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Hair loss

Hair loss can occur with some types of cancer treatment. Hair loss is also called alopecia.

Causes

Hair loss occurs because the cells of hair follicles grow quickly, which makes them sensitive to the effects of some cancer treatments. Hair loss can be caused by chemotherapy, radiation therapy, hormonal therapy or targeted therapy.

While hair loss will happen with some treatments, with other treatments it will be hard to know for certain whether or not you will lose your hair. Hair loss can vary from person to person, even if they have the same treatment.

Chemotherapy

Hair loss is a common side effect of chemotherapy. In most cases, your hair will grow back after chemotherapy. Sometimes hair will not grow back after the very high doses of chemotherapy used for a stem cell transplantation. Docetaxel (Taxotere) is a drug that sometimes causes permanent hair loss when given at standard doses.

How much hair you lose will depend on:

  • the type of drug
  • the dose of drug
  • the combination of drugs (the chemotherapy regimen)
  • how the drug is given (into a vein, by mouth, through the skin)
  • the length of treatment

Not all chemotherapy drugs cause hair loss. Drugs that are more likely to cause hair loss include:

  • cyclophosphamide (Procytox)
  • dactinomycin (Cosmegen)
  • daunorubicin (Cerubidine)
  • docetaxel (Taxotere)
  • doxorubicin
  • eribulin (Halaven)
  • etoposide (Vepesid)
  • idarubicin
  • ifosfamide (Ifex)
  • irinotecan (Onivyde)
  • paclitaxel (Abraxane)
  • topotecan (Hycamtin)

Radiation therapy

Hair loss is a common side effect of radiation therapy to the head. How much hair you lose and whether it will grow back depend on how much of the head is irradiated and the dose of radiation. Temporary hair loss usually occurs with smaller doses of radiation. Permanent hair loss is more common with higher doses of radiation.

Hormonal therapy

Hormonal therapy drugs used to treat breast cancer include tamoxifen (Nolvadex-D, Apo-Tamox) and aromatase inhibitors such as letrozole (Femara), anastrozole (Arimidex) and exemestane (Aromasin). These drugs can cause temporary hair loss. Hair loss is more common with aromatase inhibitors than with tamoxifen.

Cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors are drugs used to treat metastatic breast cancer. These drugs include palbociclib (Ibrance), ribociclib (Kisqali) and abemaciclib (Verzenio). If you take a CDK4/6 inhibitor together with hormonal therapy, you have a slightly higher chance of losing your hair than if you take hormonal therapy alone. But most people find that they don’t lose so much hair that they need a wig or other hair covering.

Targeted therapy

Some targeted therapy drugs can cause hair loss and other hair changes. Targeted therapy drugs include monoclonal antibodies and small molecule drugs like tyrosine kinase inhibitors.

The monoclonal antibodies most likely to cause hair loss are the epidermal growth factor receptor (EGFR) inhibitors (a type of growth factor receptor antagonist). An example is cetuximab (Erbitux). Tyrosine kinase inhibitors that cause hair loss include erlotinib (Tarceva), sorafenib (Nexavar) and sunitinib (Sutent).

The amount of hair lost and whether it will grow back depend on the targeted therapy drug. In most cases, hair loss is temporary, but sometimes it can be permanent.

Symptoms

Hair may become thinner over time or it may fall out in clumps. It may fall out on its own or when you brush or wash it.

Other symptoms can sometimes go along with hair loss. These vary depending on their cause and other factors.

Chemotherapy

Chemotherapy drugs can cause hair loss on all parts of the body, but the scalp is usually affected the most. Hair loss on the face and body is usually less severe because hair grows less actively in these areas than on the scalp. The amount of hair loss varies. Chemotherapy can cause mild hair loss from only the scalp or complete hair loss from all areas of the body or something in between.

Hair usually begins to fall out about 2 to 4 weeks after chemotherapy starts.

Hair loss from chemotherapy does not usually include other symptoms, but your scalp may be tender or painful before or during hair loss. Chemotherapy makes the hair thin and brittle, so it is more likely to break than it was before.

