguez et al.

    Minoxidil (Mx) as a prophylaxis of doxorubicin-induced alopecia

    Ann Oncol

    (1994)
  • J.J. Jimenez et al.

    Pretreatment with 1,25(OH)2D3 protects from Cytoxan-induced alopecia without protecting the leukemic cells from Cytoxan

    Am J Med Sci

    (1995)
  • E.M. Peters et al.

    A new strategy for modulating chemotherapy-induced alopecia, using PTH/PTHrP receptor agonist and antagonist

    J Invest Dermatol

    (2001)
  • T. Tsuda et al.

    Inhibitory effect of M50054, a novel inhibitor of apoptosis, on anti-Fas-antibody-induced hepatitis and chemotherapy-induced alopecia

    Eur J Pharmacol

    (2001)
  • G. Cotsarelis

    Gene expression profiling gets to the root of human hair follicle stem cells

    J Clin Invest

    (2006)
  • R. Paus

    Principles of hair cycle control

    J Dermatol

    (1998)
  • R. Paus et al.

    The biology of hair follicles

    N Engl J Med

    (1999)
  • R. Paus et al.

    Chemotherapy-induced alopecia in mice: induction by cyclophosphamide, inhibition by cyclosporine A, and modulation by dexamethasone

    Am J Pathol

    (1994)
  • R. Paus et al.

    Topical calcitriol enhances normal hair regrowth but does not prevent chemotherapy-induced alopecia in mice

    Cancer Res

    (1996)
  • M. Maurer et al.

    Hair growth modulation by topical immunophilin ligands: induction of anagen, inhibition of massive catagen development, and relative protection from chemotherapy-induced alopecia

    Am J Pathol

    (1997)
  • G. Lindner et al.

    Analysis of apoptosis during hair follicle regression (catagen)

    Am J Pathol

    (1997)
  • V.A. Botchkarev et al.

    p53 Is essential for chemotherapy-induced hair loss

    Cancer Res

    (2000)
  • A.A. Sharov et al.

    Fas signaling is involved in the control of hair follicle response to chemotherapy

    Cancer Res

    (2004)
  • D.M. Reeves

    Alopecia

  • D. Batchelor

    Hair and cancer chemotherapy: consequences and nursing care–a literature study

    Eur J Cancer Care (Engl)

    (2001)
  • S.J. Yun et al.

    Hair loss pattern due to chemotherapy-induced anagen effluvium: a cross-sectional observation

    Dermatology

    (2007)
  • P. Ljungman et al.

    Busulfan concentration in relation to permanent alopecia in recipients of bone marrow transplants

    Bone Marrow Transplant

    (1995)
  • D. Tran et al.

    Permanent alopecia following chemotherapy and bone marrow transplantation

    Australas J Dermatol

    (2000)
  • M. Machado et al.

    Six cases of permanent alopecia after various conditioning regimens commonly used in hematopoietic stem cell transplantation

    Bone Marrow Transplant

    (2007)
  • Cited by (92)

    • Permanent chemotherapy-induced alopecia presenting with erosive pustular dermatosis-like retention hyperkeratosis

      2022, JAAD Case Reports
      Citation Excerpt :

      Chemotherapy could trigger EPD or retention hyperkeratosis, but this does not explain the patient’s single episode, which usually follows a chronic recurrent course. pCIA can be distressing, with negative impact on quality of life and self-esteem.4,7,8 Prevention with scalp cooling,9 prompt diagnosis, and early treatment may help reduce morbidity.4

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    Funding sources: None.

    Conflicts of interest: None declared.

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