Etiology and Clinical Presentation:
Alopecia areata is an immune-mediated inflammatory disorder characterized by hair loss, which can occur in small patches or over large areas of the scalp, body hair, eyelashes, and/or eyebrows. Most patients who develop alopecia areata are under the age of 30, but it can begin at any age. Alopecia areata can be self-limiting - 50% of patients will see complete hair regrowth within 1 year without treatment, but most will relapse months or years after remission. The exact mechanism of alopecia areata is unknown, but we do understand that there is an inflammatory immune response around the hair follicle, which leads to damage and eventually hair loss. There are no biological markers to detect alopecia areata, but there are known risk factors, including: family history of alopecia areata, comorbid asthma, hay fever, atopic dermatitis, thyroid disease, vitiligo, or downs syndrome. Alopecia areata can also be drug-induced - this is commonly seen with chemotherapeutic agents such as nivolumab (nivolumab-induced alopecia areata). Your race may also affect your risk of getting alopecia areata. In a large study, researchers found that black and Hispanic nurses were more likely than non-Hispanic white nurses to develop this disease. The decision to treat alopecia areata should be done based on severity of the disease and psychosocial implications of hair loss in young adults. For example, an older male adult may not request treatment, but a 20-year old patient may become extremely distressed by repetitive loss of hair. Below is a summary of treatment strategies currently recommended for alopecia areata:
Investigational and Approved Treatment Options for Alopecia Areata (2021)
Resources:
Messenger A. Alopecia areata: Management. UpToDate. https://www-uptodate-com.jerome.stjohns.edu/contents/alopecia-areata-management?search=alopecia%20areata&source=search_result&selectedTitle=1~60&usage_type=default&display_rank=1. Last Updated 03/03/2021.
Chemotherapy-induced alopecia refers to the temporary loss of hair resulting from systemic cancer treatment. It affects approximately 65% of patients undergoing cytotoxic therapy and significantly impacts their quality of life, adding to the burden of cancer diagnosis and treatment. The psychological toll can be severe, potentially leading to treatment avoidance or delays.
The mechanism behind chemotherapy-induced alopecia involves damage to rapidly dividing hair follicle cells by cytotoxic drugs. Hair follicles cycle through stages of growth (anagen), regression (catagen), and rest (telogen), with most scalp follicles in the growth phase at any time. Chemotherapy agents interfere with the highly proliferative keratinocytes in the hair follicle matrix during the anagen phase, causing anagen effluvium. The likelihood and severity of alopecia depend on factors such as the specific drug, its route of administration, dosage, and treatment schedule. High-dose, intravenous, and combination chemotherapy regimens are associated with a higher incidence of complete or near-complete alopecia. Drugs like cyclophosphamide, paclitaxel, docetaxel, doxorubicin, and etoposide are particularly notorious for causing significant hair loss.
Chemotherapy-induced alopecia manifests as partial or complete loss of hair from areas with normal hair growth, most prominently on the scalp, including the crown and frontal regions. Eyebrows, eyelashes, and body hair may also be affected but often regrow faster than scalp hair after treatment cessation. While most cases of alopecia are reversible within three to six months post-therapy, certain chemotherapy drugs, such as high-dose docetaxel, may lead to prolonged or permanent hair loss in some patients. Studies have shown significant rates of persistent alopecia in breast cancer patients even years after treatment completion, highlighting its lasting impact on quality of life.
Managing chemotherapy-induced alopecia involves preventive measures and supportive care. Scalp cooling, or scalp hypothermia, is used in patients undergoing chemotherapy for solid tumors to reduce hair loss. It works by constricting blood vessels in the scalp, thereby reducing the delivery of chemotherapy drugs to hair follicles. However, its effectiveness varies depending on the chemotherapy regimen used, with anthracycline-based therapies showing less preservation of hair. Scalp cooling may cause discomfort, cold intolerance, and headaches and comes with financial costs ranging from $1500 to $3000 per patient, depending on the treatment duration and equipment used.
Ongoing research explores pharmacological interventions like minoxidil, finasteride, spironolactone, and calcitriol for preventing or minimizing chemotherapy-induced alopecia. These treatments, although promising, lack regulatory approval for this specific indication and require further validation of their efficacy and safety profiles.
In addition to medical interventions, nonpharmacological strategies such as wigs, head coverings, and psychosocial support play crucial roles in helping patients cope with the cosmetic and emotional aspects of hair loss during chemotherapy. It is essential for healthcare providers to discuss the potential for alopecia before initiating treatment and explore alternatives when feasible, ensuring comprehensive support for patients facing this challenging side effect of cancer therapy.
Wikramanayake, T. C., Haberland, N. I., Akhundlu, A., Laboy Nieves, A., & Miteva, M. (2023). Prevention and Treatment of Chemotherapy-Induced Alopecia: What Is Available and What Is Coming?. Current oncology (Toronto, Ont.), 30(4), 3609–3626. https://doi.org/10.3390/curroncol30040275
Rossi, A., Fortuna, M. C., Caro, G., Pranteda, G., Garelli, V., Pompili, U., & Carlesimo, M. (2017). Chemotherapy-induced alopecia management: Clinical experience and practical advice. Journal of cosmetic dermatology, 16(4), 537–541. https://doi.org/10.1111/jocd.12308