What is Anagen Effluvium?
Anagen effluvium is a type of hair loss that doesn’t cause scarring. There are two types of this hair loss condition: dystrophic anagen effluvium and loose anagen syndrome. Dystrophic anagen effluvium is often linked with chemotherapy; however, it can also occur due to lack of proteins and energy in the body, a skin disease called pemphigus, a hair loss condition called alopecia areata, and different types of severe metal poisoning. In this condition, the actively growing hairs are damaged by a harmful substance or inflammation, causing the hair to break. Loose anagen hair syndrome is a hereditary condition where the hairs are not firmly attached and can be easily and painlessly pulled out. This situation happens due to genetic defects in keratin, a protein that is crucial for hair health.
Chemotherapy-induced alopecia is a more commonly seen type of anagen effluvium because chemotherapy drugs like antimetabolites, alkylating drugs, and mitotic inhibitors often affect the growth of hair. Here, the loss of hair usually happens within two weeks from when the chemotherapy is administered. A hair and scalp examination technique called trichoscopy can show broken hairs. Unlike another hair loss condition called telogen effluvium, where the hairs fall out, the hairs in anagen effluvium break. Thus, the term “anagen effluvium” can be a bit confusing because “effluvium” generally refers to the shedding or falling out of hair.
It’s important to note that the hair loss associated with this condition can be very distressing for patients. The future for patients with anagen effluvium is uncertain as no treatments have been entirely successful in preventing or stopping the hair loss. Providing patients with information and guidance on how to manage hair loss is very important. Patients should be helped to understand the difficult reality of their condition, but they should also know that most patients experience hair regrowth after chemotherapy ends. However, it may take months or years for the hair to fully recover, and a few might experience persistent thinning of hair.
What Causes Anagen Effluvium?
Anagen effluvium, a condition that leads to hair loss, can be caused by several factors. Some of these include certain medications, exposure to heavy metals or radiation, chronic illness, autoimmune diseases, malnutrition, and specific surgeries.
It’s quite common for anagen effluvium to be associated with cancer treatments like chemotherapy. Certain chemotherapy drugs are more likely to cause hair loss than others. For example, paclitaxel, an agent that disrupts cell division, is found to be responsible about 80% of the time. Other drugs that frequently cause hair loss during treatments include topoisomerase inhibitors like doxorubicin, alkylating agents like cyclophosphamide, and antimetabolites like 5-fluorouracil.
Several other medications such as isoniazid, cyclophosphamide, colchicine, and cyclosporine among others are also known to trigger anagen effluvium. And while some drugs like methotrexate and albendazole are generally considered safe, in rare instances they have been found to also cause hair loss.
Exposure to heavy metals including thallium, mercury, boron, bismuth, copper, and cadmium can cause hair loss as well. Radiation is another factor that can lead to hair loss, which can sometimes be permanent if the stem cells of the hair follicles get damaged. For example, in certain medical procedures where radiation is used like treating cerebral aneurysms, it can result in hair loss in the area exposed to radiation.
This type of hair loss can also occur due to some inflammatory conditions such as alopecia areata and syphilis, which cause inflammation in the hair bulb. In autoimmune disorders like Pemphigus vulgaris where certain proteins in hair follicles are targeted, it can also result in anagen effluvium.
Instances of anagen effluvium have been reported following certain types of surgeries like scar reduction, mole removal, and scalp graft surgeries. Severe conditions including extreme low blood pressure, insufficient oxygen levels, and severe protein-energy malnutrition like kwashiorkor can cause an abrupt stop of cell division in the hair matrix, leading to hair loss.
While undergoing chemotherapy, there are several factors that can increase the risk and severity of hair loss. These include issues with drug metabolism especially in patients with liver dysfunction, previous exposure to scalp radiation, old age, pre-existing hair loss, prior chemotherapy-induced hair loss, and a condition called graft-versus-host disease seen in patients who have had a hematopoietic cell transplantation.
Risk Factors and Frequency for Anagen Effluvium
Anagen effluvium, a type of hair loss, does not affect one gender more than the other; it’s commonly found in both men and women across the globe. Also, the severity of hair loss, as well as the rate and pattern of hair growth, don’t seem to be linked to different hair types, ethnic backgrounds, or races.
