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Anagen Effluvium

Clinical Presentation (1, 2)

Anagen effluvium (AE) is an acute often reversible non-scarring hair loss condition. It is typically referred to as chemotherapy-induced alopecia. AE occurs when there is a sudden insult to hair follicles during the active growth phase. It presents with the shedding of the hair within 14 days of the introduction of an offending agent. Eighty to ninety percent of the hair follicles can be affected. Complete hair loss occurs within 2-3 months. The hair shaft appears as a tapered fracture and the shed hairs have a pigmented root.

  • Loose anagen hair syndrome (LAHS) (2, 3): A genetic hair loss condition typically affecting female light-haired children. LAHS hairs in the anagen (growth) phase are loosely anchored, can be easily painlessly pulled from the scalp, and do not grow long. Individuals with this condition also have patches of dull, unruly, or matted hair with increased hair shedding. Resolution of LAHS usually occurs during adulthood.


AE can affect men, women, and children of all racial backgrounds. The incidence of chemotherapy-induced hair loss is estimated to be 65% .

Causes (1, 2)

AE is caused by an agent or event that impairs the growth (mitotic/ metabolic) activity of the hair follicle

  • Anti-cancer chemotherapy medications

    • Antimetabolites, alkylating agents, and mitotic inhibitors: doxorubicin, the nitrosoureas, and cyclophosphamide 

  • Radiation therapy

    • Permanent hair loss can occur with higher doses

  • Tyrosine kinase inhibitors

    • Sorafenib, sunitinib, vismodegib

  • Other medications: Isoniazid (INH), levodopa, colchicine, and cyclosporine, bismuth

  • Toxic heavy metals: Thallium, mercury, boron, bismuth, copper, and cadmium

  • Infection/ inflammation/ autoimmune: Alopecia areata, syphilis secondary, systemic lupus, pemphigus vulgaris

  • Protein energy malnutrition

Diagnosis (1, 2)

Diagnosis is made via history, clinical scalp and hair exam (“hair pull test”), and dermoscopic evaluation

Clinical exam:

  • Hair shaft: Narrowed and fractured

  • Shed hairs: Pigmented/ dark bulb

Clinical Imitators (Differential Diagnosis)(1, 2)

Telogen effluvium, trichotillomania, androgenetic alopecia, alopecia areata

Treatment OPtions (1, 2

  • Proper education and anticipation

  • Emotional stress relief

    • AE is associated with adverse mental health effects (5)

  • Watchful waiting: After removal of a trigger/ event, regular hair cycling and full hair regrowth can take 3-18 months

  • Prevention of AE: Reduce the amount of chemotherapy delivered to the scalp, controversial for use in blood-borne tumors (leukemia, lymphoma) due to the risk of brain metastasis

    • Scalp tourniquet

      • The device placed around the hairline and inflated above the person’s blood pressure during chemotherapy

    • Scalp cooling

      • Cool scalp to less than 24 C during chemotherapy 

  • Reducing the duration of AE

    • Minoxidil

  • Scalp camouflage: scalp prosthesis/ wigs