Chemotherapy-induced alopecia - pag

Chemotherapy-induced alopecia

Nicolò Rivetti, MD Vigevano and Milano

The extent of the problem The extent of the problem

For a cancer patient, chemotherapy-induced alopecia is one of the most shocking aspects of the therapy. It is estimated that 58% of patients even consider it the most worrying adverse event of chemotherapy, even, for many women, more difficult to cope with than the loss of a breast. About 65% of chemotherapy patients experience hair loss during therapy. This aspect has a very significant impact on the patient's life, as it affects the image of his own body, sexuality and self-esteem, so that about 8% of cancer patients refuse chemotherapy if there is risk of hair loss.

Another important psychological aspect of hair loss should also be emphasized: chemotherapyinduced alopecia represents every day a sort of “reminder“ of the patient's disease, further worsening their mood.

A small percentage of patients, however, see hair loss as a positive sign that therapy is working. This interpretation of the problem should certainly be encouraged. The severity of hair loss (understood as risk and quantity) is related to: - Drugs: hair loss depends on the dosage, category, number of drugs used (for multi-chemotherapies the risk is increased) and on the type of administration (generally a higher incidence is observed in the case of intravenous therapies than to oral chemotherapy, which however is much less common). - Subjective factors: such as the patient's age, associated pathologies, pre-existence of any type of alopecia, nutritional and hormonal status.

What are the timelines? What are the timelines?

Generally, alopecia occurs within 1-3 weeks of starting chemotherapy; regrowth, on the other hand, is expected after 3-6 months from the suspension of chemotherapy, even if some patients experience faster regrowth (1-2 months from the suspension of treatment, or, sometimes, even during chemotherapy).

Why does hair fall out? Why does hair fall out?

Chemotherapy drugs target cells that replicate more actively but are not specific for cancer cells. They affect all cells that reproduce very quickly, including those of the hair follicle. Considering that most of the hair is in the ana-

gen phase (about 88/90% of the total), it is easy to understand why the scalp is the most frequently affected area.

Presentation Presentation

Each patient has an unpredictable clinical presentation, however the most affected areas of the scalp are: the frontal hairline, the occipital hairline and areas of friction, such as the one above the ears. The alopecia can be diffuse or in patches. Other hairy areas can also be affected: the beard, eyebrows, eyelashes, axillary and pubic regions, again depending on the percentage of anagen hair present. Another quite common aspect (up to 60% of patients) is the difference in thickness, color or texture at the time of hair regrowth. In any case, it must be remembered that the chemotherapy protocol that will be administered is fundamental for estimating the risk of alopecia: whether it is classic drugs (which interfere with replicating cells), or new molecular target therapies (which therefore go to hit specific cellular targets) the most common scenario is that of diffuse alopecia which, in the vast majority of cases, is reversible. Unfortunately, there are cases of permanent chemotherapy-induced alopecia, although for-

tunately they are not frequent: these are mainly patients treated with high-dose chemotherapy before bone marrow transplantation. The cases described in the literature mainly concern the use of busulfan (in high doses), cyclophosphamide (in high doses), taxanes and EGFR inhibitors. Alopecia is defined as permanent in case of total or partial absence of hair regrowth for a period of more than six months from the end of chemotherapy.

What to do before, during and after che What to do before, during and after che-motherapy motherapy

Before starting chemotherapy The first step before starting chemotherapy is the dermatological visit, during which the patient can request information, support and advice from the dermatologist. It is important, at this stage: A. to highlight previous pathologies of the scalp (sometimes the patient himself is not aware of them and the dermatological examination can highlight them); B. to investigate the existence of autoimmune diseases or a family history of alopecia; C. to identify any subclinical pathologies that can become evident with chemotherapy. Knowledge of the chemotherapy protocol that will be used is essential to estimate the risk of hair loss. Blood tests can also provide useful information to complete the patient's clinical picture: assessing iron status (especially in women), thyroid function and vitamin D levels is important to assess whether there are deficiencies that may affect the hair, even before starting chemotherapy. Unfortunately, there are no approved drugs that can prevent hair loss, although some are under study. Psychological / psychiatric support is fundamental, especially if we are dealing with patients already suffering from anxiety or depression problems.

During chemotherapy During chemotherapy

In recent years, the use of scalp cooling has become widespread. These are devices that, through the progressive cooling of the scalp,

exert a vasoconstriction action capable of reducing the amount of chemotherapy drug that reaches the hair follicles, significantly reducing alopecia. These devices have been adopted in more than 30 countries around the world, with a positive response in 50-80% of patients. Side effects of scalp cooling include nausea, headache and dry skin, but they are generally very well tolerated by patients. Finally, scalp cooling is not a device for everyone. It is recommended in the case of patients with solid tumors undergoing chemotherapy protocols with a high risk of alopecia, while it is not recommended: 1) in patients with haematological tumors, because it can increase the risk of metastasis to the scalp; 2) in patients with impaired liver function; 3) in patients suffering from cryoglobulinemia. Other recommendations to follow during chemotherapy concern the care of the hair itself: it is advisable to comb it with soft brushes (to avoid further trauma) and to limit washing to what is strictly necessary, using a mild shampoo. It is not necessary to cut the hair short, although it is preferable: in some patients it can be useful to psychologically prepare for the hair shedding, also reducing the perception of it. In addition, the adhesion of the scalp cooling on short hair is greater. Help for patients facing this condition can come from the use of a wig, which also has the function of protecting the scalp from the sun and cold. In this regard, there are autologous prostheses, obtained by cutting the patients' hair and implanting them on a prosthetic support.

Between chemotherapy sessions Between chemotherapy sessions

It is possible to use topical vasoconstrictors, which have a mechanism of action similar to that of cooling caps (they use the principle of vasoconstriction). They are administered in the form of creams, ointments, or hydrogels containing vasoconstricting agents to be applied several times a day between chemotherapy sessions. Topical vasoconstrictors are generally galenic: they are prepared by the pharmacist on the prescription of the dermatologist. Their use is entirely empirical and their real effectiveness is still being evaluated.

After chemotherapy After chemotherapy

After the suspension of chemotherapy, the most used topical drugs to promote hair regrowth are minoxidil, hydrocortisone butyrate and estrone (except in cases of breast cancer).

The chemotherapy protocol that will be administered is essential to estimate the risk of hair loss.

In classic chemotherapy regimens, alopecia is reversible, however it may happen that the hair grows back with different characteristics.

It is important for the patient to follow the doctor's instructions before, during and after therapy.