Managing Hair Loss and Wearing a Wig With Confidence

Dr. Marisa Weiss: Hello, everyone. I'm Dr. Marisa Weiss. Thank you all for joining us to talk about coping with hair loss during and after breast cancer treatment, a very personal treatment side effect that everyone handles differently. Hair loss is a potential side effect of some treatments, including chemotherapy, of course, as well as targeted treatments like immunotherapy and hormonal therapy, all those medicines like tamoxifen and Arimidex, aromatase inhibitors, things like that. Radiation to the brain can cause hair loss as well, and it can be temporary or could be permanent in some cases.

For those of you concerned about how to manage hair loss related to treatment, we hope that we can help you better understand your options. Losing your hair during cancer treatment can make you feel vulnerable, self-conscious, and exposed as a cancer patient. Full hair loss is immediately visible, which can make you look so different and feel embarrassed and make you feel angry and depressed, resulting in lower self-esteem, feeling unattractive, and making you feel like you've got to hide from everybody, causing more social isolation. And you may be faced with questions from others that you're really not ready to deal with yet.

Taking part in webinars like this one, talking to a mental health expert, and joining a support group can help people cope with the urge to hide, which can cause stress, and some people find it helpful to speak with their doctor about therapy or medications for treating depression or anxiety related to hair loss. Bottom line, hair loss can be stressful, and the goal is to reduce your stress and keep your immune system and you feeling strong. Finding ways to manage the stress of hair loss in addition to therapy, support groups, eating well, getting enough sleep are so important, and there are communities like the one at Breastcancer.org to help you manage this side effect and feel less alone.

Before we welcome our featured speakers, I want to thank wigs.com for their long-term support of Breastcancer.org, including making today's event possible. We are honored to be joined by an excellent group of hair loss experts.

Dr. Mario Lacouture, a professor and the director of the Oncodermatology Program in the Dermatology Service, Department of Medicine at Memorial Sloan Kettering Cancer Center in New York.

Alicia Giglio is the chief experience officer for wigs.com. She'll be talking about finding and wearing a wig, and she'll answer some of the commonly asked questions.

Tirzah Cooper is a breast cancer advocate. Tirzah was 36 years old when she was diagnosed with stage 2 breast cancer, and she'll be sharing a bit about her journey with us today.

Thank you all for being here. Now it's my pleasure to introduce Dr. Mario Lacouture. Dr. Lacouture received his MD degree from Javeriana University in Bogota, Colombia where he grew up. He began his career in oncodermatology at the University of Chicago. And during his first faculty appointment at Northwestern University, Dr. Lacouture established the first clinical program focused on the dermatologic care in cancer patients and survivors since hair loss really falls within dermatology. During this time, he initiated the first clinical trials in oncodermatology and described mechanisms and treatments on adverse events to novel cancer therapies.

In 2012, CancerCare named Dr. Lacouture as Physician of the Year for his contributions to the education of people living with cancer. And he has been selected as a top doctor in America and New York by Castle Connolly and the New York Magazine each year since 2014. And he's published over 280 articles in peer-reviewed journals as the author of "Dr. Lacouture's Skincare Guide for People Living With Cancer."

Dr. Lacouture, I want to start by first thanking you for your commitment to this area of medicine that is so needed, and I'm going to start by asking you which cancer treatments can most often lead to hair loss or hair thinning, and why?

Dr. Mario Lacouture: Thank you, Dr. Weiss. It's great to be here with you, the rest of the Breastcancer.org team, and the wonderful people today in the audience. In terms of which cancer treatments cause more hair loss or cause hair loss and why, I would like to start by saying that what I like to tell my patients is any cancer treatment can cause hair thinning or hair loss. It's important to recognize that because one of the worst things that can happen is for things to take you by surprise and hear that, "Oh, no. This drug doesn't cause hair loss." No, any drug can cause some degree of hair thinning or hair loss. It's also important to recognize that the concept of hair thinning or hair loss is very personal. For some people, just a little bit of hair thinning would feel very severe, very impactful, and, for other people, losing most of their hair is not problematic. So that's why I like to say that because people need to be prepared.

In terms of what the studies have shown, of course, the conventional chemotherapies, Adriamycin and cyclophosphamide, of course can cause a lot of hair loss. Taxanes are also well known for causing significant hair loss. But other drugs, as you mentioned previously, that are used for 5 to 10 years, like tamoxifen or the aromatase inhibitors, letrozole, anastrozole, or exemestane, for example, can also cause hair thinning. I can tell you though that about a third of the people that I see every day are people that have, not hair loss, but hair thinning on these aromatase inhibitors or tamoxifen, or that have already had chemotherapy and their hair did not fully regrow, which is also a big problem because people were not expecting this.

In addition to that, since we're in the topic of breast cancer, of course, the CDK4 inhibitors, palbociclib, abemaciclib, ribociclib, they really are amazing drugs, can cause hair thinning that can be very impactful for people. It is important to recognize that studies have shown, and we did one of these studies where we administer a questionnaire to patients that had lost all of their hair and that only had hair thinning, and the impact on the quality of life of hair thinning was as impactful as complete hair loss. So-

Dr. Marisa Weiss: Wow, that's saying a lot. I've seen the studies that show that losing your hair from chemotherapy is actually more devastating than the loss of a breast from mastectomy because it's so visible and it threatens your privacy and just makes... you don't look like yourself, you don't look normal. It's upsetting to everyone in your family, young children at home, and everyone wants mom to look normal and everyone to look like they usually look. Having your hair stolen from you is very upsetting.

Dr. Mario Lacouture: Yes, yes. In fact, you have said it correctly, it's not only an appearance issue, it could be a matter of wellbeing at home. I see many mothers who have young children or young family members or other family members, so they don't want them to worry so much about them because they feel like losing their hair is an indication that they have a condition that may not be treatable. And also, in the workplace, right? Unfortunately, our society places a lot of emphasis on this, so it can become, as one of my greatest mentors, we were speaking about before, who's a breast oncologist said, could be a matter of survival. If a person is working and feeding their families and, because of their appearance, cannot get that job, then it could be even a matter of survival for this.

