Hair Changes - Alopecia

Definition

The main hair change occurring with multikinase inhibitors is Alopecia, defined as a decrease in hair density compared to normal.1 Hair colour changes can also occur, for example greying of hair which has been reported with imatinib and sunitinib.2 Repigmentation of grey hair has also been reported with imatinib.3 Hair changes may include elongation and curling of the eyelashes (trichomegaly) and Hypertrichosis (including facial hirsutism) or a decrease in hair growth kinetics, whereas scalp and extremity hair may become curly, fine and brittle.2,4

Incidence

Alopecia is commonly reported with multikinase inhibitors, occurring at an incidence of 8% to 67%.5-13 Hair colour changes (greying of hair) are reported to occur in 10-18% of patients treated with sunitinib.10,14 Repigmentation of grey hair has been reported in a small proportion of patients treated with imatinib.3

Onset

Alopecia with sorafenib and sunitinib therapy is reported to occur during weeks 3–15 of therapy;2,17 hair colour changes can be seen after 4-6 weeks of treatment initiation.4 

Resolution

Alopecia is temporary and may spontaneously resolve in some patients despite continued Multikinase inhibitor therapy.2,13,16 Also see management of hair changes, alopecia.

Grading and Lesion Characteristics

According to the NCI-CTCAE V4.03v.4.03,1 alopecia is defined as “A disorder characterised by a decrease in density of hair, compared to normal, for a given individual at a given age and body location.” With targeted therapy, thinning hair is reported regularly, while partial alopecia is reported less frequently.

Grade 1 Alopecia

  • The NCI-CTCAE V4.03 definition of grade 1 alopecia reads: Hair loss of <50% of normal for that individual that is not obvious from a distance but only on close inspection; a different hair style may be required to cover the hair loss but it does not require a wig or hair piece to camouflage.
  • The MESTT definition of grade 1 alopecia reads: Terminal hair loss < 50% of normal for that individual, that may or may not be noticeable to others but is associated with increased shedding and overall feeling of less volume. May require different hair style to cover but does not require hairpiece to camouflage

Grade 2 Alopecia

  • The NCI-CTCAE V4.03 definition of grade 2 alopecia reads: Hair loss of ≥50% normal for that individual that is readily apparent to others; a wig or hair piece is necessary if the patient desires to completely camouflage the hair loss; associated with psychosocial impact.
  • The MESTT definition of grade 2A alopecia reads: Hair loss associated with marked increase in shedding and 50%-74% loss compared to normal for that individual. Hair loss is apparent to others, may be difficult to camouflage with change in hair style and may require hairpiece.
  • The MESTT definition of grade 2B alopecia reads: Marked loss of at least 75% hair compared to normal for that individual with inability to camouflage except with a full wig OR new cicatricial hair loss documented by biopsy that covers at least 5% scalp surface area. May impact on functioning in social, personal or professional situations.

Alopecia by grade

References

1National Cancer Institute Cancer Therapy Evaluation Program. Common Terminology Criteria for Adverse Events and Common Toxicity Criteria [v4.0]. 15-12-2010. (accessed 22 August 2014)
2McLellan B, Kerr H. Cutaneous toxicities of the multikinase inhibitors sorafenib and sunitinib. Dermatol Ther. 2011;24:396–400.
3Etienne G. Imatinib mesylate and gray hair. N Engl J Med. 2002; 347:446
4Segaert S, et al. Skin toxicities of targeted therapies. Eur J Cancer. 2009;45 Suppl 1:295-308.
5European Medicines Agency. Stivarga® (regorafenib) Summary of Product Characteristics 2013.
6Food and Drug Administration. Nexavar® (sorafenib) Prescribing Information 2013.
7European Medicines Agency. Nexavar® (sorafenib) Summary of Product Characteristics 2014.
8European Medicines Agency. Caprelsa® (vandetanib) Summary of Product Characteristics 2014.
9Food and Drug Administration. Caprelsa® (vandetanib) Prescribing Information 2014.
10European Medicines Agency. Sutent® (sunitinib) Summary of Product Characteristics 2014.
11European Medicines Agency. Glivec® (imatinib) Summary of Product Characteristics 2014.
12Food and Drug Administration. Gleevec® (imatinib) Prescribing Information 2013.
13European Medicines Agency. Sutent® (sunitinib) Summary of Product Characteristics 2014.
14Aparicio-Gallego G, et al. New insights into molecular mechanisms of sunitinib-associated side effects. Mol Cancer Ther. 2011;10:2215-2223.
15Multinational Association of Supportive Care in Cancer (MASCC) EGFR Inhibitor Skin Toxicity Tool (MESTT) (accessed 22 August 2014)
16Autier J, et al. Prospective study of the cutaneous adverse effects of sorafenib, a novel multikinase inhibitor. Arch Dermatol. 2008;144:886–892.
17Robert C, Mateus C, Spatz A. Dermatologic symptoms associated with the multikinase inhibitor sorafenib. J Am Acad Dermatol. 2009;60:299–305.

Last update: 22 August 2014