Hair Loss from Chemotherapy:
What Are the Options?

Here to dicuss these questions are experts Dr. John MacDonald, an oncologist at St. Vincent's Medical Center in New York City, and Dr. Michael Reed, a dermatologist and hair transplant surgeon at NYU Medical Center. Welcome.

Why does chemotherapy cause people to lose their hair to begin with?

DR. JOHN MACDONALD: Chemotherapy tends to arrest cell growth in rapidly dividing cells, and actually the cells that produce hair are rapidly dividing and they can be affected by chemotherapy, the same way that bone marrow cells that produce blood elements get affected by chemotherapy. So it's a side effect of the general antimetabolic or anti-cell division effect of chemotherapy.

DAVID R. MARKS, MD: Does all chemotherapy result in hair loss?

DR. JOHN MACDONALD: No. There are specific kinds that will do it more than others. There are some that essentially never affect the hair. Some of it may be dependent on the particular dose and schedule of a drug that's used, and as you pointed out, the thing about hair loss with chemotherapy is that the hair always grows back when the chemotherapy is stopped. It's never a permanent hair loss. The only permanent hair loss we really deal with in oncology is in people who might have to have had their heads radiated because they have a cancer on the skin on the head, or they have a cancer in the brain. Those people have minimal hair regrowth after radiation.

DAVID R. MARKS, MD: How long does it take for the hair to grow back?

DR. JOHN MACDONALD: It varies. It clearly is coming back by the first month after chemotherapy is stopped, and of course the degree of hair loss can be variable. A woman with very thick hair may have substantial hair loss that she's very much aware of as she brushes her hair. The hair comes out. But you see her on the street, you wouldn't even realize that she'd had any hair loss.

DAVID R. MARKS, MD: There are medications that can help normal people with hair loss regrow hair. What about people with chemotherapy-induced hair loss. Should they consider going on some of these medications?

MICHAEL REED, MD: I think sometimes people like to use treatment, even if it's not quite been established to be helpful, because they like to do something about it, and if we have something that they can use that's not harmful and might be helpful, we'll sometimes try it. For example, topical minoxidil, which is available over the counter as 2% or 5% Rogaine, has a nonspecific hair growth enhancement effect. It probably doesn't make a huge difference, but if somebody wanted to try that, it might give them some psychological relief to use it, and it certainly couldn't hurt their scalp as long as it does not irritate it.

It depends also, of course, on what the actual effect on the hair follicle has been by the treatment. If it's what we dermatologists call an antigen, meaning a growth phase defluvium (a narrowing and a slowing down of the hair growth rate) so they just break off, then the treatment probably isn't necessary, because it's still going to keep growing and come back. If the hairs are actually knocked into a resting phase, a so-called telogen effluvium, where they rest and they're not going to regrow for three months or so, then something like topical minoxidil might be helpful to get them in the growing phase or keep some in the growing phase that might have a tendency to come out.

DAVID R. MARKS, MD: Does chemotherapy affect the way the hair grows back? Does it grow back as thick as it was before?

DR. JOHN MACDONALD: It's an interesting question, because sometimes people find that their hair will grow back a somewhat different color. Hair that was less curly may be more curly, or vice-versa, so you can see some funny changes in the way that the hair comes back. Most of the time it comes back really as it was.

MICHAEL REED, MD: I don't think anyone really understands it, and in other conditions, too, where the hair falls out, like alopecia areata. I once had a patient who had gray hair and it grew back carrot-red, which he said was the color of his youth. It's almost like it gets rejuvenated. It gets a new lease on life, at least for a period of time, and it's certainly not unusual to have a change in hair texture where it comes back -- if it was straight it's wavy; if it was wavy, it's curly; if it's curly, it's helical -- until the hair follicle recovers not just its ability to produce the hair shaft but actually its full strength to do what it was doing before.

DAVID R. MARKS, MD: Are there cosmetic options that are popular with chemotherapy patients?

DR. JOHN MACDONALD: It's interesting. We've gone through phases. One of the phases that was quite interesting and really developed in the treatment of childhood leukemia was to use freezing caps -- and when I say that, the head is not totally frozen. That would be a bad thing -- but to put cold caps on the head, the idea being that you shunt blood away from the hair follicles and you get less chemotherapy effect. There is some benefit for this. The concern is that if you shunt blood away from the area of the head and there happen to be tumor cells there, you may not have the beneficial chemotherapy effect. So it's rarely used these days. People are much more proactive -- doctors, patients, oncology nurses -- much more proactive in dealing with the patient, saying, "Look, this is what's going to happen. It's not going to be permanent."

DAVID R. MARKS, MD: People use wigs or hairpieces?

DR. JOHN MACDONALD: Yes. In fact, that's part of the proactivism, is to say, "Look, you ought to plan for this. You might want to go right now to a wigmaker, so they can see what you're like right now so that they can make you a wig that would be appropriate." And the insurance companies or Medicare pay for that. They'll pay for wigs for patients with chemotherapy. For a man, say, you're going to be wearing a lot of baseball caps, and maybe you want to get a collection, because you're going to lose your hair, and it will come back. That tends to be the way that people handle it now.

One of the drug companies has a cell cycle inhibitor that they were showing in a mouse model. It blocked the hair loss effect of chemotherapy. Patients pick up on that. Patients look at the Internet. They look at the news programs, and this technology is obviously not ready for prime time. If you're affecting the way chemotherapy works on the hair cells, the hair follicles, you want to be darned sure you're not affecting the way it works on the tumor.

DAVID R. MARKS, MD: Where should patients who are preparing for chemotherapy go to find information about their options?

MICHAEL REED, MD: I think the best person is the person who's treating you and who's going to be there the whole time with you. Certainly, if they want the opinion of a dermatologist, we're happy to provide it, but we're sort of an accessory thing. I think also it's a good idea to go to a good hair stylist, and perhaps a person who's an expert in hair addition systems and hair make-up systems. There are sprinkle-on cover-ups, sort of make-up type things, and keratin sprinkle-ons that will actually stick to the hair that remains on the head so it looks like there's more hair. Going to a hair systems specialist in addition to the oncologist, and maybe a dermatologist, would be the three effective ways to approach it.

DAVID R. MARKS, MD: Thank you very much. We'll leave it at that. Thank you both.