Dr. Marisa Weiss: Right. And also, another way in which hair loss can impact survival is that people might decide not to have curative chemotherapy because of concern of fear of hair loss. And it might be a reason why they just sort of disappear and just avoid the whole thing rather than step forward and learn what they need to know about how to get the best treatment possible and manage the side effect of hair loss. And of course, growing older or going through a hormonal life transition can cause hair loss. So we have young people, let's say, going through breast cancer. Let's just say they've had a pregnancy, they had a hair loss from pregnancy, and then they have a breast cancer diagnosis and experienced treatment that leads to hair loss. You can get a double whammy from a life hormonal transition as well as just growing older, right?

Dr. Mario Lacouture: Yes, yes. To me, this is one of the most remarkable things about breast cancer survivors is that, contrary to what most people think, it's not even incurable disease. It's not a short treatment. I mean, people are on these treatments for chemotherapy for nine months. And then some may be on these adjuvant therapies, the hormonal therapies 5 to 10 years. So now, they have to deal with these issues for that amount of time. So of course, we are all getting older, but keep in mind that chemotherapy has been shown in studies to age us about 10 to 15 years. So therefore, any inhibition of estrogen or even the administration of chemotherapy is going to slow down the hair follicle. So that's why I like to tell everyone that I see when they are on active chemo, "We will talk when you're finished with chemo, so we can do things to stimulate the hair to grow more quickly, and for you to be back to what you were before."

Dr. Marisa Weiss: Right. I have this story, I went through breast cancer myself 13 years ago. For seven and a half years, I took tamoxifen and then an aromatase inhibitor. And even though I didn't go through chemo and I didn't have complete hair loss, I'd be just like, "Whoa, what's going on here?"-- in the sink, in the bottom of the shower, it was very upsetting. I went out to dinner one time with a bunch of women I knew from a Zumba class, and I was the only breast cancer survivor there. Yet, five out of the six of us were using minoxidil just to try to slow the loss down. And it was interesting to me because none of them had breast cancer, but they had age-related hair thinning, and they were using it to manage that part of growing older.

Dr. Mario Lacouture: Right.

Dr. Marisa Weiss: Yeah. Now, let me ask you another question. Besides the hair on your head, which we've been talking about, what body hair in other parts come out, and in what order does it happen? How do you know what to expect in terms of hair loss? What's going to come out first, next? And then how can you just be more in control by knowing what to expect?

Dr. Mario Lacouture: Yes, yes. No, that's a great question because usually people can be taken by surprise, for example, when their eyelashes and eyebrows start falling off. What we do know is that, for most people that are receiving the conventional AC and Taxol or Taxotere, that kind of chemotherapy, the hair on the scalp is the first part to fall, of course. But then, after they complete chemo, about two to three months later is when the eyebrows and eyelashes start falling off. Hair in the body is also... pubic hair and axillary hair can also fall off during the chemo, but it's this late loss of the eyebrows and eyelashes that can take a lot of people by surprise. The reason for that is because, in the scalp, 90% of our hair follicles are in the growth phase, so they are actively growing. So when we receive chemo, those hairs are affected the most. As opposed to hairs in the brows and the lashes, most of them are in the resting phase, so they are not as sensitive to chemo.

But then, that cumulative effect of the chemo and the effects that it has, if we think about it, our entire bodies... I mean, they're affecting our white blood cells, our red blood cells. In other words, the oxygen that gets to our skin and our hairs is affected. What I like to tell my patients is, "Your body has gone through a lot."

Dr. Marisa Weiss: A lot.

Dr. Mario Lacouture: A lot of stress and attack from medication. So even if you had not received chemotherapy, just the mere fact that your body has received that stressful event, that can cause temporary hair loss. So those fall off, but then the eyebrows and eyelashes recover. And then three months after you finish chemo is when you start seeing the hair grow back. Keep in mind that hair grows about a half an inch a month.

Dr. Marisa Weiss: Okay, that's good to know. That's good to know. In my clinical work -- I'm a radiation oncologist -- so I see people right around the time that they lose their eyebrows and eyelashes. But at least when the eyelashes are lost, it's the new eyelashes that are sort of coming in right after, and you'll feel a little bristle along that area that the new eyelashes will come in. And it is one of those things that you would like to know about. Maybe you were told, but you were told about so many things at once. It was overwhelming. And when you feel overwhelmed and anxious and confused, it's hard to remember anything. So even if you knew it upfront, it's important to learn about it again because it's hard to remember things that you really didn't commit very well to memory because you were so overwhelmed.

Some people choose to cut their hair short or buzz their heads rather than experiencing the hair loss that can come from chemo. The buzzing of your head, that's a big step, and it can be both bold and uncomfortable. And for anyone who wants to proactively cut their hair before the chemo makes it fall out, how much time do they have to do it?

Dr. Mario Lacouture: Oh, yes. This is very important because studies have shown, Dr. Weiss, that when people cut their hair before they start losing it and seeing it down in the drain and the shower and the pillow is less impactful. So psychologically, to be prepared for this, cutting the hair would be preferable if one is not using any treatments to prevent hair loss, like the scalp cooling devices that may be available in your area. From the time of diagnosis, the time of chemo, it takes about two to three to four weeks from the first chemotherapy. I would say that you will not lose hair after the second cycle of chemotherapy, so another three weeks or so, two to three weeks. So you have about a month to prepare. What I have heard, because I have not experienced this personally, is that when you arrange for it and becomes like a celebration with friends and family, it's actually much better tolerated or received by people.

Dr. Marisa Weiss: Right. It's like finding your inner Barbie. You're trying to feel more in control of things and make it more of a shared experience. And I'm sure that you've got people in your life or that you may not have even thought about or maybe who have volunteered already who want to help you through it, and that's one thing that they could do to help you through it. And if you don't know people like that, then anybody who's had cancer and who's been through it before would want to help you. Ask your doctor if there are people that can help you through that type of experience, if that's your choice, because everyone is different, as we've said this evening.

