Continuing medical education
Hair disorders in patients with cancer

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Cytotoxic chemotherapies, molecularly targeted therapies, immunotherapies, radiotherapy, stem cell transplants, and endocrine therapies may lead to hair disorders, including alopecia, hirsutism, hypertrichosis, and pigmentary and textural hair changes. The mechanisms underlying these changes are varied and remain incompletely understood, hampering the development of preventive or therapeutic guidelines. The psychosocial impact of chemotherapy-induced alopecia has been well documented primarily in the oncology literature; however, the effect of other alterations, such as radiation-induced alopecia, hirsutism, and changes in hair color or texture on quality of life have not been described. This article reviews clinically significant therapy-related hair disorders in oncology patients, including the underlying pathophysiological mechanisms, severity grading scales, patient-reported quality of life questionnaires, management strategies, and future translational research opportunities.

Section snippets

Epidemiology

Key point

  1. •

    Hair changes attributed to anticancer therapies are expected to occur in ≥65% of patients receiving cytotoxic therapies, 15% with targeted therapies, <2% on immunotherapies, and up to 100% in areas treated with radiotherapy

The widespread use of systemic anticancer therapies, their numerous combinations, and underreporting of hair disorders yield mixed incidence reports (Table I), but these events in varying degrees of severity are frequent across almost all types of interventions. The estimated

Clinical features

Key point

  1. •

    The spectrum of hair disorders in cancer patients encompasses all hair changes, including alopecia, pigmentary changes, textural changes, and cycle alterations

Hair disorders in cancer patients occur because of disturbances in hair follicle cycling and functioning and hair shaft synthesis, which results in effluvium during anagen or catagen.3, 4, 75 Clinical features of hair disorders induced by anticancer therapies vary depending on the anticancer therapy given, its half-life, dose, schedule,

Etiology and pathogenic mechanisms

Key points

  1. •

    The pathogenic mechanisms of anticancer therapy–induced alopecia and other hair disorders varies depending on causal therapy

  2. •

    The hair matrix keratinocytes of anagen hair follicles have a high mitotic activity, which makes them especially vulnerable to anticancer therapies

  3. •

    Paradoxically, some anticancer therapies can promote hair growth and textural and hair color changes

Although the clinical manifestation of CIA from different therapies may be similar (albeit with subtle variations), accumulating

Hair disorder severity grading

Key point

  1. •

    Adverse events in oncology clinical trials are graded using the Common Terminology Criteria for Adverse Events

The documentation of AEs is critical for patient safety and for the development of a toxicity profile for each anticancer drug/regimen. In the oncology literature, alopecia is graded by the following AE grading instruments; the World Health Organization,126 Dean scale,127 the Eastern Cooperative Oncology Group,128 Sredni et al,129 the National Cancer Institute,130 the EGFR Inhibitors

Quality of life in patients with cancer with hair disorders

Key points

  1. •

    Chemotherapy-induced scalp, eyelash, and eyebrow alopecia lead to a negative psychosocial impact

  2. •

    The impact of other hair disorders in oncology has not been reported, but is likely significant

Hair-related AEs have a profound impact on cancer patient QoL. CIA is one of the most clinically visible and distressing AEs,2 and has been cited as the most disturbing anticipated AE by 58% of breast cancer patients before chemotherapy.134 In a multicenter study, 55% of 168 breast cancer patients reported

Management

Key point

  1. •

    Most preventive or reactive strategies are based on uncontrolled studies; however, the US Food and Drug Administration has cleared 2 dynamic scalp cooling devices for the prevention of CIA in patients treated with cytotoxic chemotherapies for solid tumors

Challenges and future perspectives

Despite the prevalence and psychosocial impact of anticancer therapy–induced hair disorders, research into their clinical presentation, pathophysiology, and management strategies has not received the attention it justifies. A comprehensive knowledge of the impact of hair disorders on QoL would be critical to optimize the shared decision-making process between doctors and patients regarding cancer therapies. As patients live longer on cancer therapies, there is a need to identify risk factors of

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    Supported in part by National Institutes of Health/National Cancer Institute Cancer Center support grant P30 CA008748. Dr Lacouture is supported by the RJR Oncodermatology Fund. Dr Freites-Martinez is partially supported by Beca Excelencia, Academia Española de Dermatología y Venereología–Fundación Piel Sana. Dr Paus is supported by the National Institute of Health Research Manchester Biomedical Research Centre.

    Dr Shapiro has been a consultant for Aclaris, Samumed, Incyte, Replicel Life Sciences, and Shook, Hardy, and Bacon LLP, who represent Sanofi Aventis US LLC. Dr Goldfarb has a speaking, consultant, or advisory role with Adgero Biopharmaceuticals, AMAG Pharmaceuticals, Procter and Gamble, and Valeant women's health pharmaceuticals. Dr Nangia received clinical trial funding from Paxman to the Baylor College of Medicine for conduct of the SCALP trial. Dr Paus has a consultant role with or receives research funding from Giuliani/Italy and Unilever/UK, and is founder/owner of Monasterium Laboratory/Germany. Dr Lacouture has a speaking, consultant, or advisory role with Abbvie, Quintiles, Boehringer Ingelheim, AstraZeneca Pharmaceuticals, Legacy Healthcare, Foamix, Adgero Bio Pharmaceuticals, Janssen R&D, Novartis, Paxman, and Novocure, and also receives research grants from Berg and Bristol-Myers Squibb. Drs Freites-Martinez and Jimenez have no conflicts of interest to disclose.

    Date of release: May 2019

    Expiration date: May 2022

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    © 2018 by the American Academy of Dermatology, Inc.