Permanent Chemotherapy-Induced Alopecia (Hair Loss)

Alopecia is a common side effect of chemotherapy that may cause significant distress, especially when drugs like Taxotere make the hair loss permanent. During cytotoxic treatments and radiotherapy, pubic, axillary and scalp hair will rapidly start to thin until it falls in chunks. In some instances, even eyelashes or eyebrows may be affected. Although in most cases baldness is reversible and regrowth is usually complete after 3 to 6 months, some medications may cause an irreversible form of alopecia that has been reported in medical literature in patients treated with taxanes such as docetaxel. Permanent hair loss is defined as incomplete or absent hair regrowth within 6 months after chemotherapy treatment is stopped. In some instances, when the hair grows back it has a different color or texture and color. Some individuals find subjective relief from scalp cooling with cold caps, a technique which is also used to reduce the amount of hair that falls, especially in women.

Irreversible alopecia following Taxotere (docetaxel) treatment

The form of irreversible baldness caused by Taxotere is a form extremely similar to androgenetic alopecia without fibrosis (scarring) of the follicles. However, androgen levels are usually normal in patients affected by this condition, which also causes rarefaction of eyebrows, axillary and pubic hair that are usually unaffected. Although this may suggest the existence of a different mechanism not related to hormonal action, all patients affected by permanent chemotherapy-induced alopecia displayed biological menopause symptoms. Although the true pathophysiology is still unknown, current hypotheses include a potentially toxic damage to hair scalp cells that may disturb hair germination as well as other endocrine dysfunctions. The pattern is characterized by a distinct lack of fibrosis within the follicles, an increased number of miniaturized vellus hairs, and the presence of a small cluster of elastic fibers known as Arao-Perkins bodies.

What is androgenetic alopecia?

Androgenetic alopecia is a common type of hair loss that generally occurs in male individuals. Androgens are a family of hormones that include testosterone that promote the growth of body and scalp hair. However, an increased activity of these hormones may lead to hair loss, following a peculiar pattern that differs between males and females. In males, the hairline gradually recedes forming a characteristic “M” shape, and the hair loss keeps progressing at the top of the head eventually leading to complete baldness in some individuals. Female patterns are more variable, instead, with the hair becoming thinner all over the head without the hairline recession. Total baldness in women is extremely uncommon. The onset is gradual: hair shedding increases as testosterone shrinks the follicles until hairs transform into a wispy vellus. Eventually, whole areas are denudated. Some conditions that are associated with abnormal levels of androgens such as polycystic ovarian syndrome (PCOS) may cause androgenetic alopecia in women.

Scarring and non-scarring alopecia

When hair follicles are destroyed, and scar tissue fills them, the baldness is permanent, and hair never regrows. This is known as “scarring alopecia” or “cicatricial alopecia” and may occur after follicles exposure to chemicals, burns, fungal infections, radiation or physical damage such as traction. Other causes include autoimmune disorders such as lupus erythematosus, in which the body’s immune system destroys healthy follicles as a consequence of an inflammatory reaction. If the condition that causes the scarring is treated early enough, hair loss can be stopped in its tracks.

Non-scarring alopecias are the most common form of baldness and include the normal age-related hair thinning (senescent alopecia) as well as female and male pattern hair loss. Telogen effluvium and alopecia areata are both non-scarring forms that may also be associated with other conditions such as thyroid diseases or syphilis.

Psychological and quality of life effects of irreversible hair loss

Taxotere-induced irreversible alopecia is one of the most distressing consequences of cancer treatment. Since hair is a fundamental component of individual identity, losing one own’s hair may severely affect a patient’s self-esteem by negatively impacting his or her self-image and causing short and long-term effects on overall quality of life. This side effect is considered so troublesome by cancer patients, that many women even refused chemotherapy describing the risk of facing baldness as harder than losing a breast.

The degree of psychological distress is associated with hair loss severity as well as with the number of chemotherapy received. Patients’ reaction may include difficulties coping with the condition, negative changes in interpersonal relationships, denial and desire to interrupt the treatment or to withdraw from work. A change in the perception of body image may also cause a decrease in sexuality, especially in women. About 40 percent of female cancer patients affected by this adverse reaction had marital problems, while 63 percent of them saw their career suffer as a consequence. The loss of hair is often experienced as an identity change that damages self-esteem. Several individuals had to cope with it through a psychological journey that is strikingly similar to the grieving process. Subjects affected by irreversible alopecia have a higher risk of suffering from psychiatric disorders such as anxiety, major depression, social phobias and paranoia. All these detrimental psychological and emotional effects are further aggravated by the irreversibility of the condition when a patient is treated with taxanes such as docetaxel and paclitaxel.

Article by Dr. Claudio Butticè, Pharm.D.

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