Now, let's talk about ways that people can reduce their hair loss. And you mentioned about the cooling cap systems, the cold caps. It can be done with a machine or the manual ones that you have in an ice, on liquid nitrogen, I mean, that would be CO2. And then you change them up throughout, before and during and then after chemo. Why don't you tell us how those things work and how well do they work, and what are the barriers to utilizing those technologies?

Dr. Mario Lacouture: Sure. So this is something that's very important because it really can change the way that people approach chemotherapy, as it has shown to be beneficial in about half to two thirds of people. So what is this whole concept of scalp cooling? Well, the concept is that, during your chemotherapy, starting half an hour before and then an hour to an hour and a half after, on your scalp, you are wearing this gel or this device that is very cold because it either has been frozen as you said or because it's connected to this refrigerator-like device that circulates a very cold liquid into your scalp. What that does, it will shrink the blood vessels in your scalp. Think of what happens when you go out on a very cold night, your fingers get very cold, right? And also, it reduces the metabolism of hair follicle cells.

One way to remember that is think what happens when they transplant organs, for example, and they transfer them in an ice box. So cold makes tissue survive more. So by doing that, what has been found, and this has been published in major medical journals like the Journal of the American Medical Association, is that up to half to two thirds of people that undergo this treatment will retain the majority of their hair and they will not need any camouflaging method like a wig or a turban or a hat. So they are effective in about at least half. There are some limitations however. There are some treatments for... it may not work as well, but it still works. So what I like to tell people, and people are very grateful about this, is, "Even if you think it's not going to work with your particular type, at least try it a few times." So at least you feel, like you said before, that there is that sense, Dr. Weiss, of having control. "Okay, you tried it, and at least you gave it a shot. Whether it did or did not work..."

Because we have been very surprised to see some groups of patients in which it was not supposed to work to actually work. Now, that comes to the limitation, right? What are the limitations is that they may not be accessible everywhere. So I would encourage you to consult your local oncologist to see if they offer them, and also cost. I know that cost can be a barrier. There are some organizations that provide financial support, and I know that, increasingly, insurance companies are actually covering this. So it's important to discuss this with your care team prior to starting.

Dr. Marisa Weiss: Absolutely, and it's one of these things, you have to use it from the beginning. Because I have a patient who had one cycle of Adriamycin and Cytoxan, and then she looked into the cold caps after, but it was too late. She'd already lost her hair. Maybe it would help her recover her hair long faster if she used the cold caps from that point onward. That would be maybe a possible benefit. But to get the full potential benefit, you need to do it from the beginning.

Dr. Mario Lacouture: Yes, but when you... Oh, sorry.

Dr. Marisa Weiss: Go ahead.

Dr. Mario Lacouture: No, you brought a very important point. There was a study from Spain that showed that people who use the scalp cooling device, none of those people had that persistent or prolonged hair loss. So what you bring up is... Even if you have hair thinning, I tell people exactly that, "It's better that you did it than if you didn't do it because your hair will recover more quickly, and the risk of having that permanent hair loss is almost zero."

Dr. Marisa Weiss: Right, and permanent hair loss is rare, but it can happen. And there's certain medicines like Taxol where it's more likely to happen to a particular individual who may be sensitive to Taxol. Not only is hair loss so personal in terms of the burden of this side effect, but it's also very personal in terms of how much these various treatments affect you and your body, including your scalp. So there's only one you, and you want to make sure that you get your best chance to try to prevent it, if at all possible. Now, some of the facilities have these machines that you sit under, sort of like a hairdryer but it's to your head in terms of what it looks like from the outside. As Dr. Lacouture described, it's like this tight gel pack all over your head that's very cold.

But there are other places that may not have invested in that technology, in which case, you might need to get hooked up with a cold cap system where you rent the cold caps, they go on dry ice, and you often need people to help you do it. You can't just do it on your own. You're there getting your treatment, right? So someone's going to have to help you switch out one cap every 20 or so minutes, and you can hire a trained... they're called cappers, or you can train someone in your life, a friend, a family member to help you do that. So there's a lot you can learn about this at Breastcancer.org. I know, at Breastcancer.org, anybody who's done this, who's on, is always happy to help advise you on how to coordinate a team and how to ask for help.

As we move through life, we're not used to asking for help, we're the ones who are giving all the help. But this is a time when you might need to ask, and you might also need to get pushy. So when it comes to the insurance companies and getting it covered, this is a side effect of the treatment that you require, therefore, they should cover the solution to the side effect, which, in this case, we're talking about trying to prevent or reduce the amount of hair that you'll lose. I remember when I met you years ago, Dr. Lacouture, you told me, if I remember this correctly, that, "You, yourself, each person is so sensitive to how much hair they lose. But you can lose a lot of hair before anyone else notices it." And I think he's told me that, "You can lose actually up to 50% of your volume before anyone really notices that you've lost your hair," because you still can have the appearance of having a full head of hair, even if it's a lot thinner than you used to have, than your hair used to be.

Dr. Mario Lacouture: That's right. That's right. That's what the studies in dermatology have shown is that you need to lose more than 50% or half of your hair for other people to notice it. But the more that I have been doing this, I've now been seeing people for hair thinning or loss from therapies for 15 years, I noticed that people are still upset about it even if it's a 10% difference, I would say. We have a device that allows us to measure how many hairs are on the scalp and how thick they are. So it gives us a number, which is much more objective than just looking.

Dr. Marisa Weiss: Right, and that's so important. It helps you know or track how much you have lost. But if you try to start some of the therapies that we'll talk about in a moment, it'll also help you know if the hair loss has slowed down or stop and if you are growing more hair back, and we'll get to that. Of course, everyone wants to know the answers to that. My next question, which is on everyone's mind, is when does the hair come back on the head and other parts of the body? And what is the new hair like compared to your natural hair that you had before your hair fell out?

