Hair Loss from Cancer Treatment

Understanding Hair Loss

Why Does Chemotherapy Cause Hair Loss?

Hair follicles contain some of the fastest-dividing cells in the body. Chemotherapy targets rapidly dividing cells (the hallmark of cancer cells), but it cannot distinguish between cancer cells and normal rapidly dividing cells like hair follicles.

The Process

1. Hair growth cycle disruption: Chemotherapy damages cells in the hair follicle's growth phase (anagen)
2. Weakened hair shaft: Hair becomes fragile and breaks off at the scalp
3. Follicle shutdown: Follicle enters resting phase, stopping new hair production
4. Hair shedding: Damaged hairs fall out over days to weeks

Types of Hair Loss

Anagen Effluvium (Most Common with Chemotherapy)

• Rapid onset: 1-3 weeks after treatment starts
• Extensive: Can affect 80-90% of scalp hair
• Affects: Hair in active growth phase
• Caused by: Chemotherapy, radiation to scalp

Telogen Effluvium

• Delayed onset: 2-4 months after stress/treatment
• Less severe: Thinning rather than complete loss
• Causes: Hormonal therapies, targeted therapies, immunotherapy, stress

Not Just Scalp Hair

Hair loss can affect:

• Scalp hair (most noticeable)
• Eyebrows and eyelashes (usually later, with continued treatment)
• Body hair: Chest, underarms, pubic hair, arms, legs
• Facial hair: Beard, mustache
• Nose hair: Can lead to runny nose

Which Treatments Cause Hair Loss?

Chemotherapy

Hair loss risk varies significantly by drug:

High Risk (80-100% hair loss)

• Taxanes:
  • Paclitaxel (Taxol) - near universal
  • Docetaxel (Taxotere) - near universal
  • Nab-paclitaxel (Abraxane)
• Anthracyclines:
  • Doxorubicin (Adriamycin)
  • Epirubicin
• Alkylating agents (high-dose):
  • Cyclophosphamide (high-dose)
  • Ifosfamide
• Topoisomerase inhibitors:
  • Irinotecan (Camptosar)
  • Topotecan
  • Etoposide

Moderate Risk (50-80% hair loss or thinning)

• Cyclophosphamide (standard dose)
• 5-Fluorouracil (5-FU) (continuous infusion)
• Gemcitabine
• Methotrexate (high-dose)
• Vinorelbine
• Mitoxantrone

Low Risk (<50% hair loss, usually mild thinning)

• Platinum agents:
  • Cisplatin - minimal hair loss
  • Carboplatin - minimal
  • Oxaliplatin - minimal
• Capecitabine (Xeloda) - minimal to moderate
• Pemetrexed - minimal
• Vincristine - minimal
• Bleomycin - minimal

Combination Regimens

Common regimens and expected hair loss:

• AC (doxorubicin + cyclophosphamide): Near complete loss
• AC-T (AC followed by paclitaxel): Near complete loss
• TCH (docetaxel + carboplatin + trastuzumab): Near complete loss (from docetaxel)
• FOLFOX (5-FU + leucovorin + oxaliplatin): Mild thinning to moderate loss
• BEP (bleomycin + etoposide + cisplatin): Moderate loss (from etoposide)

Radiation Therapy

• Hair loss only in treatment field: Unlike chemotherapy, radiation only causes hair loss where the beam passes through
• Scalp/brain radiation: Causes hair loss in treated area
• Dose-dependent:
  • <30 Gy: Temporary thinning
  • 30-45 Gy: Temporary complete loss, regrows
  • >45-50 Gy: May be permanent hair loss in treatment field
• Onset: 2-3 weeks after starting radiation
• Regrowth: 2-6 months after completion (if not permanent)

Targeted Therapy

Generally causes hair thinning rather than complete loss:

• EGFR inhibitors: Erlotinib (Tarceva), gefitinib - hair thinning, changes in texture
• Multi-kinase inhibitors: Sorafenib, sunitinib - hair thinning, color changes
• CDK4/6 inhibitors: Palbociclib, ribociclib - hair thinning (20-30%)

Immunotherapy

• Checkpoint inhibitors: Pembrolizumab, nivolumab - rare, usually mild thinning if occurs
• Unusual patterns: Can rarely cause vitiligo (loss of pigmentation including hair)

Hormonal Therapy

• Aromatase inhibitors: Letrozole, anastrozole - mild thinning (30-40%)
• Tamoxifen: Mild thinning (less common)
• Androgen deprivation: Can cause thinning

