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Permanent Chemotherapy Induced Alopecia (PCIA)

A New type of Hair loss in Patients Undergoing Chemotherapy: PCIA

Every year about 650,000 patients undergo chemotherapy in the United States. Hair loss is a common side effect of chemotherapy and occurs in about 65 % of patients who receive chemotherapy. There are two main types of hair loss that can occur in patients undergoing chemotherapy. The first is hair loss that happens within weeks of starting the chemotherapy and then lasts several months before growing back.  This is known as temporary chemotherapy induced alopecia ("TCIA"). The second type is uncommon and occurs when patients fail to regroth their hair back to the level it was before undergoing chemotherapy. If hair has not grown back after chemotherapy by the 6 month after chemotherapy, we call this permanent chemotherapy induced alopecia (PCIA) and it is sometimes also called Chemotherapy Induced Permanent Alopecia (CIPAL).


Permanent Chemotherapy Induced Alopecia (PCIA) 

The failure of the hair to grow back fully 6 months post chemotherapy raises concerns about a phenomenon known as permanent chemotherapy induced alopecia (PCIA).     In recent years a number of studies have highlighted the possibility of PCIA in women with breast cancer treated with various chemotherapeutic agents, especially drugs known as taxanes. Docetaxel and paclitaxel are part of this group of drugs. The exact mechanisms are unclear although injury to the bulb as well as follicular stem cells are thought to be relevant. Adjuvant anti-estrogen hormonal therapy may be an important cofactor in many women with PCIA. A similar PCIA presentation has been reported in patients undergoing bone marrow transplantation. The scalp is predominantly affected in women with PCIA although a minority may have eyebrow, eyelash and body hair loss as well.


Different Clinical Presentations of PCIA

PCIA doesn't appear similar in all patients. In fact, three main types appear to exist including a diffuse type, a diffuse type with vertex accentuation (mimicking androgenetic alopecia) and a patchy type mimicking alopecia areata.   


Examination under the Microscope: Biopsies of PCIA

Histopathology of biopsy specimens shows a non-scarring alopecia with preservation of sebaceous glands, miniaturization, decreased anagen hairs, increased telogen hairs and end stage avascular fibrous tracts. There may be several histological presentations and the exact features remains to be defined although a high proportion show dysmorphic telogen germinal units. Some biopsies show peribulbar type inflammation.


How do we treat PCIA?

We don't really know yet how to best treat PCIA. The most common treatments described in the medical literature are oral and topical minoxidil. Both seem to provide benefit to at least a proportion of patients.  Other treatments are not known to provide benefit. 


Dr. Donovan's Articles for Further Reading

Preventing Hair Loss from Chemotherapy

Does hair always grow back after chemotherapy?





Miteva M, Misciali C, Fanti PA et al. Permanent alopecia after systemic chemotherapy: a clinicopathological study of 10 cases. Am J Dermatopathol. 2011 Jun;33(4):345-50.  

Fonia A, Cota C, Setterfield JF et al. Permanent alopecia in patients with breast cancer after taxane chemotherapy and adjuvant hormonal therapy: Clinicopathologic findings in a cohort of 10 patients. J Am Acad Dermatol. 2017 May;76(5):948-957.

Rugo HS.  Real-world use of scalp cooling to reduce chemotherapy-related hair loss.  Clin Adv Hematol Oncol. 2017


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Does Elevated ESR cause Hair Loss?

The ESR Test

The erythrocyte sedimentation rate (ESR) is a very sensitive but non specific test for inflammation. An increased ESR does not directly cause hair loss but can sometimes indicate that the patient has underlying inflammation in the body that could be giving hair loss. Determining the cause of an elevated ESR is detective work.


The upper limit for ESR is slightly greater for women than men but a normal ESR is usually less than 20-30 mm/hr.

There are some conditions associated with a high ESR that are associated with hair loss and there are some conditions associated with high ESR that have nothing to do with hair loss. However, conditions such as various infections, and especially the autoimmune diseases (lupus, rheumatoid arthritis, vasculitis, inflammatory bowel disease), as well as anemias, pregnancy, some thyroid diseases, inflammatory diseases of the gastrointestinal tract and advanced kidney failure can be associated with hair loss. Other conditions including some cancers (especially blood cancers and various metastatic cancers) are associated with increased ESR but usually are not associated with hair loss. 

Very high ESR values over 100 mm/hr represent a special group. The group includes those that can be associated with hair loss include systemic lupus erythematosus, rheumatoid arthritis, and sometimes a few types of blood cancers (ie lymphomas, leukemias). Some drug hypersensitivity reactions can give very high ESR values and can also trigger hair loss. Polymyalgia rheumatica is in this group of conditions giving very high ESR values and can also sometimes give hair loss. Conditions in this group that usually don't give hair loss are infectious diseases such as abscesses, bacterial endocarditis and osteomyelitis.

The ESR test is a non specific test and many times a cause can't be found despite the patient having a full examination. Very high ESR levels may warrant additional testing. This may included other blood tests such as CRP, ANA, rheumatoid factor, LDH and possibly various imaging tests (depending on the precise history and precise level of ESR). There are hundreds of causes of increased ESR.

Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Actinic Keratosis of the scalp

Scalp actinic keratoses

Actinic keratoses are red scaly lesions that develop from long term exposure to the sun. They are viewed as pre-cancers with the potential to become cancers known as squamous cell carcinomas (SCC).

Anywhere from 12 to 40% of individuals screened in dermatology clinics have actinic keratoses on the scalp. These lesions are far more common on the scalp in men than women, this is in part due to the increased exposure to ultraviolet radiation in men with hair loss. About 1-10 % of actinic keratoses will become a squamous cell carcinoma (SCC) over a 10 year period if left not treated. Approximately 1-2 % of SCC will metastasize making early treatment important.

Actinic keratosis: a cross-sectional study of disease characteristics and treatment patterns in Danish dermatology clinics. Erlendsson AM, et al. Int J Dermatol. 2016.

Prevalence of actinic keratosis among dermatology outpatients in Spain. Ferrándiz C, et al. Actas Dermosifiliogr. 2016.

Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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