Table II.
Hair disorders in cancer survivors: management and recommendations.
| Hair disorder | Intervention | Level of evidence |
|---|---|---|
|
| ||
| Persistent chemotherapy-induced alopecia (pCIA) | CTCAEv4.0 grade 1: | Level IV |
| Topical minoxidil foam 5% twice daily | ||
| CTCAEv4.0 grade 2: | ||
| Spironolactone (escalating dose up to 150mg daily) in addition to therapy recommended in alopecia grade 1 (caution due to the theoretical risk of hormonal stimulation of endocrine receptor-positive tumors) | ||
| Oral minoxidil (potential adverse events should be considered) | ||
|
| ||
| Persistent radiotherapy-induced alopecia (pRIA) | CTCAEv4.0 grade 1: | |
| Topical minoxidil foam 5% twice daily | ||
| Botulinum toxin type A: 5 U per 0.1 ml saline every 3 months for 12 months | ||
| CTCAEv4.0 grade 2: | ||
| Scalp reconstruction (e.g. simple excision or flaps, tissue expansion) | ||
| Hair transplant (if not severe skin damage) | ||
|
| ||
| Endocrine therapy-induced alopecia (EIA) | CTCAEv4.0 grade 1: | |
| Topical minoxidil foam 5% twice daily | ||
| CTCAEv4.0 grade 2: | ||
| Spironolactone (escalating dose up to 150mg daily) in addition to therapy recommended in alopecia grade 1 (caution due to the theoretical risk of hormonal stimulation of endocrine receptor-positive tumors) | ||
|
| ||
| Hirsutism and hypertrichosis | CTCAEv4.0 grade 1 (mild hair growth): | |
| Local therapy such as epilation, waxing, depilation, bleaching | ||
| CTCAEv4.0 grade 2 (prominent thick hairs, associated with psychosocial impact): | ||
| Laser or intense pulsed light | ||
| Spironolactone appeared to be as effective as flutamide and finasteride (avoid in hormonal-sensitive tumors) | ||
| Other physiologic causes of hirsutism may be ruled out | ||
| Laser (Nd:YAG) for hair in unwanted areas (e.g., oral cavity) | ||
|
| ||
| Permanent surgery-induced alopecia | First line: | |
| Management of scar symptoms if present (topical or intralesional steroid, laser and light-based treatment) | ||
| Second line: | ||
| Hair transplant | ||
| Scalp reconstruction (e.g. simple excision or flaps, tissue expansion) | ||
|
| ||
| Eyebrow and eyelashes alopecia | Topical bimatoprost gel 0.03% | Level IB |
|
| ||
| SCT (Chronic GvHD, conditioning therapy for SCT with chemotherapy and/or total body irradiation) | In GvHD depends upon the organs involved and severity of symptoms Topical and intralesional steroid for alopecia areata (Level II-III), and in steroid resistant; janus kinase (JAK) inhibitors (Level IV) | Level II-IV |
|
| ||
| Conditioning chemotherapy and/or total body irradiation; follow the interventions of pCIA and pRIA respectively | Level IV | |
|
| ||
| Immunotherapies: CTLA-4 inhibitors (e.g. ipilimumab), PD-1 receptor inhibitors (e.g. nivolumab and pembrolizumab), PD-L1 inhibitors (e.g. atezolizumab, avelumab) | Potent topical steroid, and orthosilicic acid | Level IV |
|
| ||
| Vismodegib | Not reported | No evidence |
|
| ||
| General recommendations | Therapy should be discussed to have realistic expectations of therapy outcome | |
| Follow-up at least 3 months after alopecia therapy started | ||
| Laboratory analysis including, ferritin, Vitamine D, Zinc levels, and thyroid function may be requested if other causes of alopecia (e.g., androgenetic, telogen effluvium, thyroid-related) are suspected | ||
| Camouflages techniques should be provided (e.g. crayons, powder, volumizers, hair weaves/hair extension, scalp micropigmentation/tattoo and hairpieces) | ||
| If emotionally affected; psychological counseling is recommended | ||
| Involve nurses and other health care providers in the cancer survivors care | ||
CTCAEv4.0, Common Terminology Criteria for Adverse Events Version 4.0; CTCAEv4.0 grade 1 for alopecia, Hair loss of <50% of normal for that individual that is not obvious from a distance but only on close inspection; a different hair style may be required to cover the hair loss but it does not require a wig or hair piece to camouflage; CTCAEv4.0 grade 2 for alopecia, Hair loss of >=50% normal for that individual that is readily apparent to others; a wig or hair piece is necessary if the patient desires to completely camouflage the hair loss; associated with psychosocial impact; CTLA-4, cytotoxic T-lymphocyte-associated protein 4; SCT, Stem cell transplant; Nd:YAG, neodymium-doped yttrium aluminium garnet; PD-1, programmed cell death protein 1; PD-L1, programmed death-ligand 1.