Hair loss (also called alopecia) is a potential side effect of chemotherapy and radiation therapy and for some people can be the most distressing side effect of treatment.  Hair loss can be hard to predict although for some fortunate people, having cancer treatment doesn’t affect their hair at all.  When it does occur it’s usually temporary and in most cases the hair will grow back. Hair loss may occur throughout the body, including the head, face, arms, legs, underarms, and pubic area and hair may fall out entirely, gradually, or in sections. In some cases, hair will simply become thin, sometimes unnoticeably, and may become duller or dryer.

For women in particular and also many men, hair can be an important part of their appearance and identity, and losing their hair can be very upsetting. It can leave you feeling uncomfortable about socialising, concerned about how your different appearance will affect relationships with family and friends and generally result in feeling less confident, vulnerable and exposed. For others – particularly as people today are much more aware of the effects of cancer treatment – their hair loss can act as a visible message that they are going through cancer treatment.  But this can also make the patient feel ‘labelled’ and forced to talk about their cancer even if they don’t want to.  So there are lots of different emotional reactions associated with hair loss and for some, losing their hair may feel like the final straw on top of the injustice of having to deal with a diagnosis of cancer and the associated treatment. But for some, accepting and adjusting to hair loss isn’t as bad as they had expected.

Why does it happen?

The normal scalp contains around 100,000 hairs and these are constantly growing with new ones replacing old ones as they fall out.  Most adults lose between 40 and 120 hairs per day as part of the healthy hair growth cycle.

In cancer treatment, hair loss can happen when chemotherapy drugs travel throughout the body to kill cancer cells. As the chemotherapy drugs destroy the cancer cells they can sometimes also damage healthy cells, including the cells in the hair follicles and this damage can cause the hair to fall out. Some patients will be affected while others will not, even when they take the same drugs. Some drugs cause only the loss of scalp hair while loss sometimes happens to pubic hair, arm and leg hair, eyebrows, and eyelashes. The hair loss caused by chemotherapy is almost always temporary and the hair will start to grow back as soon as treatment is finished (and may even start to re-grow before the chemotherapy course has completed).

Radiation therapy also affects healthy cells but only affects the hair that is close to the specific area being treated. So radiation to the head often causes scalp hair loss while having radiotherapy to the breast and lymph glands in the armpit can cause loss of underarm hair for women and men and chest hair for men. And having radiotherapy in the pelvic or groin area can cause loss of pubic hair. Sometimes, depending on the dose of radiation to the head, the hair which grows back is not identical to the original hair, with difference in texture, thickness and colour sometimes being seen. Hair re-grow is sometimes also patchy and can take 6-12 months to grow back fully.  Very occasionally the hair does not grow back at all.  This is usually associated with the radiotherapy being given at very high doses and a very high number of treatments.

Some hormone therapies for cancer such as tamoxifen can also cause hair thinning.  This is usually mild and may only occur during treatment.  Once treatment is complete the hair will usually grow back normally.

Prevention

Unfortunately there is nothing you can do to prevent hair loss caused by radiotherapy, but with chemotherapy it’s sometimes possible to reduce hair loss by cooling the scalp with the use of a cold cap. This technique reduces the blood flow to the hair follicles which in turn reduces the amount of drugs reaching them and in some cases can prevent the hair from falling out. Scalp cooling only works with certain drugs and the level of success varies from person to person. Some people find wearing a cold cap very unpleasant and uncomfortable.  As well as being very cold the caps tend to be quite heavy and need to be changed every 20-30 minutes during treatment to keep your scalp cool. They can also give you a headache but this will usually wear off very quickly. There are a number of different types of cold cap and ways of cooling the scalp so the method used will depend on what’s available at your treatment centre.

Wigs

If you think you may want a wig, and if it’s important to you that it matches your hair colour and style, you may want to choose one before your hair actually falls out. Alternatively you could cut and keep a swatch of your hair to use for matching, in case you decide later that you want or need a wig. Or you may decide you want a complete change from your usual style. Ask if it’s possible if the wig can be adjusted as your head size can shrink as you lose your hair, especially if you have very thick hair.

If you decide you want a wig you may be eligible for a free one.  However, this varies from centre to centre so you need to ask your healthcare professional.  Free or subsidised-cost wigs are usually synthetic as these are significantly cheaper than those made of real hair.  Synthetic wigs are lighter in weight than real hair and are relatively easy to care for. They are often pre-styled and can be easily washed and left to drip dry.  Real hair wigs need to be handled more carefully and may need professional cleaning and restyling. They are also usually considerably more expensive than synthetic wigs.

Hair and scalp care

If your hair is going to fall out, the first thing you may notice is your hair starts to come out more when you brush, comb or wash it. You may also find hair on your pillow in the morning. During cancer treatment the following recommendations may help you deal with hair loss;

• Your scalp may feel very sensitive to washing, brushing or combing so consider not washing it every day, don’t scrub vigorously and choose a mild shampoo such as baby shampoo.
• Try to use hair products which are natural and chemical-free.
• Choose a soft hairbrush and avoid using high heat to dry, curl or straighten your hair.
• You lose a lot of heat through your scalp so cover your head during cold weather to prevent loss of body heat.
• In warm weather use sun protection on the scalp such as sunscreen, hat or scarf when outdoors.
• Avoid colouring or curling your hair with chemical products.
• Gently massage the scalp to remove any dry skin or flakes.
• When your hair begins to re-grow it may be much finer and more easily damaged than your original hair so treat it very gently.
• It may take up to a year before your hair returns to its original texture and colour.  Before starting to use semi-permanent or permanent colour or curling products again, patch test a small area first because you may find your hair reacts differently after cancer therapy.
• Always ask your healthcare team before using any hair-growth creams or lotions.

For information on other side effects associated with cancer treatment and how to cope with them please see Chapter 3 of The Cancer Journey – Positive Steps to Help Yourself Heal.