Scalp cooling, also called scalp hypothermia and cold cap therapy, was introduced in the late 1970s, and many had high hopes for its success. However, its effectiveness in preventing hair loss varied by the type of chemotherapy administered, and because of concerns about the potential for scalp metastasis, scalp cooling quickly fell away. Now, it’s back and commonly used in clinical practice. Scalp cooling constricts blood vessels in the scalp, thereby reducing blood flow to the hair follicles and limiting the amount of chemotherapy that reaches the follicles.1
Lisa Schulmeister, MN, RN, FAAN
Lisa Schulmeister, MN, RN, FAAN
There are 2 types of scalp cooling available in the United States. Manual cold caps have gel or fluid-filled compartments that require chilling/freezing and are placed on the patient’s head about an hour before chemotherapy. The caps are changed periodically during the infusion (usually every 15-30 minutes) and worn for 90 to 120 minutes afterward. Caps, supplies, and rolling coolers are rented to patients, and shipped or delivered to the patient’s home or treatment facility. Machine-based scalp cooling systems consist of a cap connected to a device that circulates coolant through the cap. These systems provide automated continuous cooling at a set temperature throughout the chemotherapy treatment. Some models have 2 independently-controlled continuous cooling systems that enable simultaneous treatment of 2 patients, and the system can be easily detached if a patient needs to use the restroom.
IS IT SAFE?
Two recent US prospective studies of scalp cooling systems support the safety of the practice. Adverse events were minor (grade 1 or 2) and included headache, nausea, chills, dizziness, skin pain, skin ulceration, dry skin, sinus pain, paresthesia, and pruritus.2,3
DOES IT WORK?
In one of the US studies, 101 women used a machine-based cooling system and were followed for a month after the last chemotherapy cycle; 67 of the women (66.3%) lost less than half of their hair. In comparison, 16 women (100%) in the control group lost more than half of their hair. Success was documented in 83.3% of women receiving docetaxel and carboplatin, 60.2% of those treated with docetaxel and cyclophosphamide, and 83.3% treated with a taxane alone.2 In the second study, conducted at 7 US sites, successful hair preservation occurred in 50.5% of women who underwent machine-based scalp cooling compared with none of the women in the control group who did not receive scalp cooling. About a third of the 142 women received anthracycline-based chemotherapy, and 64% received taxane-based chemotherapy.3
In both studies, there was variability in the rate of hair preservation, which may have been due to improper fit of the cap, type of chemotherapy (less hair loss was observed with taxane-based treatment than with anthracycline-based treatment), and patient characteristics such as pretreatment hair thickness and texture.
WHO SHOULD CONSIDER SCALP COOLING?
Chemotherapy-induced hair loss can be a distressing effect of cancer treatment, so scalp cooling should be discussed with concerned patients. The FDA approved machinebased scalp cooling for use in women with breast cancer in 2015, and in July 2017, expanded its approval for use in all patients with solid tumors.4
Studies of scalp cooling have excluded patients with hematologic malignancies because of concerns about reducing treatment efficacy. Scalp cooling should not be used by patients with cold agglutinin disease, cryoglobulinemia, and cold-induced migraines because of the potential to exacerbate these conditions through prolonged exposure to cold temperatures.5
WHAT DOES IT COST?
Manual scalp cooling systems rent for $325 to $500 per month. A full course of manual or machine-based scalp cooling during adjuvant chemotherapy for breast cancer costs $1500 to $3000.5 Some insurance companies may cover scalp cooling treatment, and patients can apply for assistance from the nonprofit organization HairToStay (hairtostay.org).
A practical issue related to scalp cooling is how to incorporate it into the workflow of an infusion center. The prechemotherapy cooling period could coincide with administration of premedications, and manual posttreatment scalp cooling could occur in another area, such as a waiting room.5 However, machine-based cooling is more difficult to relocate to another area and may not be possible if 2 patients are using 1 machine simultaneously.
Scalp cooling is now approved for use with men as well as women, so scalp cooling may be an option for men with solid tumors who are concerned about hair loss. However, all patients considering scalp cooling need to know that data suggest it reduces but does not entirely prevent hair loss, so they should expect some degree of loss to occur. Another consideration is that there are limited follow-up data, so there is some concern about the potential for scalp metastasis. In fact, investigators planned routine follow-up visits for the women enrolled in the multisite trial for 5 years after the study to further assess safety (time and site of first recurrence) and overall survival.3
- FDA clears wider use of cooling cap to reduce hair loss during chemotherapy. National Cancer Institute website. cancer.gov/news-events/cancer-currents-blog/2017/fda-cooling-cap-chemotherapy. Published July 21, 2017. Accessed April 19, 2018.
- Rugo HS, Klein P, Melin SA, et al. Association between use of a scalp cooling device and alopecia after chemotherapy for breast cancer. JAMA. 2017;317(6):606-614. doi:10.1001/jama.2016.21038.
- Nangia J, Wang T, Osborne C, et al. Effect of a scalp cooling device on alopecia in women undergoing chemotherapy for breast cancer: The SCALP randomized clinical trial. JAMA. 2017;317(6):596-605. doi: 10.1001/jama.2016.2093.
- FDA clears expanded use of cooling cap to reduce hair loss during chemotherapy [news release]. Silver Spring, MD: FDA; July 3, 2017. fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm565599.htm. Accessed April 19, 2018.
- Kruse M, Abraham J. Management of chemotherapy-induced alopecia with scalp cooling. J Oncol Pract. 2018;14(3):149-154. doi: 10.1200/JOP.17.00038.