Radiation therapy

Radiation therapy causes hair loss only from the area of the body where the radiation is given. Hair on the scalp will only fall out if radiation is given to the head.

Hair usually begins to fall out about 2 to 3 weeks after radiation therapy starts.

Radiation therapy also affects the skin in the treated area. The skin can become dry, itchy, irritated or red. The scalp may be sensitive or red after hair loss caused by radiation. Learn more about skin problems from radiation therapy.

Targeted therapy

Targeted therapy drugs can cause hair loss on all parts of the body, but the scalp is usually affected the most.

With EGFR inhibitors, hair loss is most common 7 to 10 weeks after starting treatment. With tyrosine kinase inhibitors, hair loss begins after 3 to 15 weeks of treatment.

Targeted therapy drugs can cause other temporary changes to the hair. During treatment, hair may become thin, brittle, curly or unruly. In some people, sunitinib makes the hair lose its pigment (colour), so it looks grey. Because of the dosing cycles of sunitinib, this can lead to alternating bands of normal colour hair and grey hair as your hair grows.

Preventing hair loss

For some people with solid tumours (not blood cancers like leukemia and lymphoma), scalp cooling is an option to help prevent hair loss from intravenous (IV) chemotherapy. Scalp cooling involves wearing a cap that cools the scalp before, during and after the chemotherapy is given. The cold temperature narrows the blood vessels in the scalp and decreases blood flow. This means that less of the chemotherapy drug reaches the hair follicles, so they are less likely to be damaged.

There are 2 types of scalp cooling systems. One system uses several cold caps that are kept frozen in a portable freezer or a cooler with dry ice. About every 20 minutes, the cap is removed and replaced with a fresh cap. The newer system uses just one cap. Cold fluid is continuously circulated through the cap from a hose attached to a portable machine. The cold caps are tight-fitting. They lower the temperature of the scalp to about 3°C. Side effects of wearing the cold caps include headache, discomfort and feeling cold.

Scalp cooling does not completely stop hair loss, but it can prevent enough hair loss that the person doesn’t need a wig or other hair covering. How well scalp cooling works depends on the type and dose of chemotherapy. Talk to your healthcare team to find out if scalp cooling may be helpful for you. Scalp cooling may not be available in all cancer centres, and it is not covered under provincial health care plans. You will have to pay for the treatments yourself (unless you have coverage through a private healthcare plan).

Managing hair loss

Your healthcare team can suggest ways to manage and cope with hair loss, which may include some of the following ideas.

Wigs and hairpieces

If you think that you may want to wear a wig or hairpiece, it is best to plan ahead. Try to select one before your hair falls out so that it is easier to match your hair colour and style. You may need to get it styled, trimmed or adjusted so that it fits well and looks good. Some hair salons specialize in fitting wigs for people who have cancer. Check with your provincial and private health insurance about coverage for the cost of wigs. Learn more about finding a wig.

Hair care

Be gentle with your hair during your cancer treatment. Try to limit washing to twice a week. Use a mild shampoo and gently massage your scalp – don’t scrub. A volumizing conditioner can be used to help add body to fine or limp hair. Pat your hair dry instead of wringing or rubbing it. Use a soft hair brush or wide-tooth comb to gently style your hair. Let your hair dry naturally.

Avoid curling irons, straightening irons, hot rollers and hair dryers. Don’t use perms, hair dyes, bleach, peroxide, ammonia or other chemical products on your hair. These can damage the hair and irritate your scalp.

If your hair is long, you may want to get it cut shorter. This can make hair look fuller and thicker. It can also make hair loss seem less dramatic. If your hair loss is severe or patchy, you may want to shave your head. Use an electric shaver rather than a razor to avoid cutting your skin.

Scalp care

Without hair, your head might feel cold. Wear a hat, scarf or other head covering in cold weather. You may also want to wear your head covering to bed to help keep you warm while sleeping.

You need to protect your scalp from the sun. Wear a hat, scarf or other head covering or use sunscreen on your scalp.