Dr. Mario Lacouture: And that's something that it's important to be prepared for. So currently, we are doing a study here in which we are following 500 people that underwent breast cancer treatments and taking photos every six months and asking questions about their hair every six months. One of the things we have found is that about three to six months within the completion of the last chemotherapy is when your hair starts coming back. The opposite is true for endocrine therapies. When people start having hair thinning or loss from tamoxifen or aromatase inhibitors, it happens not immediately, like with chemotherapy, but it happens at about month three, six. Even a year later, we start noticing this because it's a much more subtle type of hair loss.

Dr. Marisa Weiss: It sneaks up on you.

Dr. Mario Lacouture: Yes, it sneaks up on people. So it's important to keep that in mind. And then when you notice that, how to quantify this, what some people like to do is they take their hair and they collect it, for example, in envelopes for specific weeks and to see if the loss of the hairs has decreased over time. However, I think that that is sometimes counterproductive because people get too focused on that. It is normal to lose up to 100 hairs every day, and I just think that, in many instances, people just are looking at this much more closely. So keep that in mind every time you see hair in your pillow, in your drain, that it's normal to lose up to 100 hairs a day.

Dr. Marisa Weiss: Okay, so it's normal to lose about 100 hairs a day. But isn't that because, generally, you're supposed to grow 100 new hairs a day? Isn't there supposed to be a balance of new hair growing as the old hair leaves? But when you're in a situation where you're going through treatment, you may be losing that, 100 or so, per day, but maybe you're not growing as many to replace them with, and that's why you have loss. Or tell me what you think about that idea.

Dr. Mario Lacouture: Yeah. No, that's a great point. Data has not been measured properly because it is difficult. It is such a slow process, and the assessments would need to be such that one would have to label the hair follicles and see if they are being replaced by new hair strands. So those studies have not been done yet. But when we finished the results of our study, which is called CHANCE for chemotherapy-induced alopecia, which means hair loss, and we also measured skin changes and nail changes as a result of chemotherapy, what we see is that about a third of people have this persistent, as you said, slowing down of the growth of the hair and the hair never fully regrows. So I think Dr. Weiss that you are correct that there may be the same amount of loss, but there's not the same amount of regrowth.

Dr. Marisa Weiss: After you've lost your hair and the new hair comes in, how does it look different or feel different than your natural hair that you had before?

Dr. Mario Lacouture: Yes, and this is very variable because, from studies that have been conducted, about one to two thirds of people reveal that their hair grows differently in color. So people that had dark hair, the hair is now gray, because the cells in our bodies that form pigment to color the hair are very easily damaged. This is why we grow gray hair with age. These cells are very susceptible to aging. And if we know that chemotherapy causes accelerated aging, then it's only natural that one would have gray hair after chemo. Now, in terms of the texture of the hair, many people say, and I've heard this probably from about a third of the people that I see, that their hair becomes more dry and frizzy. So it is not surprising because if you think about it, many people will also say that their skin is also drier. They feel their skin after... The estrogen is being blocked, the skin is also drier, their nails can be thinner.

Remember that the hair is formed within the skin. So what we're seeing, the dryness in the skin, is also something that is happening in the hair. The hair is dryer, the nails are thinner. So the overall structure of these adnexas, as we call them in dermatology, the hair and the nails, is affected. If they have straight hair, about a third of people will say that it becomes curly. And if they have curly hair, now it becomes straight. Some people are actually very happy about that because they used to go to a salon to have that done, now they don't need to do that.

Dr. Marisa Weiss: Right. Speaking of salons, I mean, one big reason why the new hair comes in gray is because maybe many people who are listening were dyeing their hair over so many years, every month or so. It was already gray, but they never saw the gray or very much of the gray because they were dying it for all those years. And then when it comes back, it may be the same gray color that it was before you went through treatment because, let's say, you're 60, whatever. You can be 50 and have gray hair. So that brings up one question, I'm sure you get this all the time and people just ask you, how soon can I start dyeing my hair again once it grows back? What's your answer to that?

Dr. Mario Lacouture: And yes, I do mention that, and sometimes people will tell me, "How did you know I was going to ask you that?" So yes, as soon as you feel like the hair is covering your scalp, which again is going to be between month three and six after chemotherapy, people can start dyeing their hair. We do advise against using permanent hair dye. So semi-permanent hair dyes are ideal just because there have been some epidemiological studies showing that permanent hair dyes can be associated with a risk for certain types of cancer. However, usually, these studies have not been replicated prospectively because they cannot do that, and it would take too many people and it would take too long to ever find the answer to that.

Dr. Marisa Weiss: And also, women don't really want the answer to that. They want to dye their hair, they're going to dye their hair. They don't want to hear about it being a problem. But I did see it in San Antonio, this meta-analysis where they gathered all the data from the world to see just dyeing your hair increase the risk for breast cancer recurrence, and there wasn't any connection there that was statistically significant.

Dr. Mario Lacouture: Right.

Dr. Marisa Weiss: Okay, let's just say you're growing over the median age of a woman getting breast cancers, around age 61. You've already experienced a little bit of thinning. And then you get slammed with a diagnosis of breast cancer and you're going through chemo or you're on these medicines, as you say, for years, and you want to know what can you do to reduce the amount of hair loss. What about Rogaine or minoxidil, Nutrafol, Latisse, all these things, platelet-rich plasma, all these things that you see advertised, which one of these things... how do you consider these options? And tell me how you discuss them with patients who are asking you about them.

Dr. Mario Lacouture: Yes. Usually, what I like to tell people is that, "Most things that are over the counter, they are over the counter for a reason." Usually, it's because they are not extremely effective. So most of the things that are effective are going to be prescriptions. Therefore, they may have more side effects. The reason that most people use it is because the benefits outweigh the risks. So let's start with minoxidil. So most people, as you said, Dr. Weiss, know the Rogaine and minoxidil, which is the same thing, and this is a drug that was discovered for high blood pressure. And what was found was that when people were taking this drug as a pill, their blood pressure was lowering, but also they were growing a lot more hair.

