HAIR LOSS (ALOPECIA)

Hair Loss (Alopecia)

Hair loss (alopecia) is one of the most common and visible side effects of cancer treatment and can have a profound impact on a patient's emotional wellbeing, self-image, confidence, and quality of life. While often considered a cosmetic side effect, many patients describe hair loss as one of the most distressing aspects of treatment because it serves as a constant reminder of their diagnosis and may make their illness visible to others. Some patients report that concerns about alopecia influence their treatment decisions, highlighting the importance of proactive education, assessment, and supportive care.

Healthcare professionals should discuss the possibility of hair loss before treatment begins, explain what patients can expect, provide strategies to minimise distress, and ensure patients are aware of available supportive resources.

Causes of Hair Loss

Hair loss may occur as a result of several cancer treatments, including:

Chemotherapy (most common cause)
Radiation therapy (limited to the treatment field)
Endocrine therapies (e.g. tamoxifen, aromatase inhibitors)
Selected targeted therapies, including CDK4/6 inhibitors, which may cause gradual hair thinning rather than complete hair loss

The severity of alopecia varies depending on:

Treatment regimen
Drug dose and schedule
Combination therapies
Radiation dose and treatment site
Individual patient factors

Hair loss may involve:

Scalp hair
Eyebrows
Eyelashes
Facial hair
Body hair

Assessment

Hair loss should be assessed before, during, and after treatment as part of routine supportive care.

Assessment should include:

Treatment-related factors

Planned chemotherapy, endocrine therapy, targeted therapy or radiation
Likelihood and severity of alopecia
Expected timing of onset
Risk of permanent or prolonged hair thinning

Physical assessment

Assess for:

Extent and pattern of hair loss
Scalp tenderness
Itching or irritation
Dryness or flaking
Evidence of infection
Skin integrity, particularly if the scalp has been shaved

For patients receiving radiation therapy, assess only the treated area, as hair loss is typically localised.

Psychosocial assessment

Explore the patient's:

Feelings about hair loss
Concerns regarding appearance and body image
Cultural or religious significance of hair
Anxiety about returning to work or social activities
Interest in wigs, scarves, hats or cosmetic options
Need for psychological or peer support

Some patients may not be distressed by alopecia, while others may find it one of the most challenging aspects of treatment. Individualised assessment is essential.

Preparing Patients Before Hair Loss Occurs

Early counselling allows patients time to prepare emotionally and practically.

Discuss:

Whether hair loss is expected
Approximately when hair loss will begin
Whether hair loss will be partial or complete
Whether eyebrows and eyelashes may also be affected
Likelihood of hair regrowth after treatment

Encourage patients to consider their preferred approach before hair begins to fall out.

Some patients choose to:

Cut their hair short before treatment
Shave their head once shedding begins
Purchase a wig before treatment so it can be matched to their natural hairstyle and colour
Explore scarves, hats or turbans
Continue without head coverings

There is no "right" choice, and patients should be supported regardless of their preference.

Hair and Scalp Care During Treatment

Patients should be advised to treat both their hair and scalp gently throughout treatment.

Recommend:

Mild shampoos
Gentle washing with lukewarm water
Patting hair dry rather than rubbing
Using a soft-bristled brush or wide-toothed comb
Avoiding excessive brushing
Limiting blow-drying, straightening or curling
Avoiding chemical colouring, bleaching or perming
Avoiding tight hairstyles that place tension on the hair

If patients choose to shave their head:

Recommend an electric shaver rather than a razor
Avoid shaving irritated or damaged skin
Monitor for cuts or infection

Scalp Care

Hair loss exposes the scalp to environmental irritation.

Advise patients to:

Wear sunscreen on exposed scalp
Wear hats outdoors
Keep the scalp warm during cold weather
Use fragrance-free moisturisers if dryness develops
Use gentle conditioners if the scalp becomes itchy or tender

Patients receiving radiation therapy should follow any additional skin care recommendations provided by the radiation oncology team.

Hair Preservation During Treatment

Scalp Cooling

For eligible chemotherapy regimens, scalp cooling may reduce chemotherapy-induced alopecia.

