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Original Investigation
August 5, 2020

Assessment and Treatment Outcomes of Persistent Radiation-Induced Alopecia in Patients With Cancer

Author Affiliations
  • 1Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
  • 2Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
  • 3Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
  • 4Dermatology Service, Hospital Ruber Juan Bravo and Universidad Europea, Madrid, Spain
  • 5Department of Dermatology, Mount Sinai Medical Center, New York, New York
  • 6Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
  • 7Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
  • 8Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
JAMA Dermatol. 2020;156(9):963-972. doi:10.1001/jamadermatol.2020.2127
Key Points

Question  What are the clinical features, associated factors, and treatment response of persistent radiation-induced alopecia in patients with cancer?

Findings  In this cohort study of 71 children and adults with cancer who underwent cranial radiotherapy, alopecia had localized, diffuse, or mixed localized plus diffuse patterns with frequent white patches on trichoscopy; severe alopecia was associated with greater scalp radiation dose and proton irradiation. Alopecia improvement was observed in 82% of patients treated with topical minoxidil, 5%, solution and 100% of patients treated surgically.

Meaning  The findings of this study suggest that topical minoxidil may improve alopecia observed in persistent radiation-induced alopecia, and surgical procedures may be effective in nonresponders.


Importance  Persistent radiation-induced alopecia (pRIA) and its management have not been systematically described.

Objective  To characterize pRIA in patients with primary central nervous system (CNS) tumors or head and neck sarcoma.

Design, Setting, and Participants  A retrospective cohort study of patients from January 1, 2011, to January 30, 2019, was conducted at 2 large tertiary care hospitals and comprehensive cancer centers. Seventy-one children and adults diagnosed with primary CNS tumors or head and neck sarcomas were evaluated for pRIA.

Main Outcomes and Measures  The clinical and trichoscopic features, scalp radiation dose-response relationship, and response to topical minoxidil were assessed using standardized clinical photographs of the scalp, trichoscopic images, and radiotherapy treatment plans.

Results  Of the 71 patients included (median [range] age, 27 [4-75] years; 51 female [72%]), 64 (90%) had a CNS tumor and 7 (10%) had head and neck sarcoma. Alopecia severity was grade 1 in 40 of 70 patients (56%), with localized (29 of 54 [54%]), diffuse (13 of 54 [24%]), or mixed (12 of 54 [22%]) patterns. The median (range) estimated scalp radiation dose was 39.6 (15.1-50.0) Gy; higher dose (odds ratio [OR], 1.15; 95% CI, 1.04-1.28) and proton irradiation (OR, 5.7; 95% CI, 1.05-30.8) were associated with greater alopecia severity (P < .001), and the dose at which 50% of patients were estimated to have severe (grade 2) alopecia was 36.1 Gy (95% CI, 33.7-39.6 Gy). Predominant trichoscopic features included white patches (16 of 28 [57%]); in 15 patients, hair-shaft caliber negatively correlated with scalp dose (correlation coefficient, −0.624; P = .01). The association between hair density and scalp radiation dose was not statistically significant (−0.381; P = .16). Twenty-eight of 34 patients (82%) responded to topical minoxidil, 5% (median follow-up, 61 [interquartile range, 21-105] weeks); 4 of 25 (16%) topical minoxidil recipients with clinical images improved in severity grade. Two patients responded to hair transplantation and 1 patient responded to plastic surgical reconstruction.

Conclusions and Relevance  Persistent radiation-induced alopecia among patients with primary CNS tumors or head and neck sarcomas represents a dose-dependent phenomenon that has distinctive clinical and trichoscopic features. The findings of this study suggest that topical minoxidil and procedural interventions may have benefit in the treatment of pRIA.

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