So then, what has been done, especially in the past 10 to 20 years in our field of dermatology, is that the dose of minoxidil that is taken for blood pressure, for high blood pressure, it's about 40 to 80 milligrams a day, we are only using half of a 2.5 milligram tablet or one 2.5 milligram tablet, prescribing this. And what we have seen is that there's about a 20% to 25% increase in hair growth with the use of oral minoxidil. Some would say, "Well, why use oral minoxidil? It causes more growth of very fine hairs in the face," for example, "than the topical minoxidil." In our experience using topical minoxidil, which is the liquid you apply on the scalp, is something that is not sustainable. Most people get very tired of applying it. They say there's scalp itches, which can cause irritation of the scalp, and they get tired of using it. It's not as effective as the oral one. So therefore, in order to get better results and for people to be happier with the results, we use the oral minoxidil as first line.

In addition to that, there is a shampoo, ketoconazole shampoo or Nizoral. It's an antifungal shampoo, but it also has an anti-androgen effect or male hormone. So as a woman, you have estrogen levels here and androgen or male hormone levels here, and those estrogen levels go down, then the male hormones will have a greater activity in the hair follicles. And we think this is one of the reasons why these estrogen-blocking therapies cause hair loss. So what we're doing here is decreasing these androgen levels even further down with this topical shampoo that is used two to three times a week, and studies have shown that it does cause a modest benefit. So we combine the oral minoxidil and the topical minoxidil shampoo. Now if we go into the other-

Dr. Marisa Weiss: So you said minoxidil shampoo, the ketoconazole shampoo?

Dr. Mario Lacouture: Minoxidil is the tablet, the pill, and the ketoconazole shampoo.

Dr. Marisa Weiss: Right, that's right. Okay, go ahead. And then Nutrafol?

Dr. Mario Lacouture: And then Nutrafol, there was only one study published with that. I try not to use proprietary names of products, but I'm just going to talk about all the supplements. In terms of all of the supplements, usually, they are backed by only one study, and sometimes the results are too good to be true, and they have not been replicated. What we have found is that these many meta analysis and many large studies that have combed through the studies with these supplements have not found a significant benefit. So I would say that most of us do not advocate for these.

Dr. Marisa Weiss: Okay, and how about the product that is... I mean, people know it as Latisse, but are there other names where you apply it to the eyelashes to increase the growth there? Does that work?

Dr. Mario Lacouture: Yes. Yes. So bimatoprost or Latisse, Latisse was the trade name but the generic is bimatoprost, is a drug that was originally used for high pressure inside the eye. And coincidentally, it was found that it made the lashes grow twice in length and third in width. So now, what we're using this for is for people that have persistent loss of the eyelashes, and it does work in people who use this, and also it can be applied on the eyebrows to stimulate eyebrow growth. It's also a prescription. It may not be covered by insurance, so I would recommend for you to ask your doctor for the generic version of the product.

Dr. Marisa Weiss: How do you spell that, besides the brand name, the regular name? It's-

Dr. Mario Lacouture: B-I-M-A-T-O-P-R-O-S-T.

Dr. Marisa Weiss: Okay. That's a long... Okay, tell us about platelet-rich plasma for hair growth, and how it's done, and if it works or not.

Dr. Mario Lacouture: Yes. So platelet-rich plasma is a procedure by which your own blood is drawn and then the platelets, which are the structures in your blood that are in charge of clotting, in other words, if you bleed from a wound or something, to stop that bleeding... These platelets are harvested and then they are injected directly onto your scalp. So yes, there is pain associated with this procedure, although there are many ways that this can be mitigated through the use of topical anesthetics or medications to mitigate this sensation of pain. It is done at a doctor's office. These, unfortunately, in most instances, as you said before, Dr. Weiss, may not be covered by insurance.

We just finished a study with one of my colleagues, Dr. Anthony Rossi, who is a terrific restorative oncodermatologist. So he focuses on the sequelae of treatment. What we did is we injected the own patient's platelet-rich plasma, which is a component of the blood, into their scalp, and we found that there was a benefit. Even though we only used it in half of the scalp, because we were trying to compare, we found benefit in both sides. Yes, so that's something that I would say, if the other medications have not worked, consider platelet-rich plasma.

Dr. Marisa Weiss: Well, thank you. And what about vitamins or other nutritional topical supplements?

Dr. Mario Lacouture: Yes, definitely, any nutritional vitamins. Topical, I wouldn't advocate for those because they are usually degraded and they do not penetrate unto the hair follicle, deep into the hair follicle. In terms of oral or supplements or vitamins, most of us do not have vitamin deficiency, so I would recommend to ask your doctor to check your blood for a micronutrient panel, which contains all the vitamins. And if there's any deficiencies, then of course those should be replenished. However, with our Western diet, there are very few instances of vitamin deficiencies.

Dr. Marisa Weiss: Well, thank you so much. You've given us such excellent advice. Thank you so much, Dr. Lacouture, for joining and for all of your smart answers. We're all grateful. This is such an important topic, and I know we'll have a lot more questions to address later.

Dr. Mario Lacouture: Thank you.

Dr. Marisa Weiss: I mean, there are options to help manage hair loss during breast cancer treatment. There are wigs, there are wig pieces, extensions, hair coverings, like hats, scarves, turbans, and beanies. If you're open to it, experimenting with different head wear options can really help you feel more confident and comfortable. You can even have some fun with them.

Up next, we have chief experience officer for wigs.com, Alicia Giglio. Alicia is a passionate and dedicated alternative hair expert who has left an indelible mark in the beauty and hair industry. With a background as an executive for two leading manufacturers and an entrepreneur, Alicia fell in love with the purpose behind the business. Fueled by a desire to revolutionize the customer experience, she ventured into the world of online consultation and established her own business, offering natural-looking alternative hair options at affordable prices while emphasizing the importance of education. So thanks for being here with us today, Alicia. Let's get started. First, I thank you for your support for today's event.

Alicia Giglio: Thank you for having me. It's a huge honor. We absolutely love Breastcancer.org and everything that you are doing to supply so much great information to women.

