Hair Shaft Alteration in Children Undergoing Chemotherapy

Reti Anggraeni, Ardelia Dyah Ayu, M. Eko Irawanto, Suci Widhiati, Muhammad Riza

Faculty of Medicine Sebelas Maret University/ Dr. Moewardi General Hospital, Surakarta

Keywords: alteration, chemotherapy, hair shaft

Abstract: Hairs have no vital function but it may use as an indicator for the human’s health. Hair shaft is a unique

structure which composed of inner cortex and protective outer cuticle. Hair shaft disorders may be inherited

or acquired, as in a local or systemic disease. One of the acquired causals is chemotherapy. Chemotherapy

agent can damage the structure or morphology of the hair including hair shaft pattern. Cross sectional

analytical study was conducted in Dr. Moewardi General Hospital Surakarta. Forty five subjects, aged 1-14

years old were enrolled. The study subjects (n=30) were pediatric patients undergoing chemotherapy, the

control group (n=15) comprised of children who never had chemotherapy. Of the 30 subjects from study

group, 27 (90%) had altered hair shaft. Two (13.3%) of fifteen children in control group had hair shaft

alteration. Statistical analysis using Mann-Whitney U Test obtained p=0.000 which means there was a

significant different between incidents of hair shaft alteration between children undergoing chemotherapy and

children never had chemotherapy. Further study is needed to describe more about the most common group of

chemotherapeutic agents which cause the alteration and the relation between the type of cancer and hair shaft

alteration.

1 INTRODUCTION

Humans have over 2 million hair follicles, which may

have significant positive and negative influences on

skin health.(McElwee and Sinclair, 2008) The hair

shaft is protected by the cuticle layer with its

overlapping cells which resemble shingle on its roof.

If there is damage in cuticle, the exposed hair cortex

is still bonded but it is more susceptible to

environmental damages and fractures.(yu et al., 2006;

Mirmirani et al., 2011)

The most common treatment performed for cancer

is chemotherapy. It has adverse side effects to healthy

tissue and organs including the hair. It affects the hair

in two mainly parts, the hair growth and the hair shaft.

About 65% of patients undergoing chemotherapy will

get chemotherapy-induced hair loss (chemotherapy-

induced alopecia), known as anagen effluvium, which

is usually reversible when the therapy ends.(Trüeb,

2010)

Chemotherapy may also affect the structure and

morphology of the hair leading to the damage of the

hair follicle and later causing hair shaft

alteration.(Lindner et al., 2012) The alteration of hair

shaft reveals in many patterns caused by diminishing

of the follicle function, such as fractured hairs,

narrowings (the most common is Pohl-pinkus

constriction), node-like appearance, curls and twist

hairs, short hairs and disorders on the band hair.

There have been many studies about anagen

effluvium due to chemotherapy agent but there are

only a few studies about hair shaft alteration.

Therefore we performed this study to reveal whether

chemotherapy may cause the hair shaft alteration.

Thus when we have patients undergoing

chemotherapy, especially with altered hair, we can

give more education supports. As it would be a

psychologically problem leading to negative impact

on their perceptions of appearance.

2 METHODS

Cross sectional analytical study was conducted in

pediatric ward of Dr. Moewardi General Hospital

Surakarta between December 2017 and January 2018.

Forty five subjects, aged 1-14 years old were enrolled

in our study by using consecutive sampling method.

The study subjects (n=30) were pediatric patients

undergoing chemotherapy and the control group

(n=15) comprised of children who never had

chemotherapy. Each subject’s scalp was

104

Anggraeni, R., Ayu, A., Irawanto, M., Widhiati, S. and Riza, M.

Hair Shaft Alteration in Children Undergoing Chemotherapy.

DOI: 10.5220/0008151801040107

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 104-107

ISBN: 978-989-758-494-7

photographed by using dermoscope, 20 hairs were

removed, put under object glass and examined under

microscope. The photograph and microscopic

features were interpreted by three observers.

3 RESULTS

Of the 30 study subjects, there were 27 (90%) had hair

shaft alteration whereas the control group 2 (13.3%)

of 15 subjects experienced altered hair shaft (Figure

1).

Figure 1. The percentage of the hair alteration of the

enrolled subjects

Table 1. The hair shaft alteration of study subject compared

to control group

Total

Percentage

(%)

Study Subject

(n=30)

Altered 27 90

No-

alteration 3 10

Control (n=15)

Altered 2 13.3

No-

alteration 13 86.7

This present study used Mann-Whitney U Test

(p=0.000) which revealed that there was a significant

difference of hair shaft alteration between children

undergoing chemotherapy and children never had

chemotherapy.

The demographic characteristic (Table 2)

obtained that the diagnosis of acute lymphoblastic

leukemia (ALL) was the most common cancer (30%,

n=9) followed by osteosarcoma (16.8%, n=5). The

chemotherapy agents was varied, used as a single or

combination therapy. The most chemotherapy agent

combination used was methotrexate and vincristine

(36.8%, n=11) while the single therapy was mostly

cyclophosphamide (10%, n=3).

Of the 27 altered hair shaft subjects, there were

many patterns with the most common pattern was

Pohl-pinkus (n=9) followed by hair cast node-like

appearance (n=3) (Figure 2).

4 DISCUSSION

The hair consist of two distinct structures, the hair

follicle, the living part located under the skin, and the

hair shaft which is fully keratinized nonliving part

above the skin surface. The follicle is the essential

growth structure of the hair and basically has two

main parts, upper part consists of infundibulum and

isthmus whereas the lower part comprise of hair bulb

and suprabulbar region.(Berker et al., 2012) The hair

shaft has three layers: cuticle, cortex and

medulla.(Berker et al., 2012; McElwee and Sinclair,

2008) Hair has no essential function but if there is a

damage it leads to hair loss or even the alteration of

hair shaft. The individual will have a psychosocial

problem related to his/ her physical performance.

