Anagen Effluvium

Are You Confident of the Diagnosis?

What to be alert for in the history

Anagen effluvium refers to rapid hair loss, mainly affecting the scalp. It most often occurs 7-14 days after chemotherapy exposure. Full hair loss occurs after 1-2 months.

Characteristic findings on physical examination

On physical examination, diffuse hair thinning up to complete baldness is found.. Hair pull is positive (see dystrophic anagen hairs under microscope or hairs that break at scalp level) Anagen effluvium rarely involves hair at other body sites, because the anagen phase is shorter for these follicles (Figure 1, Figure 2). Nails often show transverse ridges.

Normal telogen hair added to contrast anagen versus telogen. Normal telogen. Note the differences between the anagen hair. (Courtesy of Bryan Anderson, MD)

Normal anagen hair. (Courtesy of Bryan Anderson, MD)

Diagnosis confirmation

The clinical examination and history confirm the diagnosis. Hair regrowth after chemotherapy may be gray, a different color, or different texture. Hair typically regrows after 3-6 months after discontinuation of chemotherapy

Who is at Risk for Developing Anagen Effluvium?

Persons experiencing any condition/exposure that disrupts anagen phase of the hair follicle cycle are at risk for this disease (see Etiology section, below).

What is the Cause of Anagen Effluvium?

Etiology

-Chemotherapy: Adriamycin, cyclophosphamide, daunorubicin, docetaxel, epirubicin, etoposide, ifosfamide, irinotecan, paclitaxel, topotecan, vindesine, vinorelbine

-Protein malnutrition

-Radiation therapy

-Intoxications: mercury, thallium, colchicine

Pathophysiology

The pathophysiology involves disruption of mitotic activity, which leads to cell arrest and a weakened hair shaft. Anagen hair breaks off at the scalp level or dystrophic anagen hairs are dislodged with a gentle pull.

Systemic Implications and Complications

Protein malnutrition requires an in-depth systemic work-up. Common laboratory abnormalities include hypoalbuminemia, hypoglycemia, and hypoproteinemia (transferrin, essential amino acids, and lipoprotein)

Treatment Options

Treatment options are outlined in Table I.

Table I.

	Chemotherapy	Radiation	Intoxication	Protein Malnutrition
Therapy	Reassurance; Topical minoxidil	May be temporary or permanent with discontinuation of therapy (>10 Gy single or >45 Gy if fractionated may lead to permanent alopecia)	Reassurance after the intoxication is corrected	Reassurance after malnutrition is corrected

Optimal Therapeutic Approach for Anagen Effluvium

Focus is chemotherapy-induced alopecia as this is the most common cause of anagen effluvium.

Educate patients about the course of hair loss — see “Diagnosis” section, above.
Reassure them that hair regrows after 3-6 months after discontinuation of chemotherapy.
Topical 2% minoxidil solution twice daily to scalp after onset of hair loss may hasten regrowth of hair. One study found that females who had breast cancer experienced faster regrowth of chemotherapy-induced hair loss by 50 days.

Patient Management

Instruct the patient to contact you 6 months after discontinuation of chemotherapy if hair regrowth does not occur. Perform a 4-mm punch biopsy of the scalp for horizontal sections in order to render a prognosis as to whether hair loss is permanent (ie, scarring in the sense that follicles are permanently destroyed: see Unusual Clinical Scenario below).

Patients often inquire about scalp cooling as a method to prevent anagen effluvium from chemotherapy. Scalp hypothermia limits hair follicle exposure to the chemotherapy agent. Most published data, which often report a benefit, are of poor of scientific quality and involve small number of subjects, thereby limiting the validity of their interpretation. More clinical and biophysical research is necessary.

Scalp cooling should not be used in curative chemotherapy regimens for hematologic malignancies. The concern for long-term scalp metastases after scalp cooling warrants further investigation. Scalp cooling is neither a standard nor a widely accepted treatment for preventing chemotherapy-induced hair loss.

Unusual Clinical Scenarios to Consider in Patient Management

Permanent chemotherapy-induced alopecia rarely occurs. It is reported to occur most commonly following high-dose chemotherapy followed by bone marrow transplantation, but can occur with chemotherapy alone. Entertain suspicion for this condition if no growth is appreciated after 6 months.

Busulfan is most commonly implicated agent; skin biopsy confirms reduction of hair follicles without inflammation. It is theorized that chemotherapy targets hair follicle stem cells.

What is the Evidence?

Duvic, M, Lemak, N, Valero, V, Hymes, SR, Farmer, KL, Hortobagyi, GN. “A randomized trial of minoxidil in chemotherapy-induced alopecia”. J Am Acad Dermatol. vol. 35. 1996. pp. 74-8. (2% topical minoxidil twice daily decreased duration of alopecia from chemotherapy. The trial had few subjects and more studies are needed to say definitively that topical minoxidil is effective in this condition.)

Tallon, B, Blanchard, E, Goldberg, LJ. ” Permanent chemotherapy-induced alopecia: case report and review of the literature”. J Am Acad Dermatol. vol. 63. 2010. pp. 333-6. (This report and review of the literature highlights the rare instances that chemotherapy (+/- bone marrow transplantation) can lead to permanent hair loss.)

Tosti, A, Pazzaglia, M. “Drug reactions affecting hair: diagnosis”. Dermatol Clin. vol. 25. 2007. pp. 223-31. (Excellent review of chemotherapy medications that lead to anagen effluvium. Authors also cite chemotherapeutic agents that do NOT lead to hair loss in a table format.)

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