
How To Cope With Alopecia or Hair Loss During Cancer Treatment?
Highlights
- Alopecia or in other terms hair loss is one of the most physically visible and traumatic side effects that patients living with cancer experience quite frequently.
- Alopecia affects patients who receive certain types of chemotherapy and can be observed in up to 65% of the patients.
- Alopecia can develop 1 to 3 weeks after the start of cancer therapy.
- Scalp hypothermia is the proven strategy used in the treatment of alopecia.
- Topotecan, irinotecan, etoposide, teniposide and mitoxantrone are the most alopecia causing cancer drugs.
What are the grades of alopecia due to cancer treatment?
According to the National Cancer Institute (1), alopecia is categorised either as grade 1 or grade 2.
- Grade 1: Grade 1 alopecia is demonstrated as less than half hair loss which is not cognisable from a distance but is obvious at short distances. In grade 1 alopecia, patients do not need a wig or a piece of hair for camouflage.
- Grade 2: Grade 2 alopecia is when hair loss is more than 50% and is obvious to others from a distance. A hairpiece or a wig is necessary if the patient desires to camouflage the hair loss. This type of alopecia has a psychosocial impact.
According to an article published in The New England Journal of Medicine (2), alopecia is classified under 4 main grades that present the percentage of hair loss and is named as Dean Score.
- Grade 1: Up to 25% hair loss
- Grade 2: 25% to 50% hair loss
- Grade 3: 50% to 75% hair loss
- Grade 4: More than 75% hair loss

What are the cancer drugs causing alopecia?
Every cancer patient who is receiving certain types of chemotherapy may experience alopecia. Although some cancer drugs are highly associated with alopecia, the rest can either sometimes or rarely has hair loss effect. An article published in Seminars in Cutaneous Medicine and Surgery (3) classified the cancer drugs causing alopecia.
Cancer drugs that are highly associated with alopecia | ||
Doxorubicin | Daunorubicin | Etoposide |
Irinotecan | Cyclophosphamide | Epirubicin |
Docetaxel | Paclitaxel | Ifosfamide |
Vindesine | Vinorelbine | Topotecan |
Cancer drugs that are moderately associated with alopecia | ||
Amsacrine | Cytarabine | Bleomycin |
Busulphan | 5-fluorouracil | Vincristine |
Vinblastine | Lomustine | Thiotepa |
Gemcitabine | ||
Cancer drugs that are rarely associated with alopecia | ||
Methotrexate | Carmustine | Mitoxantrone |
Mitomycin | Cisplatin | Procarbazine |
6-mercaptopurine | Streptozotocin | Fludarabine |
Raltitrexed | Capecitabine | Carboplatin |
Some cancer drugs have minimal effect on hair loss, but some associated with increased rates. The table below demonstrates the percentages of hair loss depending on the type of cancer drugs used. Combinational treatments increase the rate of alopecia.
Name of cancer drug | Frequency |
Vincristine, vinblastine, vinorelbine, vinflunine, docetaxel, paclitaxel | 80% |
Topotecan, irinotecan, etoposide, teniposide, mitoxantrone | 60-100% |
Bendamustine, cyclophosphamide, estramustine, ifosfamide, mechloretamine, melphalan, carboplatin, cisplatin, oxaliplatin, dacarbazine, procarbazine, temozolomide | More than 60% |
Methotrexate, 6-mercaptopurine, 6-thioguanine, azathioprine, fludarabine, 5-Fluorouracil, capecitabine, cytarabine | 10-50% |
Cetuximab, panitumumab, erlotinib, gefitinib, lapatinib, canertinib | 50-90% |
Sorafenib, sunitinib | 5-21% |
Pazopanib | 8-10% |
Vemurafenib, dabrafenib | Up to 30% |
Rametinib, cobimetinib, binimetinib, selumetinib | Up to 17% |
Vismodegib | 58-63% |
Rubio-Gonzalez B, International Journal of Dermatology (4), 2018
Prevention and the treatment of alopecia during cancer treatment
1. Scalp cooling/Scalp hypothermia
Scalp cooling is one of the most important strategies that is used to prevent alopecia. Scalp-cooling devices (which have been approved by FDA) cool the scalp, causing thinning of the blood vessels to some extent which decreases the cancer drug reaching hair follicles. It is widely used, and success rates have been reported to be from 50% to 80%.