Timeline and Pattern

Typical Chemotherapy Timeline

Weeks 1-2 After First Treatment

• Usually no visible hair loss yet
• Some patients notice scalp tenderness or tingling
• Hair may feel thinner or weaker

Weeks 2-3

• Hair shedding begins: Most common timeframe
• Gradual or sudden: Can happen either way
• Pattern:
  • Increased hair on pillow in morning
  • Large amounts in shower drain
  • Clumps coming out when brushing/combing
• Sometimes rapid: May lose most hair over 1-2 days

Weeks 3-6

• Progressive hair loss continues
• Extent depends on regimen (thinning vs. complete loss)
• Eyebrows and eyelashes may start thinning (usually later than scalp)
• Body hair begins falling out

During Ongoing Treatment

• Hair remains absent or very sparse
• Some fine "peach fuzz" may appear between cycles
• Each treatment cycle prevents regrowth

Pattern of Hair Loss

Diffuse (Most Common)

• Hair thins evenly all over scalp
• Typical for most chemotherapy drugs

Patchy

• Less common with chemotherapy
• More typical with immunotherapy or alopecia areata

Rapid Shedding

• Some patients lose most hair over 24-48 hours
• Can be emotionally shocking but medically normal
• More common with taxanes and anthracyclines

Individual Variation

Factors affecting hair loss severity:

• Drug and dose: Most important factor
• Age: Younger patients may have more hair loss (faster cell turnover)
• Hair characteristics: Thickness, growth rate
• Genetics: Family history of hair loss may play role
• Previous chemotherapy: May affect current hair loss pattern

Prevention: Scalp Cooling (Cold Caps)

Scalp cooling is the only proven method to reduce chemotherapy-induced hair loss.

How It Works

• Cooling caps are placed on head before, during, and after chemotherapy infusion
• Temperature: Cools scalp to 18-22°C (64-72°F)
• Mechanism:
  • Constricts blood vessels in scalp (vasoconstriction)
  • Reduces chemotherapy delivery to hair follicles
  • Slows metabolic activity of follicle cells
  • Makes follicles less susceptible to chemotherapy damage

Types of Scalp Cooling Systems

1. Automated Cold Cap Systems

• Examples: DigniCap, Paxman Scalp Cooling System
• FDA-approved for chemotherapy-induced alopecia
• How it works: Cap connected to machine that continuously circulates coolant
• Availability: Increasingly available at cancer centers
• Fitting: Multiple cap sizes for proper fit

2. Manual Cold Caps

• Examples: Penguin Cold Caps, Elastogel
• How it works: Gel-filled caps stored in freezer, changed every 20-30 minutes
• Requires: Helper to change caps, access to deep freezer
• Portable: Can be used at centers without automated systems

Effectiveness

• Success rate: 50-80% of patients retain enough hair to avoid wig
• Definition of success: Retaining ≥50% of hair
• Varies by regimen:
  • Best results: Taxane-based regimens (70-80% success)
  • Good results: Anthracycline-based regimens (50-60% success)
  • Less effective: High-dose chemotherapy, continuous infusions
• Individual variation: Some people respond better than others

Procedure

• Before chemotherapy: Cap applied 30-45 minutes before infusion starts
• During chemotherapy: Worn throughout infusion
• After chemotherapy: Continued for 60-120 minutes after (varies by drug half-life)
• Total time: 3-6 hours per session
• Hair care: Wet hair first for better contact and cooling

Side Effects and Tolerability

• Cold sensation: Uncomfortable, especially first 5-10 minutes
• Headache: Common (30-40%), usually mild
• Scalp discomfort: Pressure, heaviness
• Chills: Bring warm blankets, layers
• Tolerability: Most patients adapt; <5% discontinue due to discomfort

Who Can Use Scalp Cooling?

Good Candidates

• Solid tumors (breast, ovarian, lung, etc.)
• Chemotherapy regimens known to cause hair loss
• Curative intent or long-term treatment
• Motivated to preserve hair despite time commitment

NOT Recommended For

• Blood cancers: Leukemia, lymphoma, multiple myeloma (theoretical concern about protecting circulating cancer cells)
• Scalp metastases: Concern about reduced drug delivery
• Cold sensitivity conditions: Cold agglutinin disease, cryoglobulinemia, cryofibrinogenemia
• Severe migraines or headaches: May worsen

Cost and Insurance

• Cost: $1,500-$3,000 per chemotherapy regimen (or $150-$500 per session)
• Insurance: Increasing coverage but still often out-of-pocket
• Medicare/Medicaid: Generally not covered
• Financial assistance: Some manufacturers offer programs
• Tax deductible: May qualify as medical expense

