P9.128 Atrophic telogen effluvium’ from cytotoxic drugs and an investigation into a protective effect of pretreatment with a topical vitamin D₃ analogue in man

Tanya O. Blieker, Nicolas Nicolaou, Jette Traulsen and Peter E. Hutchinson

Hair loss from cytotoxic drugs is classically ascribed to the loss of fractured hairs (anagen effluvium).  Telogen hair loss has also been described but some authors have denied any effect on the hair cycle.  There are conflicting reports on a protective effect of pre-treatment with a vitamin D analogue on cytotoxic induced hair loss in rodents.  The aims of this study were to investigate the process of cytotoxic hair loss and any protective effect of pre-treatment with topical calcipotriol.  Breast cancer patients who received cycles of chemotherapy with cyclophosphamide 600 mg / m,² methotrexate 40 mg / m² and 5-fluorouracil 600 mg / m² to a total of six consecutive cycles. were recruited and were treated with either calcipotriol scalp solution 50 mg/ml or vehicle.  The solution was applied four days prior to chemotherapy and continued for 14 days in each treatment cycle.  Hair investigations were 5 day shed hair collections, plucked telogen counts, hair density from cut areas of 0.5 cm² and the new anagen hair count (NAH) (a measure of regrowth from a new hair cycle), which was estimated from the ratio of hairs < 5 cm long with uncut distal tips, to the whole sample, in the plucked and cut samples.

24 patients completed 3 treatment cycles (14 V, 10 CPL) and 18 completed 6 cycles (9 V, 9 CPL).  There was no significant effect of calcipotriol.  Combining results of the treatment groups, there was a large variation in the impact of chemotherapy, from minimal in five patients to total loss in 5.  Maximal increase in mean shedding occurred after cycle 2, 93%, CI 89-96%, were telogen hairs (of which 64%, CI 55-72%, had tapering proximal shafts and 30%, CI 20-39%, were normal telogen hairs) and the rest were fractured or anagen hairs.  70%, CI 60-80%, of the increased shed hairs were tapered.  Severely affected patients experienced earlier onset of shedding and a greater proportion of shed fractured hairs.  At cycle two, the mean plucked telogen count was 34% (tapered telogen 12%), fractured hair 28% (18% tapered fractured) and 30% of all hairs were tapered (respective proportions at baseline 17%, 0%, 4%, 0%, 0%). There was a strong correlation between the proportion of tapered hairs and total shed rate at cycle 2 (r = 0.71, P = 0.0001).  The mean NAH 3 months later was 47% (baseline 14%) and there was a strong correlation between increase in NAH at this point and increase in shed rate at cycle 2 compared to baseline(r = 0.78 P = 0.0001).  Thus regrowth was of new anagen hairs, i.e. not of continued growth of fractured hairs.

It is concluded that the cardinal effect of cytotoxic drugs is to produce tapering of the proximal hair shaft and premature entry of the follicle into telogen. These conflicts with the conventional view that affected hair follicles continue in anagen.  There is a resulting effluvium of a mixture of tapering telogen hairs and fractured hairs.  We propose the term ‘atrophic telogen effluvium’.  There was no obvious protective effect on the hair fall of prior treatment with topical calcipotriol.