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Original Investigation
September 29, 2021

Clinicopathologic Characteristics and Response to Treatment of Persistent Chemotherapy-Induced Alopecia in Breast Cancer Survivors

Author Affiliations
  • 1Sinclair Dermatology, Melbourne, Australia
  • 2The Dermatology Centre, Salford Royal National Health Service Foundation Trust, Salford, Greater Manchester, United Kingdom
  • 3Hair and Nail Medicine, Bonn, Germany
  • 4Department of Dermatology and Allergy, University Hospital of Bonn, Bonn, Germany
  • 5Alan Lyell Centre for Dermatology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
  • 6University of Melbourne, Melbourne, Australia
  • 7Department of Histopathology, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
  • 8Centre for Dermatology Research, University of Manchester, Manchester Academic Health Science Centre and National Institute for Health Research Manchester Biomedical Research Centre, Manchester, United Kingdom
JAMA Dermatol. 2021;157(11):1335-1342. doi:10.1001/jamadermatol.2021.3676
Key Points

Question  What are the clinicopathologic features of persistent chemotherapy-induced alopecia (pCIA) in breast cancer survivors?

Findings  Most patients in this case series presented with either diffuse alopecia or hair thinning in the distribution of female pattern hair loss, with trichoscopic and histopathologic features indistinguishable from those of androgenetic alopecia. A few patients presented with inflammatory scarring alopecia.

Meaning  This study suggests that hair follicle miniaturization (the hallmark of androgenetic alopecia) is a prominent feature in pCIA; recognized androgenetic alopecia treatments, including minoxidil and antiandrogen therapy, can also improve hair density for patients with pCIA.


Importance  Alopecia induced by classic chemotherapy affects up to 65% of patients and is usually reversible. However, there are increasing reports of persistent chemotherapy-induced alopecia (pCIA), especially for patients treated with taxane-containing chemotherapy regimens.

Objective  To analyze the clinicopathologic characteristics and response to treatment of patients with pCIA after chemotherapy for breast cancer.

Design, Setting, and Participants  In this case series, a retrospective evaluation was performed of patients with a diagnosis of pCIA after chemotherapy for breast cancer in 4 specialist hair clinics from November 1, 2011, to February 29, 2020.

Main Outcomes and Measures  Clinical, trichoscopic, and histopathologic characteristics and treatment outcomes were analyzed. For patients who presented with diffuse alopecia or diffuse rarefaction of hair over the midfrontal scalp with widening of the central part line and preservation of the frontal hairline, the Sinclair scale (grades 1-5, where 1 indicates normal hair density and 5 indicates the most severe stage of hair loss, with little or no hair in the centroparietal region) was used to assess severity.

Results  One hundred patients (99 women [99%]; mean age at presentation, 54.0 years [range, 29.0-74.1 years]) were included. Most patients had diffuse nonscarring alopecia (n = 39), female pattern hair loss (n = 55), or male pattern hair loss (n = 6). Six patients developed cicatricial alopecia. Taxane-containing regimens were used for most patients (92 [92%]) and were associated with more severe alopecia than regimens that did not contain taxanes (median Sinclair grade, 4 [IQR, 3-5] vs 2 [IQR, 2-2.5]; P < .001). A total of 76 of 86 patients (88%) had trichoscopic signs indistinguishable from those of androgenetic alopecia. Of 18 patients who had biopsies, 14 had androgenetic alopecia–like features, 2 had cicatricial alopecia, and 2 had features of both. Both topical and oral minoxidil, sometimes combined with antiandrogen therapy, were associated with an improvement in hair density (median Sinclair grade, 4 [IQR, 3-5] before treatment vs 3 [IQR, 2-4] after treatment; P < .001).

Conclusions and Relevance  This case series outlines previously unreported features of pCIA in patients with breast cancer, including a trichoscopic description. Cosmetically significant regrowth was achieved for a significant proportion of patients with topical or systemic treatments, suggesting that pCIA may be at least partly reversible.

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