Signs and Symptoms of Anagen Effluvium
Anagen effluvium is a hair loss condition often resulting from chemotherapy. A typical physical sign of this condition is a fractured, thinned hair shaft. The situation becomes complicated as patients undergoing chemotherapy may experience overlapping hair loss cycles – both anagen (active growth phase) and telogen (resting phase) effluvium. These hair cycles are distinguishable even to the naked eye, but microscopic examination may give a clearer view; anagen hairs have full pigment and root sheaths, while telogen hairs have club-shaped roots and a depigmented part of the shaft. Anagen effluvium doesn’t involve signs of inflammation or scarring, unlike another hair loss condition called cicatricial alopecia.
Chemotherapy mostly affects the scalp hair, particularly areas with fewer hair like the crown and front regions. But, hair loss is not only limited to the scalp. Madarosis is a condition characterized by loss of eyebrows, eyelashes, and hair in the extremities, underarm region, and public region. This can occur even after chemotherapy ends. Hair regrowth tends to be faster in these regions than on the scalp. When and how the hair loss begins depends on the specific type of treatment, dosage, and regimen used. Hair loss generally starts two to three weeks after the first chemotherapy dose and discontinues by the end of the second cycle. While weekly chemotherapy might cause slower hair loss, prolonged treatment can lead to eventual hair regrowth.
Chemotherapy and other treatments like immune therapy, molecular targeted therapies, and endocrine agents can alter hair in different ways, apart from causing hair loss. For example, treatments like Methotrexate can affect the hair color cells, leading to darkening of eyebrows, eyelashes, and scalp hair. This might appear as alternating color bands, a phenomenon known as the flag sign. Treatments can also cause partial hair loss, curling of the hair, and depigmentation. Certain biological treatments and hormonal therapies have the potential to cause mild or partial hair loss. Immune checkpoint inhibitors, a type of immunotherapy, may cause sporadic loss of skin and hair pigmentation, a condition known as vitiligo and poliosis, respectively. They may also cause hair loss.
Testing for Anagen Effluvium
Anagen effluvium is a type of hair loss that can usually be identified based on a patient’s medical history and a physical examination of the hair and scalp, often making more invasive procedures like a biopsy unnecessary. However, if there are any doubts, a biopsy could be conducted for a clearer diagnosis and to rule out telogen effluvium, which is another form of hair loss.
If a biopsy is performed, it would involve looking at a small sample of scalp tissue under a microscope. In anagen effluvium, the proportion of hair follicles in the resting (telogen) phase would be less than 15%. More than 15% in the telogen phase would suggest a diagnosis of telogen effluvium instead.
Another diagnostic tool is a trichogram, which measures the ratio of actively growing (anagen) hairs to resting (telogen) hairs by pulling out a sample of hairs. The examination would reveal an abnormal number of poorly formed anagen hairs. Healthy anagen hairs generally have long, colored roots covered by protective sheaths, while telogen hairs have a club or round shaped end. Regardless of the hair loss, the hair follicle openings remain intact on the scalp.
Your doctor might also order tests for conditions known to cause hair loss, like iron deficiency, thyroid disorders, lupus, and infections like syphilis.
Trichoscopy is another test which uses a handheld device to closely examine the scalp and hair. This can help identify characteristic signs of anagen effluvium like hair that tapers to a point (often called ‘exclamation hair’) and hair thinning in response to chemotherapy treatments. These changes are due to the chemotherapy drugs interfering with the cells that produce hair, causing the hair to thin and break at the weakest point.
To assess the severity of hair loss, the Dean Scale can be used. It grades hair loss on a scale of 0 to 4. An assessment of 0 indicates no hair loss while 4 signifies more than 75% hair loss. This scale helps evaluate the effectiveness of treatments to combat hair loss. Similarly, the Hair Mass Index provides another way to measure hair loss. The emotional impact of hair loss can be rated using the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) scale.
Treatment Options for Anagen Effluvium
The main aim when managing anagen effluvium, a condition where hair falls out rapidly during its growth phase, is to reduce the duration of hair loss as this can have a major emotional and psychological impact on the patient. Although many treatments have been studied, currently no treatment is effective at preventing or stopping hair loss. Hence, it is important to educate patients about this type of hair loss and offer aesthetic suggestions such as hairpieces or scarves to help camouflage the hair loss and protect the scalp during cold weather.
One treatment approach involves reducing the amount of blood reaching the hair bulb using tourniquets (devices that squeeze the blood vessels) on the scalp during chemotherapy. However, this method should not be used if there’s the possibility of scalp or brain metastases (cancer spread), so that the chemotherapy drugs can reach these areas.