Dr. Marisa Weiss: Thank you. Thank you. We really are grateful, Alicia. But I want to hear from you, when is the best time to get fitted for a wig, and how do you get started in selecting a wig that's right for you? I mean, you get fitted before you've lost your hair, when your hair is still there, or after you've lost it? When's the best time?

Alicia Giglio: It's really up to the person who's looking for the wig. My advice is look for a wig when you feel your best and when you have a little bit of time to do your research. When you wait too long, sometimes you will panic buy and get something that doesn't work and then you're stuck with a piece that doesn't work for you. And so what we say is, "Do it when you feel your best." The most important thing is to work with a professional, so someone who is well-versed in the world of alternative hair because so much of the vernacular used in our space is pretty foreign to most people if they haven't had hair loss before. And so a great starting point there is look for a style that resembles your biological hair, at least for your first wig, until maybe you want to venture out and be a little bit more playful with it.

Stick with your same color family and think about your willingness and ability to style the hair, meaning, time and how you feel and your lifestyle. If you are doing something that's really rigorous, you really want to keep that in mind when picking the style. Most importantly, and the reason why you want to work with a professional besides having a proper measuring because size does matter with wigs, is keep in mind that how the wig looks on the model is probably not how the wig is going to look on you. And that's why working with professional is going to help with guiding you to the right style.

Dr. Marisa Weiss: Thank you. Well, how do you get started, selecting a wig that is right for you?

Alicia Giglio: Yeah. I mean, I think, first and foremost, you have to think about where are you going to wear the wig and why are you wearing the wig. You referenced some of this earlier in the webinar, women are not wearing the wig because of vanity and because they want to look a specific way, they're really wearing it to sort of deflect questions about why they may be experiencing hair loss. And so that's why sticking with a wig style that resembles your biological style is really a great starting point. And so starting there and figuring out how much time you could put into styling and maintaining the wig will also guide you to the fiber, to the style, and to the color.

Dr. Marisa Weiss: Yeah, I mean, I have very curly hair, and it's easier to find a straight hair wig or a wavy wig than a curly hair wig that looks normal. But working with an expert, you can find something that is right for you. For people who are in active treatment for breast cancer, some of them may prefer shopping from the comfort of their home. So let us know, how does online wig shopping work without the help of an expert being there with you to do all the measurements?

Alicia Giglio: Yeah. I mean, there's so many benefits from shopping online and also so many benefits from an in-person consultation. Of course, the biggest benefit for an in-person consultation is that you get to try it on before you buy. At wigs.com, one of the things that we spare no expense on is having a team of experts, many who are licensed cosmetologists or have worked in the alternative hair industry for many years, and we have rigorous training in onboarding them and really educating them on how to consult with our customers. We implemented virtual consultations. They're constantly going through education. So know that, even though it feels intimidating to look online, there's a whole team of people waiting to help you with an expert consultation.

The biggest benefit besides having a team like that to help you is the inventory is really what's available in the industry versus going into a wig shop where there's a little bit more limited options. But everyone is different in how they want to shop. I think, so many of us got really comfortable shopping online, especially in the last three years. And so we work really hard to provide tons of tools that help it make it easier to shop online, from color education, to cap construction, to style, to care and maintenance, to fitting, to all the things that you need to be a wig wearer.

Dr. Marisa Weiss: Yeah, and what if you order the wig, and it comes, and it doesn't fit right or you just don't like the color or the style of it? Can you typically return a wig or exchange it when you buy it online?

Alicia Giglio: You can at wigs.com. Obviously, I can't tell you what other companies' policies are, but we give our customers 30 days from the time that they buy it to return it, which is a really generous piece of time for you to try it on, share it with your loved ones, get feedback from your honest friends and family, and really try it on and see if it is you. And if it isn't, the only thing that we ask is that you return it in the same condition that you received it in, and you'll get a full refund. We don't charge a restocking fee. There's shipping to and from that you will have to pay, but at least you're not stuck with a wig that doesn't work for you. And if that does happen, which it does happen, I mean, all of us have purchased things online that just didn't work, we recommend scheduling a virtual consultation with one of our experts. That way, they can guide you to the wig that will be better for you, better suited.

Dr. Marisa Weiss: That makes a lot of sense. I mean, you're sort of therapists, not just wig experts. You help people through such a difficult time. Can you explain to our audience the differences between wigs, let's say, synthetic, all synthetic, or all human hair, or some combination? And how do you make a decision about which one to buy in terms of price point, how comfortable it is, and what it's like to take care of it?

Alicia Giglio: Yeah. I mean, this is a topic I could spend a whole hour on. In preparation for that, I actually wrote a blog that we'll post this week that recaps everything that we're talking about on because I also know that we're running short on time. The shortest answer that I can give you is the fiber that you get will determine how much time you spend carrying and styling it. It will determine cost. It will determine how natural it looks. Of course, human hair is going to look the most natural because that's the texture that matches our biological hair. But there's so many benefits to synthetic wigs, and there's been so much innovation in the last 10 and 20 years that makes synthetic wigs look more natural, even like the one that I'm wearing. And then there's tips and tricks that you can do to make it look even more natural.

And so the short answer is with synthetic, especially if you're going through treatment, oftentimes women will opt to start with a synthetic wig because even just putting on the wig might be a lot of work and might be difficult. And so we recommend something like a synthetic wig that has style memory and requires very little styling because it already has a style memory baked into it, start with the synthetic wig. The lifespan is shorter on synthetic. You're going to get three, maybe six months depending on care and maintenance. A human hair wig is going to cost you more obviously. Sourcing human hair, it is more expensive to source, and so it does cost more. You're going to get more life out of that human hair wig, but it also requires more care and maintenance. So it really depends on what you're looking for. And the real truth is most women have more than one wig, so they can sort of switch in and out based on what they're doing, how they're feeling. Those options make life a little bit easier if you have more than one.