Limitations and Realistic Expectations

• Not 100% effective: Most people still have some hair loss/thinning
• Variable results: May save most hair or only reduce loss
• Hair quality: Remaining hair may be thinner, weaker
• Time commitment: Adds 2-4 hours to each chemotherapy session
• Not a guarantee: Success cannot be predicted in advance

Preparing for Hair Loss

Before Hair Loss Begins

1. Consider Cutting Hair Short

• Advantages:
  • Less dramatic transition
  • Easier to manage during shedding phase
  • Less hair in drains, on pillows
  • If regrowth is different, shorter starting point
• Not required: Completely optional based on preference
• Timing: Before first treatment or when shedding begins

2. Take Photos

• Document your current hairstyle from multiple angles
• Helpful for wig matching or recreating style later
• Can help with emotional processing

3. Shop for Head Coverings/Wigs BEFORE Hair Loss

• Advantages of early shopping:
  • Less emotionally overwhelming
  • Wig can be cut/styled to match current hair
  • Time to explore options without pressure
  • Items ready when needed
• See sections below on wigs and head coverings

4. Consider Donating Hair

• Organizations: Locks of Love, Wigs for Kids, Pantene Beautiful Lengths
• Requirements: Usually 8-12 inches minimum length, no chemical damage
• Meaningful: Hair goes to children or adults with medical hair loss
• Timing: Cut before chemotherapy starts (chemotherapy-treated hair usually not accepted)

When Hair Loss Begins

Option 1: Shave Your Head

• Take control: Rather than waiting for gradual loss
• Less messy: No constant shedding
• Emotionally empowering: For some people
• Make it an event: Some people involve family/friends, salons offer "shave parties"

Option 2: Let It Fall Out Naturally

• Some people prefer gradual transition
• Can be emotionally easier for some
• More mess to manage during shedding phase

Managing the Shedding Phase

• Sleep on dark pillowcases (shows less hair)
• Use drain catchers in shower
• Brush gently over sink or trash can
• Consider hair nets at night to contain shedding
• Limit hair washing to 1-2 times per week (still falling out even if not washed)

Wigs and Hairpieces

Types of Wigs

Synthetic Wigs

• Cost: $50-$500
• Advantages:
  • Less expensive
  • Pre-styled (holds style even after washing)
  • Low maintenance
  • Wide variety of styles and colors
• Disadvantages:
  • Less natural appearance (though improving)
  • Cannot be heat styled
  • Shorter lifespan (3-6 months with daily wear)
  • Can be hot/less breathable

Human Hair Wigs

• Cost: $800-$3,000+
• Advantages:
  • Most natural appearance
  • Can be cut, colored, heat styled
  • More comfortable, breathable
  • Longer lifespan (1-2+ years with care)
• Disadvantages:
  • Expensive
  • Requires more maintenance (washing, styling like real hair)
  • Style doesn't hold in humidity/rain (like natural hair)

Synthetic-Human Hair Blend

• Middle ground: $300-$800
• Combines advantages of both types
• Good option for many people

Wig Shopping Tips

Where to Buy

• Wig boutiques specializing in medical wigs: Best for first-time buyers, expert fitting and styling
• Online retailers: Wider selection, lower prices, but no fitting assistance
• Beauty supply stores: Less expensive but may not understand medical needs
• Hospital/cancer center resources: Some have free wig banks or boutiques

Getting the Right Fit

• Measure head circumference: Around hairline (usually 21-23 inches)
• Adjustable straps: Most wigs have them for custom fit
• Should feel secure but comfortable: Not too tight (headaches) or loose (slipping)
• Wig grips/bands: Can help secure wig on smooth scalp

Choosing a Style

• Match current style: Many choose similar to their natural hair for familiarity
• Try something new: Cancer treatment is a chance to experiment
• Consider lifestyle: Low-maintenance styles if you don't want to fuss
• Multiple wigs: Some people get 2-3 for variety (casual, professional, special occasions)

Insurance and Financial Assistance

• Some insurance covers "cranial prosthesis": Get prescription from doctor
• Itemized receipt: Request bill listing as "cranial prosthesis" not "wig"
• Tax deductible: May qualify as medical expense
• Free wig programs:
  • American Cancer Society (limited availability)
  • CancerCare
  • Local cancer centers often have wig banks
• Discount programs: Many wig companies offer cancer patient discounts

Wig Care

Synthetic Wigs

• Wash: Every 10-12 wears (or when looks dirty/dull)
• Use wig-specific shampoo (gentle, no sulfates)
• Air dry on wig stand (never heat dry)
• No heat styling (will melt fibers)
• Store on wig stand or in box