Scalp cooling works by reducing blood flow to hair follicles during chemotherapy infusion, thereby reducing exposure of hair follicles to cytotoxic drugs.

Potential benefits include:

Reduced severity of hair loss
Greater likelihood of retaining sufficient hair to avoid a wig
Improved body image and quality of life

Patients should be informed that:

Effectiveness varies by chemotherapy regimen.
It is generally less effective with some anthracycline-containing regimens.
It may not completely prevent hair loss.
Additional treatment time is required before and after chemotherapy.

Not all patients are suitable candidates, and availability varies between treatment centres.

Wigs and Head Coverings

Many patients find wigs or head coverings improve confidence during treatment.

Healthcare professionals should discuss available options before hair loss occurs.

Wigs

Patients may choose:

Synthetic wigs
Human hair wigs
Partial hairpieces
Hair toppers

Advantages include:

Restoring a familiar appearance
Increasing confidence in social settings
Providing warmth

Potential disadvantages include:

Cost
Heat and discomfort
Scalp irritation
Maintenance requirements

Patients should be encouraged to select a wig before hair loss begins so colour, texture and style can be matched more closely.

Some cancer organisations and community services provide:

Wig banks
Financial assistance
Professional wig fitting
Cosmetic services

Scarves, Hats and Turbans

Many patients prefer:

Cotton scarves
Bamboo or soft fabric head coverings
Turban-style wraps
Beanies
Wide-brim hats

Eyebrow and Eyelash Loss

Loss of eyebrows and eyelashes may significantly affect appearance and eye comfort.

Patients may benefit from:

Cosmetic eyebrow pencils or powders
Artificial eyelashes (if appropriate)
Protective glasses when eyelashes are absent
Referral to appearance support programs

Advise caution with adhesives or cosmetic products if skin is irritated or immunity is compromised.

Hair Regrowth After Treatment

Most chemotherapy-related hair loss is temporary.

Following chemotherapy

Hair commonly begins growing back within 2–3 months after treatment finishes.

Initially, hair may:

Be very fine
Grow slowly
Have a different texture
Be curlier or straighter
Be lighter or darker in colour

These changes often improve over time.

Following radiation therapy

Hair generally begins regrowing within 3–6 months, depending on radiation dose.

Patients who receive high-dose radiation may experience:

Permanent thinning
Patchy regrowth
Permanent hair loss within the treatment field

Advise patients to continue gentle hair care while new hair is fragile.

Management of Persistent Hair Loss

Patients experiencing prolonged or distressing hair thinning may benefit from specialist referral.

Management options may include:

Topical minoxidil
Oral minoxidil (under specialist supervision)
Dermatology assessment
Low-level laser therapy
Platelet-rich plasma therapy
Cosmetic camouflage products such as coloured powders or hair fibres

These treatments are generally considered after chemotherapy has been completed and should be discussed on an individual basis.

Psychosocial Support

Hair loss may affect:

Self-esteem
Identity
Privacy
Relationships
Sexuality
Social participation
Employment confidence

Healthcare professionals should routinely assess emotional wellbeing and provide opportunities for patients to discuss concerns.

Support may include:

Counselling
Oncology social workers
Psycho-oncology services
Peer support groups
Cancer support organisations
Appearance support programs
Family education

Encourage patients to discuss anticipated hair loss with family members, including children, to reduce anxiety and prepare loved ones for visible changes.

Patient Education

Patients should understand:

Why hair loss occurs
Whether their treatment is likely to cause alopecia
When hair loss is expected
How to care for their scalp
Available options for wigs and head coverings
Strategies to reduce discomfort
When hair is likely to regrow
When to seek medical advice for scalp irritation, infection or prolonged hair loss

Providing education early allows patients to make informed decisions, access supportive resources, and feel more prepared for treatment.

When to Refer

Consider referral to appropriate services when patients:

Experience significant emotional distress related to hair loss
Require specialised wig fitting or appearance support
Have persistent alopecia beyond expected recovery
Develop scalp complications
Wish to discuss medical therapies for hair regrowth
Require psychosocial or mental health support

Early intervention and ongoing supportive care can significantly reduce the psychosocial burden of treatment-related alopecia and improve overall quality of life throughout the cancer continuum.