All Is Not Lost

Hair loss, or alopecia, is one of the most common and distressing side effects of chemotherapy. The degree, pattern, and timing of hair loss depends on the type of treatment and dose, and can vary among patients, as do the changes that can occur during hair regrowth.

Chemotherapy, targeted agents, and radiation therapy kill cancer cells, but in the process, can also damage rapidly dividing healthy cells, such as those in the hair follicles. Chemotherapy drugs most likely to cause complete hair loss include Adriamycin (doxorubicin), Taxol (paclitaxel), Taxotere (docetaxel), and Cytoxan (cyclophosphamide).

According to Mario Lacouture, MD, director of the Cancer Skin Care Program at Robert H. Lurie Comprehensive Cancer Center in Chicago, anti-estrogens and the newer targeted therapies, such as Sutent (sunitinib), Gleevec (imatinib), Erbitux (cetuximab), and Tykerb (lapatinib), are less likely to cause hair loss.

“As opposed to blocking the growth of all dividing cells, they (anti-estrogens) just block the growth of specific pathways or proteins that are critical to the cancer,” he says, adding that estrogen inhibitors, such as tamoxifen and Faslodex (fulvestrant), are more commonly associated with hair thinning, which usually lasts for the duration of therapy, but can also be permanent.

Chemotherapy can cause hair loss all over the body—the head, face (eyelashes and brows), arms, legs, and pubic area—whereas radiation only causes hair loss on the area treated. Depending on the dose of radiation, hair loss may be permanent or it may grow back after treatment.

Hair loss sometimes starts with a tingling feeling as the first strands come out, and the loss may be sudden or gradual. It can begin as soon as a week after the first chemotherapy treatment and within two weeks after beginning radiation.

Lacouture recommends that patients ask their doctor or nurse about the possibility of hair loss before treatment in order to anticipate and prepare for it, such as buying a wig or cutting hair short to make the transition easier.

Patients recommend a soft or satin pillow case to cut down on friction and wearing a cap when hair begins to fall out. For those who keep some hair, the scalp may be more sensitive during treatment, so patients should use soft hairbrushes, mild shampoos, low heat while drying the hair, and avoid dying, perming, or relaxing it during treatment.

Experts also recommend that patients plan in advance for a head covering, such as a wig, so that a hairdresser can match it to their current color, texture, and style. Many insurance companies cover all or part of the cost of wigs, but they may require a prescription that uses a special term such as “cranial prosthesis.” Nonprofit organizations such as the American Cancer Society and CancerCare provide free wigs to patients who can’t afford the cost.

Hair usually begins to grow back at a normal rate within a few weeks after the end of chemotherapy. In about one-third of patients, Lacouture says, hair will grow back with a different color or texture—previously straight, dark hair may come back curly or gray. The hair usually returns to normal over time, but the changes can be permanent.

Though results have been inconsistent, some studies show that applying a “cold cap” to the head during chemotherapy infusions may prevent or reduce hair loss by restricting blood flow to the head, thus, limiting the amount of chemotherapy that reaches the scalp and hair follicles.

“This will be effective only in drugs that last in the body for a short period of time because the caps are only used during the infusion,” Lacouture says.