Human Hair Wigs

• Wash: Every 7-10 wears
• Use sulfate-free shampoo and conditioner
• Can use heat tools (with heat protectant)
• May need professional styling periodically
• Store on wig stand

Alternatives to Full Wigs

• Toppers/wiglets: Partial coverage for thinning (not complete loss)
• Extensions: Add volume to thinning hair
• Hair integration systems: Combine natural hair with added hair

Head Coverings and Accessories

Types of Head Coverings

Scarves and Turbans

• Versatile and affordable
• Many tying styles (search online tutorials)
• Fabrics: Cotton, silk, jersey
• Pre-tied options: Available for convenience
• Can layer with hats

Sleep Caps

• Soft, comfortable for nighttime
• Keep head warm while sleeping
• Bamboo or cotton fabrics breathe well

Beanies and Caps

• Casual, easy option
• Baseball caps: Very casual, may show bald areas at sides
• Chemo caps: Designed to fit close and provide full coverage

Hats

• Sun protection important (scalp sunburns easily)
• Wide-brimmed hats for outdoors
• Bucket hats, fedoras, cloches

Accessories

For Wigs

• Wig grip/band: Velcro headband that keeps wig secure on smooth scalp
• Wig liner/cap: Bamboo or cotton cap worn under wig for comfort
• Wig tape: Double-sided tape for extra security
• Wig stand: For storage and styling

Eyebrows and Eyelashes

• Eyebrow pencils/powders: Fill in thinning brows
• Eyebrow stencils: Guide for drawing natural-looking brows
• Stick-on eyebrows: Pre-formed, reusable
• False eyelashes: Individual or strip lashes
• Eyelash glue: Medical-grade for sensitive skin
• Eyeliner: Can create illusion of lashes
• Look Good Feel Better: Free program teaching makeup techniques for cancer patients

Going Without

• Some people embrace baldness
• Can be empowering
• Comfortable, low-maintenance
• Protect scalp from sun (sunscreen or head covering outdoors)
• Keep head warm (significant heat loss from bare scalp)

Scalp Care

Basic Scalp Care

Cleansing

• Wash 1-2 times per week (or as needed)
• Gentle, fragrance-free shampoo
• Baby shampoo is good option
• Lukewarm water (not hot)
• Pat dry gently (don't rub)

Moisturizing

• Scalp can become dry
• Gentle, fragrance-free moisturizer or oil
• Options: Coconut oil, jojoba oil, aloe vera, unscented lotion
• Avoid: Harsh alcohols, fragrances that may irritate

Sun Protection - CRITICAL

• Scalp sunburns easily without hair protection
• Wear hat or head covering outdoors
• Sunscreen: SPF 30+ on scalp if uncovered
• Reapply frequently (sweats off easily from scalp)
• Seek shade

Temperature Regulation

• Heat loss: Significant heat escapes from bare scalp
• Wear cap/head covering: Indoors if cold, always sleep in cap
• Layering: Better than one heavy covering
• Summer: Light, breathable fabrics; stay cool
• Winter: Warm hat or layered coverings

Scalp Issues

Tenderness or Sensitivity

• Common during active hair loss phase
• Usually improves after shedding complete
• Soft pillowcases, gentle touch
• Cool compresses if very tender

Dryness or Flaking

• Regular moisturizing
• Increase humidity (humidifier)
• Gentle exfoliation with soft washcloth if needed

Itching

• Often during regrowth phase
• Moisturize regularly
• Avoid scratching (can damage follicles)
• Cool compresses
• If severe, ask about gentle anti-itch lotion

Rash or Irritation

• May be reaction to head covering fabric
• Try 100% cotton or bamboo liners
• Wash new items before wearing
• If persists, see doctor (could be scalp infection or dermatitis)

Emotional and Psychological Impact

Why Hair Loss Is So Difficult

• Visible reminder of illness: Hair loss announces "I have cancer" to the world
• Loss of control: One more thing cancer takes away
• Identity and self-image: Hair is tied to how we see ourselves and how others see us
• Gender and attractiveness: Cultural associations between hair and femininity/masculinity
• Privacy lost: Can't hide cancer diagnosis if you choose
• Constant reminder: See it every time you look in mirror

Common Emotional Responses

• Grief and sadness: Mourning loss of hair, normalcy, former self
• Anger or frustration: At cancer, at side effects
• Anxiety: About appearance, others' reactions
• Self-consciousness or embarrassment: In public
• Loss of femininity/masculinity: Feeling less like yourself
• Depression: Especially if prolonged or coupled with other changes

All of these feelings are normal and valid.

