Expert consensus for prevention, diagnosis and management of persistent chemotherapy‐induced alopecia

BACKGROUND: Persistent chemotherapy-induced alopecia (pCIA) is a distressing side effect of antineoplastic agents, imposing significant psychological burdens on cancer survivors. Despite its impact, there are no standardized guidelines for diagnosis, prevention or management. OBJECTIVES: To establish consensus-based definitions, diagnostic criteria, grading systems and management recommendations for pCIA. METHODS: A two-round Delphi method was conducted with 15 international experts in supportive oncodermatology and hair diseases from both Europe and the Americas. Statements were rated on a 5-point Likert scale, with a strong consensus defined as ≥75% agreement. Statements that did not achieve strong consensus in the first round were revised based on expert feedback and re-evaluated in a second-round survey. RESULTS: Strong consensus was reached on 47 statements (75.8%). pCIA was defined as non-scarring alopecia persisting beyond 6 months post-chemotherapy. Causes were attributed to the destruction of hair follicle stem cells, with taxanes, thiotepa and anthracyclines identified as key contributors. Consensus emphasized the importance of prevention of pCIA through scalp cooling devices, and the early intervention with topical or low-dose oral minoxidil was also recommended. Interestingly, the experts did not recommend the use of bicalutamide, oral finasteride and dutasteride (including in mesotherapy) for breast cancer patients with pCIA, citing potential safety concerns. CONCLUSIONS: This Delphi study established unified guidelines for pCIA, providing clinicians with a clear framework for diagnosis and treatment. Highlighting prevention through scalp cooling and timely interventions may improve outcomes for cancer survivors. Further research is necessary to assess new treatments and the long-term impact of chemotherapy on hair follicles.