Hair loss is one of the more dreaded side effect of chemotherapy for cancer, but not all chemotherapy drugs have the same effect. Some medications almost always result in hair loss, whereas others cause minimal hair loss. We will look at the particular drugs most likely to cause hair loss (alopecia), but there are other factors that can affect hair loss as well, such as the dose of the drug, the timing of administration, and the combination of drugs you receive. Fortunately, there are options available to help people cope with this symptom, ranging from a wide array of hats, wigs, and scarves, to the relatively recent approach of using cooling to attempt to prevent hair loss partially or completely.

In addition to chemotherapy, some targeted therapies and hormonal therapies for cancer can cause hair changes as well, such as thinning, curling, and dryness.

Hair Loss From Chemotherapy

Hair loss is very common during chemotherapy for breast cancer as well as other cancers, though some drugs and methods of administration are more likely than others to disrupt hair follicles.

Why it Happens

Chemotherapy drugs work systemically (throughout the body) by interfering with the division and growth of rapidly growing cells. While these drugs can be effective in eliminating cancer cells, they also damage normal cells in our bodies which divide rapidly. This includes hair follicles (leading to hair loss), cells in the digestive tract (leading to nausea and vomiting), and cells in your bone marrow (leading to fewer red blood cells, white blood cells, and platelets).

Factors That Affect Whether Hair Loss Will Occur

Whether or not you develop hair loss and the degree of your hair loss depends on a number of factors including:

Dose of chemotherapy
How often the chemotherapy is given
The route of administration
The drugs or combination of drugs you receive
Your individual makeup: Some people are more likely to lose hair than others, even with the same doses of the same drugs

Timing of Hair Loss

Hair loss often begins around the time of your second chemotherapy infusion, though this varies widely. It may start slowly, but increases rapidly around 1 month to 2 months after starting treatment. Some people do not lose all of their hair until they have nearly completed chemotherapy. Hair re-growth typically begins within 3 months of concluding chemotherapy. When your hair does grow back, many people find they have what's been coined chemo curls. If your hair was straight prior to chemotherapy it will likely become straight again, but this process can take up to several years.

Permanent vs Temporary Hair Loss

The good news is that chemotherapy-induced hair loss is almost always temporary and reversible, though there have been a few rare exceptions.

Some women with breast cancer have developed permanent hair loss following a combination of taxanes (such as Taxol or Taxotere) and hormonal therapy, though this is rare. There have also been a few reported cases of permanent and severe hair loss in women with breast cancer who have received a combination of FEC (fluorouracil/epirubicin/cyclophosphamide) with docetaxel.

Some techniques have been tried to prevent or reduce hair loss (see below).

Which Chemotherapy Drugs Cause Hair Loss?

There are a number of chemotherapy agents used in breast cancer—many of them used in combination. Common regimens for adjuvant treatment such as Cytoxan and Adriamycin followed by Taxol are usually associated with hair loss.

Here is a list of chemotherapy drugs—not exclusive to breast cancer—that are most and least likely to cause hair loss.

Chemotherapy Drugs Most Likely to Cause Hair Loss

Chemotherapy medications which cause hair loss, or at least significant hair thinning in the majority of people include:

Adriamycin (doxorubicin)
Cytoxan or Neosar (cyclophosphamide)
Taxol (paclitaxel)
Taxotere (docetaxel)
Cerubine (daunorubicin)
Ellence (epirubicin)
VePesid (etoposide)
Hexalen (altretamine)
Idamycin (idarubicin)
Ifex (ifosfamide)
Ixempra (exabepilone)
Camptosar (irinotecan)
Hycamtin (topotecan)
Navelbine (vinorelbine)
Ixempra (Ixabepilone)
Vincristine (vinorelbine)

Chemotherapy Drugs That Sometimes Cause Hair Loss

Chemotherapy medications which cause hair loss for some but not all people include:

Blenoxane (bleomycin)
Myleran or Busulfex (busulphan)
Cytosar-U (cytarabine)
5-FU, Fluorouracil, Adrucil (5-fluorouracil)
Gemzar (gemcitabine)
Gleostine (lomustine)
Alkeran (melphalan)
Thioplex (thiootepa)
Velban (vinblastine)
Oncovin (vincristine)

Chemotherapy Drugs That Rarely Cause Hair Loss

Some chemotherapy drugs result in only minimal hair loss, though these are often combined with drugs that cause more hair loss. These include:

Paraplatin (carboplatin)
Xeloda (capecitabine)
Gliadel (carmustine)
Platinol (cisplatin)
Fludara or Oforta (vludarabine)
Trexall, Otrexup, Rasuvo (methotrexate)
Mutamicin (mitomycin C)
Novantrone (mitroxantrone)
Procarbazine (sold by generic name in US)
Purinethol (6-mercaptopurine)
Zanosar (streptozotocin)

Targeted Therapies and Hair Loss

The newer targeted therapies for cancer don't usually cause total hair loss like chemotherapy drugs, but can result in changes such as thinning of the hair and dryness, as well as changes in texture similar to the chemo curls noted above. Some targeted therapies may also affect the pigmentation of hair, often causing the hair to become darker.

