Prevention is better than cure for chemo-induced alopecia: Prof Rod Sinclair

By Mardi Chapman

12 Oct 2021

The majority of breast cancer survivors with persistent chemotherapy-induced alopecia will respond to topical minoxidil or low dose oral minoxidil (LDOM), according to dermatologist Professor Rod Sinclair and international colleagues.

However prevention of hair loss via scalp hypothermia or novel approaches such as cyclin-dependent kinase 4/6 inhibitors to mitigate taxane-induced hair follicle damage, will be the best option for patients.

A retrospective case series of 100 breast cancer survivors attending specialist hair clinics in Australia, the UK and Germany, found most had received a taxane-based chemotherapy (92%).

Only five patients had a preexisting hair or scalp condition.

The study, published in JAMA Dermatology, also found only six patients had received prophylactic scalp hypothermia during their cancer treatment.

Thirty-nine patients presented with diffuse alopecia while 55 patients had thinning of the centroparietal scalp hair in a female pattern hair loss (FPHL) distribution.

Five female patients had bitemporal recession or balding of the crown resembling male pattern hair loss (MPHL) while the only male patient in the cohort had extensive baldness resembling MPHL.

Six patients also developed cicatricial alopecia with clinical and/or histologic features consistent with lichen planopilaris, fibrosing alopecia in a pattern distribution, or frontal fibrosing alopecia.

Ancillary features included persistent thinning of eyebrows (n = 50) and eyelashes (n = 32).

The study authors noted that women exposed to a taxane had more pronounced hair loss than those who were not (median Sinclair grade 4 v 2; P < .001).

However the severity or pattern of hair loss did not differ significantly between patients who received adjuvant endocrine therapy and those who did not.

Trichoscopic examination revealed the most common features were hair shaft diameter variability, increased vellus hairs and predominant single-hair follicular units.

The authors said the features of pCIA were therefore indistinguishable from those of androgenetic alopecia.

Hair loss treatment

Of the 49 patients who received treatment for their hair loss – topical minoxidil (2% or 5%), LDOM monotherapy (0.5-10 mg/d), and LDOM combined with an antiandrogen – all had a significant improvement in hair density.

The study said hair loss persisting more than 6 months after cessation of chemotherapy was relatively common yet underrecognised by oncologists and rarely included as an adverse event in clinical trials.

The authors said persistent chemotherapy-induced alopecia (pCIA) might be related to genetic variance as hair follicle stem cells were usually resistant to chemotherapy.

“Another theory proposed to explain pCIA is that chemotherapy “unmasks” previously unrecognised FPHL,” they said.

They noted a few patients presented with inflammatory scarring alopecia with clinical and histologic features supporting the diagnosis of lichen planopilaris or its variants.

“It is not inconceivable that chemotherapy-induced HFSC damage could trigger these processes in a small number of susceptible individuals.”

Professor Sinclair, from the University of Melbourne and Epworth Healthcare, told the limbic that neither oral nor sublingual minoxidil were TGA approved for the treatment of chemotherapy-induced hair loss.

“Samson Clinical Pty Ltd is currently conducting a development program, with a view to generating the necessary data to ultimately enable them to take these medications forward for regulatory approval,” he said.

“In the meanwhile, for patients currently experiencing pCIA there are a number of treatment options available.”

He said patients concerned about their pCIA could request a referral to a dermatologist.

“Similarly we would recommend that patients about to undergo chemotherapy who are concerned about the potential for hair loss should consult a specialist dermatologist with experience in the field.”

Disclosures: Professor Sinclair is the inventor of both oral and sublingual minoxidil treatments for hair loss and a director and founder of Samson Clinical.

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