Dr. Marisa Weiss: I have a patient whose mailman is so confused about how many women live at the house because, every time she enters the door, she's wearing another wig. He can't keep it straight, but-

Alicia Giglio: I had a neighbor that got confused because I came out as a brunette once, and they called my husband.

Dr. Marisa Weiss: Oh, my God. There's somebody, "You're having an affair, I'll tell your wife," right?

Alicia Giglio: Right.

Dr. Marisa Weiss: So many different wigs. That's so funny. That's really funny story. What about in terms of the wig you select? Some of them have a lace front or some of them have a monofilament. What do those terms mean, and how do you decide between them, and how does it impact on how comfortable or uncomfortable it is to wear those wigs?

Alicia Giglio: That's a great question. And again, this will be in the blog because this is another topic that I could spend a whole hour on talking about. Each component on the wig cap determines the style and how natural a wig looks. So the more hand-tied components on the wig, the more it's going to look like the hair's growing out of your scalp, which is great, especially if you have a hairstyle where you want it to look like that. Some women want more volume, and so they might want more layering, more sort of higher volume hair, and that doesn't require a lot of hand-tied. And then the lace front, it mimics a natural hairline. So if you wear your hair off your face, it's going to look like it's growing out of your scalp. The mono top, same thing. It looks like the hair's growing out of your scalp.

The more hand-tied elements on a cap is going to increase the price because each hair is hand tied individually by a human onto the scalp. So oftentimes, people say, "Why are wigs so expensive? Even synthetic wigs are so expensive." The labor involved in tying each hair, I mean, if you think about how tedious that would be, it is tremendous. And it takes hours and hours to make one wig, sometimes days. That terminology will be in the blog.

But if you have a sensitive scalp, and oftentimes women know if they're sensitive to tags or hats or anything that sort of touches your skin, you'll know if that's going to bother you. And there are caps that are going to be more comfortable or there's strategies that you can use to avoid that sort of sensory. You can use the bamboo wig liner. You can use this product called Headline It, which is a liner for wigs. Not only it wicks away the moisture, especially if you run hot, but it also just sort of creates a really soft barrier between the cap and your scalp. And also, size matters. So if you are getting a headache or you just feel like it feels tight, it probably doesn't fit well. And so, that's where you need to work with one of us to make sure that we get you into the right fitting wig.

Dr. Marisa Weiss: Give me a ballpark idea of the range of costs for the least expensive synthetic wig and then a human hair wig and then the combination. Just generally speaking, what cost are we looking at?

Alicia Giglio: Yeah. I mean, for a really basic synthetic wig, you could probably get one for $100 at the lowest, and you could also buy one that has all the bells and whistles for $650. And the difference is going to be how that wig was made, how much labor was involved in making it, if the style is specific to something you're looking for, how natural it looks. And we get asked a lot, "Why are they so expensive? Why don't they last longer?" And the answer is anything that you wear on your body every single day or multiple times a week for hours at a time, it's going to wear down. It is like the shoes that we wear. If we wore the same shirt every day, you're going to start to get that kind of pilling in underneath your armpits and anything that sort of rubs on it, right?

Dr. Marisa Weiss: Right.

Alicia Giglio: And so the cost is really associated with the labor. The other thing is anything that you wear in your body is probably not going to last forever. And so you have to have a realistic sort of timeframe that it's going to last. One of the things that I tell a lot of our clients is, "If you get your hair done at the salon every six weeks-ish, it kind of is about the same cost depending on what kind of services that you're doing." And not everyone does that, I understand that also. But it just depends on what's important to you, and having those key components in a wig that you want will determine the cost.

Dr. Marisa Weiss: What about a full human hair wig? I have patients who spend thousands of dollars, several thousand dollars on them as well.

Alicia Giglio: Yeah. I mean, we have human hair wigs that probably start around $900 and go up to $4,500. For human hair wigs, that cost, closer to that $4,500 range, you're paying for length, you're paying for quality of hair, because there's different grades of hair that's going to help determine the price. And then, also, how much of that cap is hand tied will factor into the price as well.

Dr. Marisa Weiss: Right. What about when it's hot as hell outside, or you're going through endocrine therapy and you're having hot flashes and just you want to wear the coolest possible wig? Given that situation, what would your advice be to that person?

Alicia Giglio: As a perimenopausal woman, I will tell you that there's lots of strategies. So if you have a longer style, like I'm wearing, I often will put my hair up either in a ponytail, sometimes in braids, in a bun. I usually won't wear a hat with it, but it didn't look great today. And so I decided I needed to wear a hat to sort of... And I live in California, always trying to protect myself from the sun. There are liners -- I mentioned that bamboo liner, the Headline It -- those wick away moisture and help keep your scalp cooler. Even though it's additional layer, it has that wicking benefit of keeping your scalp cooler. You can go into the bathroom and take off your wig for a couple of minutes. You can run cool water on your wrist. You can wear a shorter style. If it's not touching your neck, usually it can keep you a little bit cooler. And then-

Dr. Marisa Weiss: What about a baseball cap with just a fringe around the outside, little ponytail in the back kind of thing?

Alicia Giglio: Absolutely. A lot of our customers will wear that for working out or going to the beach, going to the pool, going boating. That's an absolute option.

Dr. Marisa Weiss: Great, great. I know we don't have much time left, but there's so much more we want to learn from you. What about easy styling, caring for it, and storing the wig for someone who's... They're going through treatment, they have no extra energy or time to do it, what's the easiest way to manage that?

Alicia Giglio: Yeah. I mean, all wigs, if you're wearing it daily, need to be washed six to eight wears. I always do mine on Sunday nights. That way, they're ready for the week. For a synthetic wig, which is oftentimes where someone who's going through chemotherapy would probably start because it's the easiest maintenance, you are going to wash that. I wash mine at night. By the next morning, it's dry. Once you wash and condition it, you put it on a wig stand after you've combed it out, and sort of set it there in the style that you want it to dry in, because synthetic wigs have that style memory. And the great thing about synthetic is it requires very minimal styling. And so you could use a little bit of hairspray, a little bit of dry shampoo, but very minimal styling is going to be your best bet.

