ALOPECIA: how can you support your patients?

Alopecia is a common side effect of cancer treatments but not all treatments will cause hair loss. It is often temporary and reversible but no less distressing. You must support your patient and inform them about this side effect, which can be anxiety-inducing and upsetting.

What is Alopecia?

According to the Common Terminology Criteria for Adverse Events, “alopecia” is a disorder characterized by a decrease in hair density compared to normal for a given individual at a given age and body location¹. More specifically alopecia (medical term) refers to the loss of hair on the whole body, including the face. It differs from baldness which refers only to hair loss affecting the scalp².

The 2 grades of alopecia¹

Grade 1

Hair loss of <50%. This is described as minimal thinning, which can be camouflaged using different hair styling techniques. Hair loss at this stage may be so slight that it goes unnoticed.

Grade 2

Hair loss of ≥50%.It is apparent to others; a wig or hairpiece is necessary if the patient desires to completely camouflage the hair loss; it is associated with the psychosocial impact

Features of alopecia¹²

To support your patient and reassure them, you can tell them that the likelihood of alopecia is not linked to the severity of the illness, nor the effectiveness of the treatment. To be noticed, that hair loss can vary from person to person, even if they have the same treatment.

At the end of the treatment, hair will start to gradually regrow. However, you should warn your patient that the texture and/or color of their hair could be different when it grows back. Your role as a pharmacist is to participate in the therapeutic education of your patient by indicating the different phases they are likely to experience.

Treatments that cause alopecia²³:

Chemotherapy
Alopecia is a common side effect of chemotherapy but not all chemotherapy drugs cause it – it depends on the protocol prescribed. Tell your patient that in the large majority of cases, alopecia is temporary and can be reversed after treatment. Sometimes, hair loss is preceded or accompanied by pain or tingling on the scalp for a few days.
A cold cap may be offered during chemotherapy sessions to help limit or prevent alopecia. How effective this depends on the chemotherapy product used.
Alopecia usually begins 2 to 4 weeks after the start of chemotherapy. Hair begins to grow back approximately 2 to 6 months after treatment ends. At the end of the treatment, hair will start to gradually regrow. However, you should warn your patient that the texture and/or color of their hair is likely to be different when it grows back, although it may gradually return to its original appearance (after 12 to 18 months).

Radiotherapy radiation-induced alopecia, which may or may not be reversible depending on the dose delivered to the skin, is another common side effect for patients undergoing treatment for cancer in the head area. Hair loss occurs only around the irradiated area and starts two to three weeks after the start of radiotherapy.
Hair generally starts to grow back around two to three months after the treatment has ended. When the radiotherapy dose is less than 45 grams, hair is likely to grow back.

Hormone therapy and some medications used to treat breast cancer – such as tamoxifen or aromatase inhibitors, in particular, combined with targeted therapy – can also cause temporary and moderate hair loss or a change in hair texture (thinning). If alopecia occurs, this will be noticed six to 12 months after the start of treatment. Hair will remain sparse or patchy for the rest of the hormone therapy and will start to grow back a few months after treatment has ended.

Immunotherapy, generally speaking, immunotherapy does not tend to cause hair loss. However, a small proportion of patients treated with immunotherapy may present with alopecia5,7.

Targeted therapy some forms of targeted therapy – in particular, EGFR inhibitors – are highly likely to cause alopecia, while others do not at all. While hair on the head is often the target of targeted therapy, hair loss can affect the whole body. When alopecia occurs, it generally happens seven to ten weeks after treatment with EGFR inhibitors. Alopecia is accompanied by a change in hair texture; hair can become finer, more fragile, and more difficult to style7. In most cases, alopecia is temporary and hair starts to grow back several months after the treatment has ended. However, it can also sometimes be permanent.

Advice on caring for your patient²

1. Prevention

A cold cap may be offered during chemotherapy sessions to help limit or prevent alopecia. How effective this is depends on the chemotherapy product used.
You also can advise your patient to cut their hair short, i.e. shave it off, to reduce the shock that hair loss can cause. Direct your patient to a specialist hairdresser in your network so that they can be best supported.

2. The day of a chemotherapy treatment

Advise your patient to not brush their hair.

3. After the treatment

For the eight days following cancer treatment, using a soothing shampoo and/or serum can help reduce itchiness on the scalp.
Generally speaking, hair should be treated with care, in particular by washing it with lukewarm water the day before treatment, leaving it to air dry, and using a brush with soft bristles.
Limiting hair washing within three days of the treatment being administered is also recommended.
Between courses of treatment and until normal hair regrowth resumes, advise your patients to avoid dyes, styling, blow dries, or perms, as these can all weaken the hair.