Hair loss can cause considerable distress in patients and negatively affect body image, self-esteem, and well-being.
Interventions to mitigate hair loss or its impact depend on etiology; eg, scalp cooling may be prescribed as a preventive measure before chemotherapy, or minoxidil may be prescribed for chronic telogen effluvium.
Because effective treatment options are limited, physicians can advise patients on various coping strategies.
Whatever the etiology, hair loss can be severely distressing to patients. The sociocultural importance of hair cannot be downplayed, with even limited hair loss resulting in negative mental health effects and loss of psychosocial function in some patients.
It’s important for physicians to address these effects of hair loss, as well as impact on quality of life. In writing for the journal Skin Appendage Disorders, Cameron Moattari, MD, and Mohammad Jafferany, MD, recommend that dermatology and psychiatry residents specifically learn how to manage psychodermatology and psychotrichology issues via dermatology-psychiatry liaison clinics.
Although the psychological impact of hair loss is uniformly detrimental, strategies to combat hair loss in patients ultimately tie back to etiology.
Hair loss's common beginning
A variety of medical specialists, aesthetic surgeons, and beauty specialists like cosmetologists help patients with different forms of psychodermatology, with a sub-branch of this field being psychotrichology. Researchers in this emerging field are defining the link between the skin and its appendages with the psyche.
The nervous system and skin are derived from the same embryonic tissue, called the ectoderm, resulting in complex interplay between the nervous, endocrine, and cutaneous systems, according to Moattari and Jafferany.
“The skin has begun to be viewed as a peripheral neuroendocrine organ. Indeed, human scalp hair follicles exhibit a fully functional hypothalamic-pituitary-adrenal axis equivalent, which includes cortisol synthesis and feedback regulation,” they wrote.
“Activation of this axis with psychological stress and subsequent release of corticotropin-releasing hormone may induce degranulation of mast cells to trigger premature catagen leading to hair loss.”
"These findings highlight the role stress may play in hair loss disorders such as alopecia areata."
— Drs. Moattari and Jafferany, writing for Skin Appendage Disorders
Diagnosing and treating: Anagen effluvium
This is the most common form of hair loss linked to cancer therapy and is usually noticed within 1-2 weeks of starting chemotherapy, progressing over the following 4-8 weeks. Although chemotherapy is linked to many adverse effects, hair loss is among the most distressing, resulting in depression, anxiety, negative body image, decreased self-esteem, and a decreased sense of well-being.
Moattari and Jafferany wrote that complete hair loss manifests between 2 and 3 months following chemotherapy. (Some evidence shows that hair is lost in an androgenic pattern.) Hair typically regrows between 1 and 3 months following the discontinuation of the therapy, but 65% of patients regrow hair of a different color, thickness, or texture.
The prospect of chemotherapy-induced hair loss can be so distressing that 8% of women consider foregoing chemotherapy altogether. Moreover, Moattari and Jafferany noted results of a cross-sectional study indicating that 55% of women felt severe psychological distress due to anagen effluvium, which was negatively linked to lower body image, decreased well-being, and depression.
There are limited treatment options for patients with chemotherapy-induced hair loss. Medications like minoxidil have not been shown to be beneficial in these patients. Results from Moattari and Jafferany’s meta-analysis suggest that preventive scalp cooling may help mitigate hair loss by vasoconstricting scalp vessels and decreasing hair-follicle biochemical activity.
The American Cancer Society (ACS) noted potential treatment options that work by cooling the scalp. “Controlled studies of older forms of scalp hypothermia (such as using ice packs) have had conflicting results. However, some studies of newer, computer-controlled cooling cap systems have shown benefits.”
“Recent studies of women getting chemo for early-stage breast cancer have found that at least half of the women using one of these newer devices lost less than half of their hair,” the ACS said in the online report. “The most common side effects have been headaches, neck and shoulder discomfort, chills, and scalp pain. The success of scalp hypothermia may be related to the type of chemo drugs used, the chemo dosage, and how well the person tolerates the coldness.”
ACS also cited research that individuals with thicker hair might have a higher risk of hair loss compared with those with thinner hair. This could be due to thicker hair preventing sufficient cooling, but rather insulating the scalp.
Of note, a handful of scalp cooling devices like Paxman and Amma are FDA-approved for chemo-induced hair loss.
Physicians can provide effective coping strategies for their patients experiencing hair loss, including referral to psychiatry and providing resources for wigs and other hair coverings, such as scarves or wraps. Patients can also be advised to pre-emptively shorten or remove hair to soften the blow. According to Moattari and Jafferany, education and planning can minimize patient distress.
Providers should note that wigs or other scalp coverings may be covered by insurance. When prescribing, use the term “cranial prosthesis” and not “wig,” the ACS advised.
Diagnosing and treating: Alopecia areata
This hair-loss disorder is marked by temporary, nonscarring alopecia secondary to an autoimmune cause, with stress also playing a role. Hair loss can be in circumscribed patches or total.
Patients often describe stressful life events before the onset of the condition. Alopecia areata affects 2% of the population at some point during their lifetime, according to Moattari and Jafferany.
The Skin Appendage Disorders authors also note that this condition can be especially distressing in children and adolescents. Studies have demonstrated that peers often express fear of those with the condition, and alopecia areata has been linked to teen suicides in those with no previous psychiatric history.
Providers should advise patients that remission may be natural without the use of drugs. Standard treatments for alopecia areata are topical or injected corticosteroids. Patients with alopecia areata should be screened for mental health concerns. Psychosocial interventions include antidepressants, psychotherapy, hypnosis, and the use of synthetic wigs.
Diagnosing and treating: Telogen effluvium
Marked by excessive shedding that is diffuse and nonscarring, this female-predominant condition typically occurs following an inciting event.
Hair follicles prematurely shift from the anagen to telogen phase, such as during the postpartum period, during which hormone changes result in the condition. (Trichodynia is more common in patients with telogen effluvium vs alopecia areata.)
Hair loss may not be readily apparent to a clinician in patients with thick hair due to the shedding being diffuse. Hair loss may also accentuate androgenic alopecia patterns. When recording medical history and administering a patient physical, it’s important physicians probe for an inciting event and establish a timeline.
Telogen effluvium occurs between 2 and 3 months following a triggering event, with remission in 95% of cases. The chronic form affects middle-aged women and exhibits a fluctuating clinical course that lasts greater than 6 months and may not be linked to an inciting event.
Triggering events include comorbidities, major emotional stress, nutritional deficiencies, hormonal imbalances, and drugs.
A recent study found that during the COVID-19 pandemic the incidence of telogen effluvium was four-times greater in minority-predominant communities, as noted by Moattari and Jafferany.
As for treatment, minoxidil may help stimulate hair growth—especially in those with chronic telogen effluvium—as well as discontinuing any medications causing hair loss.
"Patience is necessary for recovery. Reassurance should be made that the patient will not go bald, and hair loss rarely exceeds 50% of the scalp."
— Drs. Moattari and Jafferany, writing for Skin Appendage Disorders
Ultimately, it’s important to target the inciting causes, according to Moattari and Jafferany; isolated events typically resolve on their own, but illness or nutritional deficiencies along with drug exposures must be addressed.
What this means for you
It’s common for patients experiencing hair loss to face considerable distress. Because treatment options for this condition are limited, and hair loss is caused by a variety of factors and disorders, it’s important for patients to find coping strategies, including therapy and using head coverings. Patients should also be counseled that, in many cases, hair grows back over time. Physicians may want to monitor their patient’s mental health for severe symptoms of depression and anxiety following hair loss.