If your scalp is sensitive, using a satin pillow case may reduce friction between your scalp and the pillow. This can make you more comfortable as you sleep. Gentle massage or lotions may help ease scalp discomfort. An antidandruff shampoo may help with an itchy scalp.

Loss of eyebrows and eyelashes

You can use makeup to create eyebrows if your eyebrow hairs fall out. Semipermanent makeup may also be an option for you. False eyelashes can be used to temporarily replace eyelashes that have fallen out.

Self-image

Losing hair can be emotionally challenging. Hair loss is a very visible side effect and can affect your self-confidence. For some people, losing their hair is the hardest part of cancer treatment. Programs such as Look Good, Feel Better can make a difference to how you feel about yourself. This program offers tips on makeup, skin care, dealing with hair loss and other appearance-related side effects of cancer treatment. Looking good can help you feel better – physically and emotionally.

Hair regrowth

Hair often grows back once cancer treatments are finished. The time it takes for the hair to regrow is different from person to person. After chemotherapy is finished, hair usually begins to grow back in about 2 to 6 months. Some people find that their hair starts to grow back even before they finish their chemotherapy treatment. Complete regrowth can take 6 months to 2 years. After radiation therapy, hair usually grows back in about 2 to 3 months.

When your hair starts to grow back, it may not look or feel the same way it did before. Some people find that the new hair is a different texture or colour. The new hair may be finer or coarser, lighter or darker, straighter or curlier. These changes are usually temporary.

When hair is regrowing, it may be more likely to break than it was before. Continue to treat your hair gently. Until your hair returns to normal, avoid hair treatments like perms, dyes and chemical straighteners.

Special considerations for children

How a child feels about hair loss depends a lot on their age. A young child might not mind losing their hair, but a teenager may be devastated. The following may help a child prepare for and cope with hair loss.

Be aware of how you react to your child’s hair loss. Children may feel differently about their hair loss than parents do. Your feelings could affect how they feel. For example, your child may not be very upset about losing their hair, but your distress could be upsetting to them.

Take your child’s picture before they start to lose their hair. If your child decides to wear a wig, the hair stylist can use the picture to help match the style. Keep a small piece of your child’s hair to help match the colour and texture.

Let your child take the lead on how they want to deal with their hair loss. Talk to your child about their choices. If your child is willing, it may help to cut their hair short before it starts to thin or fall out. This can make the hair loss seem less dramatic and make the transition to less hair easier. They may wish to wear a hat, bandana or other head covering. Let them chose one they like. If your child wants to wear a wig, it may need some styling, trimming or other adjustments to fit and look good. If they do not want to cover their head, that’s OK.

Try to minimize the emotional trauma of the hair loss. You can highlight your child’s strength in dealing with illness and hair loss. Help your child see hair loss as a sign of bravery. It may be helpful for your child to talk with other children who have lost their hair. Sometimes family members or friends shave off their hair in support of the child, to show that they’re not alone. The social worker or child life specialist at your child’s cancer treatment centre may be able to offer other suggestions on how you can support your child emotionally.

When your child returns to school, let theirteacher know about any hair loss. Make sure your child will be allowed to wear a hat, bandana or other head covering in class. The teacher can speak to the other students ahead of time so that they are prepared and know how to act.

monoclonal antibody

A substance that can find and bind to a particular target molecule (antigen) on a cancer cell.

Monoclonal antibodies can interfere with a cell’s function or can be used to carry drugs, toxins or radioactive material directly to a tumour.

tyrosine kinase inhibitor

A drug that blocks the actions of the enzyme tyrosine kinase, which helps transmit the signals that occur after a growth factor binds to its receptor. Tyrosine kinase is involved in cell communication, development, division and growth.

Tyrosine kinase inhibitors are a type of growth factor inhibitor therapy. They may be used to help prevent tumour growth.

growth factor receptor antagonist

A substance that blocks growth factor receptors on cells so that they cannot receive chemical signals that tell them to grow.

solid tumour

An abnormal group of cells without any areas of liquid in it. Solid tumours can be non-cancerous (benign) or cancerous (malignant).

intravenous (IV)

Within or into a vein (a blood vessel that carries blood from tissues and organs in the body to the heart).

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