Some of the targeted therapies that have been linked with hair changes include:

Erbitux (cetuximab)
Erivedge (vismodegib)
Gilotrif (afatinib)
Gleevec (imatinib)
Ibrance (palbociclib)
Imbruvica (ibrutinib)
Kisqali (ribociclib)
Mekinist (trametinib)
Nexavar (sorafenib)
Sprycel (dasatinib)
Tafinlar (dabrafenib)
Tarceva (erlotinib)
Tasigna (nilotinib)
Zelboraf (vemurafenib)

Hormonal Therapies and Hair Loss

Some of the hormonal therapies commonly used for breast cancer have been associated with thinning of the hair for some people. Unlike chemotherapy, people may be using the drug for many months or even years before they notice the changes in their hair. Hormonal therapies more often linked to hair loss include:

Tamoxifen
Aromatase inhibitors: Hair loss appears to be more common with Arimidex (anastrozole), and Femara (letrozole) than with Aromasin (exemestane)
Faslodex (fulvestrant)
Octreotide (sandostatin)

Other Drugs and Conditions That Cause Hair Loss

Immunotherapy drugs for cancer, at least checkpoint inhibitors, do not usually cause hair loss, though often times these drugs are used along with chemotherapy. In fact, researchers are currently looking at ways of harnessing the gene involved in autoimmune alopecia (hair loss such as with alopecia areata) to look for ways of improving the effectiveness of chemotherapy.

There are a number of non-cancer related medications that are associated with hair loss, that might accentuate the effects of chemotherapy drugs if used in combination. Some of these include retinoids (such as Accutane), anti-thyroid medications, L-Dopa (levodopa), amphetamines, non-steroidal anti-inflammatory medications, and several antidepressants such as tricyclic antidepressants and Wellbutrin (bupropion).

In addition to medications, illness, surgery, or dietary changes (low protein diets or very low calorie diets) may lead to hair loss. Thyroid disease (either hypothyroidism or hyperthyroidism) may cause hair loss, and may occur with cancer treatment (such as chemotherapy-induced hyperthyroidism or hypothyroidism which is very common with immunotherapy).

Preventing Chemotherapy-Induced Hair Loss

For those who are interested, it may sometimes be possible to prevent hair loss from chemotherapy.

Scalp cooling units can reduce roughly 50 percent of hair loss, but comes with a price. Many infusion centers do not have these units and therefore you may have to rent a cooling device, and depending on the device, this can be fairly pricey.

Scalp cooling (referred to as scalp cryotherapy) works by narrowing the blood vessels in the scalp so that chemotherapy drugs are less able to reach hair follicles. With some cancers, especially blood-related cancers like leukemia and lymphomas, there has been concern that cooling could reduce the effectiveness of chemotherapy. While it's not likely to be a problem with breast cancer, scalp cooling can be very uncomfortable, similar to the symptoms of brain freeze you may remember while eating ice cream in the past.

Medications such as Rogaine (minoxidil) have also been tried, but are not very effective in reducing hair loss.

Care to Reduce Hair Loss

When hair loss is not complete or when it begins to regrow, taking good care of your hair can reduce further loss. Measures that can make a difference include:

Avoiding hair dryers: If you need to blow dry your hair, choose a cool setting even though it takes longer to dry.
Avoid chemical coloring or straightening products
Avoid hair curlers: For those who like a little curl, heated rollers might give the same result but with much less damage.
Choose a soft pillowcase that provides little friction that could rub off tender hair
Use a gentle shampoo and try to skip days between hair washes
Avoid brushing your hair when wet or vigorously drying your hair with a towel. Some brushes such as a "wet brush" may help remove snarls if you need to brush wet, but with less hair loss. Using a good conditioner may help as well.

Handling Hair Loss From Chemotherapy

It can be very emotional coping with the hair loss you experience during chemotherapy. Even though this complication is more of a nuisance, it remains one of the most feared side effects. Many oncologists recommend that you purchase a wig, hats, or scarves before beginning chemotherapy. All or a portion of the cost of a wig may be covered by your insurance. To have it covered, however, you will need to have your oncologist write a prescription for a "hair prosthesis."

Before you go, you may want to check out the basics for buying a chemotherapy wig. There are also organizations that provide free wigs, hats, or scarves for people living with cancer.

It's important to keep in mind that hair loss may occur all over your body. This includes eyelashes, eyebrows, pubic hair, and more. While women may appreciate a reprieve from shaving their legs (and men, their faces), our eyelashes perform a protective function you may not realize until you open an oven door or are outside on a dusty day. Check out these 6 ways to prepare for hair loss from chemotherapy.

A Word From Verywell

Many chemotherapy drugs result in hair loss, including those used for breast cancer. Some people choose scalp cooling as a way to reduce hair loss whereas others prefer the comfort of a warm head and planning ahead with a scarf or wig. The preference is very personal and it's important that you do what is best for you alone. Fortunately, most hair loss is temporary and many women find that their hair grows back even healthier than before.