More Variants of Persistent Chemotherapy Induced Alopecia: Erosive Pustular Dermatosis-Like

Description of a New Variant of PCIA: Erosive Pustular Dermatosis Like Retention Hyperkeratosis

About 65 % of cancer patients experience hair loss after chemotherapy. The chance of hair loss depend to some degree on the exact type of chemotherapy used. Paclitacel, cyclophosphamide, doxorubicin and fluorouracil are likely to give hair loss.

There are two main types of hair loss that can occur after chemotherapy: Temporary and persistent. Temporary chemotherapy induced alopecia (TCIA) lasts a few months and then complete regrowth occurs. Hair loss starts 2-3 weeks after chemotherapy is administered and once the chemotherapy is finished the hair regrows within 3-6 months. Hair loss is reversible in temporary CIA. Persistent chemotherapy induced alopecia (PCIA) refers to a situation whereby the hair does not all come back by month 6.

Permanent CIA has been described following the use of busulphan, cyclophosphamide, thiotepa,

melphalan, etoposide, carboplatin, docetaxel, and paclitaxel.

the likelihood of PCIA depends on the type of chemotherapy. In general, PCIA is reported in up to 14 % of children and up to 30 % of women receiving chemotherapy for breast cancer.

Variants of PCIA

There are many variants of persistent chemotherapy induced alopecia including a diffuse hair loss type, female pattern hair loss, male pattern hair loss and scarring alopecia type (resembling a condition known as frontal fibrosing alopecia). Authors of a new study report yet another variant - an erosive pustular dermatitis like variant.

Kolla et al. 2022

Kolla and colleagues report a 70 year old female patient who developed PCIA after completing chemotherapy with paclitaxel 1 year prior. What was unusual about this patient’s presentation were the thick brown scaly plaques and plates on the frontal and vertex scalp. Removal of the scales revealed a pustular -like base. A biopsy showed retention hyperkeratosis. A subsequent biopsy showed preserved sebaceous glands, miniatured hairs and reduced density. It did not show evidence of scarring alopecia or true evidence of EPD. So it’s best called and Erosive pustular dermatosis-like clinical variants.

Treatment with doxycycline (14 days) and silver sulfadiazine cream (4 weeks) improved the eruption and she has been maintained with good success on daily compounded 6% salicylic acid with mineral oil, fluocinolone 0.01% topical oil, and alternating between ketoconazole 2% and T-Sal shampoos. Minoxidil and spironolactone were also added.

Photo from paper by Kolla et al. 2022 showing thick retention type scale that many be part of a new “erosive pustular dermatosis-like” variant of PCIA. Full Reference: Kolla et al. Permanent chemotherapy-induced alopecia presenting with erosive pustular dermatosis-like retention hyperkeratosis. JAAD Case Rep. 2022 Jan 6;21:77-79. Images published here through creative commons license.

Commment

This is a nice paper reminds us of the need to keep an open mind when evaluating PCIA. There are a variety of clinical variants now reported and a variety of histological variants. The 6 clinical variants include diffuse, FPHL like, male pattern like, patchy alopecia areata-like and scarring and now in this paper possibly EPD-like.

Histological variants include AGA like and alopecia areata like (with peribulbar inflammation). Most cases of PCIA show reduction in follicle number with vellus hairs and a lack of inflammation and scarring. It generally resembles androgenetic alopecia. With the realization that some perhaps might have peribulbar inflammation (and therefore resemble alopecia areata) we have come to realize that there may not be one simple PCIA model.

REFERENCE

Kolla et al. Permanent chemotherapy-induced alopecia presenting with erosive pustular dermatosis-like retention hyperkeratosis. JAAD Case Rep. 2022 Jan 6;21:77-79.