Table 2. Demographic characteristics of study subjects

Total

(n=30)

Percenta

(%)

Age (year)

0 – 5 14 46.7

6 – 11 12 40

12 – 17 4 13.3

Diagnosis

Acute

Lymphoblastic

Leukemia 9 30

Osteosarcoma 5 16.8

Acute Myeloid 3 10

Rhabdomyosarko

ma 2 6.7

Trombositopenia 2 6.7

Systemic Lupus

Erythematosus 2 6.7

Nephtiris Lupus 1 3.3

Retinoblastoma 1 3.3

Nephroblastoma 1 3.3

Pheochromocyto

ma 1 3.3

Genu Cell Tumor 1 3.3

Carcinoma Testis 1 3.3

Nephrotic

Syndrome 1 3.3

Hair Shaft Alteration in Children Undergoing Chemotherapy

105

Chemotherapy Agent

Methotrexate +

vincristine 11 36.8

Etoposide +

carboplatin 8 26.7

Cyclophosphamid

e 3 10

Doxorubicin +

vincristine +

cyclophosphamid

e 2 6.7

Ifosfamide +

etoposide 1 3.3

Cyclophosphamid

e +

metilprednisolone 1 3.3

Methotrexate +

doxorubicin 1 3.3

Etoposide +

bleomycine +

vincristine 1 3.3

Cisplatin +

bleomycine +

vincristine 1 3.3

Vincristine 1 3.3

One of the causal factors for hair disorder is

chemotherapy which is the most common treatment

for cancer. The chemotherapeutic agents either use as

single or combination regimen may damage the

follicle function of the hair which later will destroy

the growth of the hair shaft appearing to the skin

surface. Firstly hair loss which can be seen within

days to weeks of the initiation of chemotherapy and

complete loss occurs in 3 months later. In 60% cases

after the hair loss, patients experiencing differences

in hair color, alteration in thickness, texture or

waviness of their regrowth hair in 1 to 3 months after

chemotherapy ends.(Kanwar and Narang, 2013;

Kanti et al., 2014)

Figure 2. The varieties of hair shaft patterns of the 27

altered hair shaft subjects

The alteration of the hair after hair loss occurs the

shape of the hair shaft. As the hair follicle is

surrounded by dense of capillaries network, growing

hair is sensitive to metabolic imbalances resulted

from internal disease, local inflammation or drug-side

effects.(Rogers, 1995; Tosti and Pazzaglia, 2007)

This remains unclear why chemotherapy agents may

lead to the alteration of hair shaft.(Trüeb, 2010)

The hair shaft alteration reveals in many patterns

consisting of fractured hairs (trichoptilosis,

trichoschisis or trichoclasis, broken (fractured) hairs

and golf tee hairs), narrowings (monilethrix,

monilethrix-like congenital hypotrichosis,

monilethrix-like hairs or Pohl-pinkus constriction,

pseudomonilethrix, exclamation mark hairs and

tapered hairs), node-like appearance (trichonodosis,

trichorrhexis nodosa, trichorrhexis invaginata and

hair casts), curls and twist hairs (pigtail, coiled,

comma, corkscrew, zigzag, pili torti and wooly hairs),

short hairs (upright regrowing, vellus hairs, dark

lines, tulip hairs, block hairs, i-hairs, broom hairs,

broom fibers and flame hairs) and disorders on the

band hair (continuous or interrupted medulla, pilli

annulati, and interrupted hairs).(Itin and Fistarol,

2005; Tosti and Piraccini, 2006; Rudnicka et al.,

2012) The most common alteration is Pohl-pinkus

constriction in which its morphological change

occurs in the hair roots.(Williamson and de Berker,

2005) De Berker et al stated that the monilethrix

pattern caused by cortical defect resulting in a

disorientation of the fibrils which lie along the

cortical cells.(Rogers, 1995) Another study by Ito et

al suggests that the basic cause of the monilethrix

alteration is malfunction of the germinative cells of

the hair matrix leading to abnormalities affecting the

cuticle, internal sheath and mostly affects the

cortex.(Ito et al., 1990) There is an intermediate state

whereas the follicle function decreases but does not

stop the hair fibre production, therefore there is a

short span along the hair of diminished

bore.(Williamson and de Berker, 2005)

In the present study, we found that there was 27

(90%, total n=30) in study subjects got hair shaft

alteration and only 2 (13.3%, total n=15) in the

control group had altered, as it is seen by the result of

Mann-Whitney test with p<0.05 (p=0.000) which

means that there was a significant difference of hair

shaft alteration between children undergoing

chemotherapy and children never had chemotherapy.

Of the 27 study subjects who had altered, there was

many varieties of patterns. The most common pattern

was Pohl-pinkus constriction (n=9), followed by

node-like appearance hair cast (n=3) and Pohl-pinkus

constriction combined with node-like appearance hair

cast (n=3).

A further study is required to determine the most

common group of chemotherapeutic agents which

may cause hair shaft alteration and the relation

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

106

between the type of cancer and the hair shaft

alteration.

5 CONCLUSIONS

Children undergoing chemotherapy experienced a

significant hair shaft alteration. This suggest that

chemotherapy may damage the hair structure leading

to the alteration of hair shaft. The most common

pattern of the hair shaft alteration in our study was

Pohl-pinkus constriction.

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