If you are willing to invest more time or you have someone that's going to help you, then, again, you want to get them ready on the weekends for the rest of the week or whenever it's most convenient for you based on your schedule. But you have to take perfect care of it. Every six to eight wears, you have to use specially formulated shampoo and conditioner and care products because, even if it's human hair and you have a great biological shampoo that you love, the human hair wigs are not attached to a blood source anymore. And so they require a specially formulated shampoo. And I can't stress that enough because people get a little bit passionate about the care products that they use, but it's not the hair that's attached to your head, and so you have to use these special products.

Dr. Marisa Weiss: Right. I think that the synthetic wigs end up being looking a lot better because, over time, the human hair wigs, while they might look natural upfront in the beginning, they tend to look kind of tired over time because they don't have that natural source of nutrients and oil that your scalp would naturally produce on them.

Alicia Giglio: Well, that's why you also have to do deep conditioning treatments at least once a month, especially with a blonde.

Dr. Marisa Weiss: Yeah. Okay. Good to know. Thank you. What about people who have hairpieces? They've got good head of hair, but there's a patch or a significant patch where they have hair loss. Or let's say, they've been through chemo and they use the cold caps, and they've got hair, but it's thin. They want to add volume. So what about hairpieces or hair extensions? Is that good, and is it healthy? Is that going to damage their hair that is left behind? What do you recommend?

Alicia Giglio: So every situation is different, and it's really about preference. We have women that are in an active regrowth stage that will reach out to us, and they've been wearing wigs, and they're ready to transition to a hair topper or extensions. A hair topper is really a top of the head hair extension. That is great. You have to have healthy hair follicles to clip it into, and you have to make sure that you apply it properly so that you don't cause traction alopecia. And so that's, again, why you want to work with a professional. If you want to have it color matched, you'll probably have to have it customized. But a hair topper, also known as a hair extension, is a great option, but you will have to style your bio hair in with it, which a lot of people love.

Dr. Marisa Weiss: Right. When you say traction alopecia, it's when you attach an extension onto the hair that's on your head, it may create some traction or some weight, and that can traumatize that hair that might be sort of struggling to stay on your head. So you want to do that. So that topper sounds like a good idea to give you some more volume that way without traumatizing the hair that you have left on your head.

Alicia Giglio: Yes.

Dr. Marisa Weiss: Are those good pieces to use as your hair's growing back in, as an example?

Alicia Giglio: Absolutely.

Dr. Marisa Weiss: Yeah. We talked about the cost of these, of the wigs. This being a side effect of treatment, it makes sense that it should be covered by insurance. But not everyone's insurance covers the cost of a wig or as many wigs as you need. Are there buzzwords, are there tricks... not tricks because it's not like you're pulling anything on you, but are there more effective ways to get your insurance company to cover the cost of wigs by using the right words in your appeal or your application to the insurance company?

Alicia Giglio: I mean, the most medical term that I'm aware of is cranial prosthesis. It is sort of the fancy term that is really another phrase for wigs.

Dr. Marisa Weiss: Right. Cranial prosthesis. We use that a lot. Yep.

Alicia Giglio: Kind of speaking of budget, because I'm not an expert with insurance, but what I can recommend is think about what your budget is. What are you willing to budget for hair, and what would it mean to you? As women, we budget for the things that are most important to us. I might bring my lunch in order to afford getting my nails done. I don't know. I mean, that's an extreme example. But think about what it will mean to you and then figure out your budget. There are wigs within every budget.

Obviously, the more natural the wig is going to look, it might cost a little bit more. And then think about the life that you're going to get out of that wig. For a great synthetic wig, you'll probably get three, maybe four or five months out of that wig if you care for it perfectly. A human hair wig, you could get nine months to several years depending on how often you wear it and how you treat it. So it really just depends on what is your budget. And then, if you work with someone like us, we will help find something within that budget.

Dr. Marisa Weiss: Right. Sometimes, you pick something that you really want and it costs more than what the insurance company will pay, but at least you get partial coverage hopefully. I know there are organizations, like the American Cancer Society may provide free wigs or reduced cost wigs. I know, at my hospital, we have some wigs that have been donated that weren't used that some people can use. But basically, this is such a personal thing. And people, they don't want to look like they're wearing a wig hat, they want look like they're wearing... they look natural, normal, and good so they can feel better about themselves as they move through life, their life at home, and their life at work, their life in the community. They want that privacy, and to feel good about themselves.

Alicia Giglio: Absolutely.

Dr. Marisa Weiss: We are so grateful to talk to you, Alicia. Thank you for your support. You know so much about it, and we look forward to getting the link to your blog so that people can learn more. This has been a great evening.

As we wrap up, I would just want to say that wearing a wig for the first time can be overwhelming. It can feel strange, perhaps uncomfortable and daunting. It's natural to feel apprehensive. However, some wigs can give back that sense of privacy and confidence to give you that positive impact on your mental health. And it's important to feel as much like yourself as possible when you're out with friends, as I was saying, at home, particularly with young kids who want mom to look natural, normal. And where it's possible, trying to be as proactive and positive about it. Compliment yourself. Give yourself room to heal after your treatment. If you've got hair loss, time to come back. But in the meantime, to use these solutions that can help you feel good about yourself so that you can embrace a life that you fought so hard to have.

You can also join one of Breastcancer.org's virtual support groups to meet other people going through active breast cancer treatment. For sure, you're not alone. There are a lot of other people who've experienced some of these really difficult challenges. I want to thank everyone who's attending today. I hope that today's webinar helps you become more empowered in your care. And we'll email you a link to the recording of the webinar. And for more information about coping with hair loss or hair thinning, you can visit Breastcancer.org/hair-loss. And if you're looking to connect with others who understand what you're going through, we welcome you to join the Breastcancer.org online community. We'll include a link to register in the email. We'll also send that out after today's program. Thank you very much to our wonderful speakers and to everyone who's on. Please take care, and let us know how we can be helpful to you.