Another proven approach is inducing ‘scalp hypothermia,’ which makes the scalp very cold (below 24 °C or 75.2 °F) during chemotherapy, reducing blood flow to the scalp and hence less of the drug reaches the hair follicles. This approach has helped patients who are being treated for cancer types such as ovarian, prostate, and breast cancer. However, because this treatment involves making the scalp very cold, some patients might experience cold sensations, headaches, nausea, dry skin, and claustrophobia. There are also certain circumstances in which scalp hypothermia should not be used; for example, in children, those with blood disorders triggered by cold, and patients undergoing specific types of cancer treatments.
Other treatments that have been tested include minoxidil, a medicine known for promoting hair growth. While it might not prevent hair loss, it has been shown to reduce the duration of baldness in some patients. There is also a product called topical bimatoprost which might help in the treatment of eyelash or eyebrow hair loss caused by chemotherapy. Finasteride and Spironolactone, both of which are medications commonly used to treat hair loss, have been tested but are generally not recommended due to a lack of sufficient data and potential side effects. Topical Calcitriol, a type of Vitamin D, has been tested as a potential preventative solution, but limited data and potential side effects have limited its usage. Lastly, there is a therapy called photobiomodulation where light is used to stimulate hair regrowth post-chemotherapy, however, more evidence is needed to evaluate its effectiveness.
Overall, while there are several treatments being explored, currently there are no proven preventative treatments for anagen effluvium, and managing the condition includes education, aesthetic advice, and certain techniques to reduce chemotherapy’s effect on the hair follicles.
What else can Anagen Effluvium be?
When a person has anagen effluvium, a type of hair loss, it could be mistaken for other similar conditions. These include:
- telogen effluvium
- trichotillomania, a hair-pulling disorder
- androgenetic alopecia, commonly known as male or female pattern baldness
To tell these conditions apart, this is what doctors do:
- They examine a patient’s medical history
- They perform a hair pull test
- They use a special tool to look at the hair and scalp called trichoscopy
Hair loss might be a sign of another health problem. So, it’s crucial to check for other possible causes of hair loss. These can include nutritional deficiencies, problems with metabolism or hormones, and infections.
What to expect with Anagen Effluvium
Hair loss caused by chemotherapy is usually temporary. This is because chemotherapy targets the fast-growing cells in the hair bulb but doesn’t affect the resting stem cells that are responsible for restarting hair growth. When chemotherapy is finished, the hair usually starts growing back to normal within 3 to 6 months.
However, about 65% of people notice changes in their hair when it grows back. It might turn grey, or change from straight to curly (or vice versa). This is thought to be due to the way chemotherapy affects different parts of the hair follicle. Over time, these changes often lessen.
Permanent hair loss after standard chemotherapy for breast cancer is rare. But research has found some evidence that long-lasting or permanent hair loss can occur after standard chemotherapy, specifically when the drug docetaxel is used. The amount of drug given in each treatment and the length of treatment seem to be linked to this lasting hair loss.
A study found a link between a specific gene (named ABCB1) and permanent hair loss after docetaxel treatment in people with breast cancer. Another study found that delayed hair regrowth can occur with the drug paclitaxel, but this is rare with the doses given today.
Possible Complications When Diagnosed with Anagen Effluvium
Losing hair, or alopecia, is a well-known side effect for cancer patients undergoing chemotherapy. This sudden hair loss can negatively affect their mental health and quality of life, especially in young women. Some patients become so upset by this, they might choose less effective treatments, or delay or reject treatment that could be beneficial to them.
In most cases, when the hair grows back, it usually follows a normal pattern. However, some people might find that their hair has changed – for example, those with straight hair might find it’s now curly. The color may also change. Usually, hair loss caused by chemotherapy (known medically as anagen effluvium) is temporary and the complete hair growth returns. Though, certain chemotherapy treatments can cause permanent hair loss, depending on the dosage given. This type of hair loss is similar to alopecia caused by hormonal factors, known as androgenetic alopecia.
Common Side Effects:
- Hair loss or alopecia
- Emotional distress
- Delay or refusal of treatment
- Change in hair texture (such as straight to curly)
- Change in hair color
- Permanent hair loss, depending on chemotherapy dosage
Preventing Anagen Effluvium
Before starting chemotherapy, which can lead to hair loss, it’s important for every patient to be fully informed about this possible side effect. They should also be provided with information about alternative ways to conduct the chemotherapy. We do this because we know that taking these steps can help lessen the emotional distress related to losing hair.
For women who have breast cancer and are receiving docetaxel treatments at doses of 75 mg/m² or higher, it’s particularly important that they receive clear information about the potential for lasting or prolonged hair loss. One suggested method to prevent long-term hair loss is to cool the scalp, although there isn’t a lot of data on this method yet.