The application process is quite easy but some side effects such as headache, nausea/vomiting may occur. Patients should bear in mind that the device is only advised for patients who are at high risk of alopecia, depending on the cancer drugs used.
Patients receiving cisplatin, carboplatin or other platinum-based drugs may be sensitive to cold as these drugs may increase the sensitivity threshold. Therefore, the process should be avoided in patients receiving cisplatin or carboplatin.
Scalp cooling is also not advised in patients having:
- A rare disease called cold agglutinin disease
- A type of blood vessel inflammation called cryoglobulinemia
- Posttraumatic cold injury

2. Topical epinephrine/norepinephrine
Topical epinephrine and norepinephrine led to a decrease in the width of the blood vessels surrounding the scalp and can be used in the treatment of chemotherapy or radiotherapy-related alopecia. 3 times a day use of topical epinephrine and norepinephrine has a long-lasting effect.
Topical applications and also scalp cooling is relatively safe and there is no risk of bleeding due to thinning of blood vessels surrounding the scalp as vessel arrangement is different in the scalp than in other parts of the body. Patients should bear in mind that this treatment does not provide prevention but has an effect on hair regrowth after chemotherapy.
3. Topical minoxidil
2% and 5% formulations of topical minoxidil are also used in the treatment of alopecia but are not as effective as topical epinephrine/norepinephrine. According to a study published in Annals of Oncology (5), nearly 90% of the patients experienced hair loss during cancer treatment despite the treatment with minoxidil. It is not recommended to be used as a preventing hair loss during the treatment but may be effective in regrowth after discontinuation of cancer therapy. For visible results, minoxidil should be applied twice daily for half a year period.
Therefore, patients should not use minoxidil for preventing alopecia during cancer treatment and this is because of a lack of evidence about its safety and also ineffective results.
4. Topical bimatoprost
Bimatoprost 0.03%, medically known as prostaglandin analogue, can be used like minoxidil. According to a study published in the British Journal of Dermatology (6), bimatoprost solution was found to be twice as effective as the control group. It is associated with less frequently observed side effects. Like minoxidil, bimatoprost is not recommended for preventing alopecia during the treatment but for having greater regrowth after chemotherapy.
5. Calcitriol
Calcitriol or in other words 1,25-dihydroxyvitamin D3 has favourable effects against alopecia during cancer therapy. Although some studies show effective results, some studies impart controversy and various side effects. In a study published in the journal Anti-Cancer Drugs (7), the topical application of calcitriol was ineffective in preventing alopecia in cancer patients.
Conclusion
Cancer is a complicated disease affecting patients’ lives. Additional side effects like alopecia/hair loss decrease the quality of life and have a synergistic effect on the patient’s psychological well-being. Although there are several preventive and treatment strategies for alopecia, scalp cooling is the only proven effective technique. Other topical applications including topical calcitriol and minoxidil have no proven effects in prevention but may have an effect on regrowth after cancer therapy. Coping with alopecia shouldn’t only include physical applications to prevent or treat the side-effect but also seeking psychological help will have an additive benefit on mental well-being.
7 Sources
- National Cancer Institute https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/ctcae_v5_quick_reference_5x7.pdf
- The New England Journal of Medicine https://pubmed.ncbi.nlm.nih.gov/514322/
- Seminars in Cutaneous Medicine and Surgery https://cdn.mdedge.com/files/s3fs-public/issues/articles/vol28_i1_Chemo-Induced_Alopecia.pdf
- International Journal of Dermatology https://pubmed.ncbi.nlm.nih.gov/29377091/
- Annals of Oncology https://pubmed.ncbi.nlm.nih.gov/7826913/
- British Journal of Dermatology https://pubmed.ncbi.nlm.nih.gov/25296533/
- Anti-Cancer Drugs https://pubmed.ncbi.nlm.nih.gov/10378674/