Coping Strategies

Acknowledge Your Feelings

• It's okay to be upset about hair loss
• It's not vain or shallow - it's a real loss
• Allow yourself to grieve
• Don't minimize your feelings

Talk About It

• Share feelings with trusted friends, family
• Support groups - others who understand
• Counselor or therapist
• Online communities

Focus on What You Can Control

• Choose how you'll cover head (or not)
• Style choices (scarves, wigs, hats, bare)
• Makeup and accessories
• How you talk about it with others

Reframe Perspective

• "Hair grows back; life doesn't. I'm fighting for my life."
• "This is temporary; my treatment is working."
• "I'm stronger than I thought."
• "My worth isn't defined by my hair."

Find Empowerment

• Some people feel liberated by baldness
• Time saved not styling hair
• Opportunity to try new looks
• Badge of courage and survival
• Connect with other survivors

Talking to Others

Children

• Be honest and age-appropriate
• Explain it's temporary: "Mommy's/Daddy's medicine makes hair fall out, but it will grow back"
• Let them ask questions
• Involve them: Let them help pick scarves, hats
• Reassure them you're still you

Coworkers and Acquaintances

• You decide how much to share
• Simple explanation: "I'm undergoing treatment and will lose my hair temporarily"
• It's okay to set boundaries: "I'd rather not discuss details"

Strangers' Stares or Comments

• People may stare - it's about their discomfort, not you
• You don't owe anyone an explanation
• Responses: Smile, ignore, or educate - your choice
• Some wear shirts/pins: "Yes, it's a wig. Yes, I have cancer. No, I don't want to talk about it."

When to Seek Help

• Depression interfering with daily life
• Severe anxiety about appearance
• Avoiding social situations entirely
• Thoughts of self-harm
• Unable to cope despite trying strategies

Mental health is part of cancer care - ask your oncology team for counseling referral.

Hair Regrowth

Timeline

During Treatment

• Hair remains absent or very sparse
• Some "peach fuzz" may appear between cycles
• Each treatment prevents regrowth

After Final Treatment

• Weeks 1-4: Follicles "wake up" - may feel tingling or itching
• Weeks 4-8: Fine, soft hair appears ("baby fuzz")
• Months 2-3: Visible hair growth, about 1/2 inch
• Months 3-6: Noticeable hair, may be able to style
• Months 6-12: Continued growth toward pre-treatment length
• Full regrowth: 12-18 months typically

Growth Rate

• Hair grows approximately 1/2 inch (1 cm) per month
• Slightly slower immediately after chemotherapy
• Accelerates over time

Changes in Regrown Hair

Common Differences

• Texture:
  • Straight hair may come back curly ("chemo curls")
  • Curly hair may come back straight
  • May be coarser or finer
• Color:
  • May be darker or lighter
  • Gray or white (loss of pigment cells)
  • Different shade than before
• Growth pattern:
  • May grow in patchy at first
  • Different cowlicks or whorls

Permanent Changes?

• Usually temporary: Most changes are temporary
• First year: Hair may continue evolving
• Second year: Usually settles into pattern
• Some permanent changes: Texture or color may remain different for some people

Caring for Regrowing Hair

Be Gentle

• New hair is fragile
• Avoid harsh chemicals (perms, relaxers) for first 6-12 months
• Delay coloring if possible; use gentle, semi-permanent color when ready
• Minimize heat styling
• Gentle brushing with soft-bristle brush

Nutrition for Hair Growth

• Protein: Hair is made of protein (keratin)
• Biotin: B-vitamin supporting hair growth (but ask doctor before supplements)
• Iron: Deficiency can slow growth
• Zinc: Important for hair follicle health
• Overall balanced diet: Best approach

Products

• Gentle, sulfate-free shampoo
• Moisturizing conditioner
• Avoid: Harsh products marketed for hair growth (may irritate sensitive scalp)
• Scalp massage: May stimulate circulation (feels good, unclear if speeds growth)

Patience

• Regrowth is slow - can be frustrating
• Compare to photos: Monthly photos help see progress
• Celebrate milestones: First visible fuzz, first inch, first ponytail
• It will grow back - almost always does

When Hair Doesn't Regrow

• Very rare with chemotherapy alone
• Possible with:
  • High-dose radiation to scalp (>45-50 Gy)
  • Bone marrow transplant (in some cases)
  • Underlying conditions
• If no regrowth by 6 months: Discuss with oncologist
• Dermatology referral: May be helpful
• Permanent solutions: Long-term wigs, hair systems, microblading (eyebrows)

Frequently Asked Questions