Hair loss (or alopecia) is one of the most common side effects of cancer treatments, particularly chemotherapy.
The drugs given during chemotherapy target all rapidly dividing cells, including hair follicles, which results in hair loss about two weeks after beginning treatment.
Chemotherapy-induced alopecia may seem like a small price to pay to prevent and treat cancer, however, it has a significant psychological burden. It affects the self-image of the patients, contributing to their stress and anxiety. Hair loss becomes a constant reminder of the disease for these patients.
Scalp cooling, sometimes called scalp hypothermia, is a procedure in which cold temperatures are applied to the scalp to help prevent hair loss in people undergoing chemotherapy for cancer.
Scalp cooling systems and cold caps are tight fitting, helmet-type, strap-on caps filled with a gel coolant, which is chilled between -15 to -40 degrees Fahrenheit.
Scalp cooling helps to reduce the damage to the hair follicles caused by chemotherapy. It helps to improve self-esteem of the patients and their attitude towards treatment.
How was Scalp Cooling invented?
In the 1950s, Eric Paxman had invented the beer cooling system for breweries. For the next 30 years, the Paxman family flourished by developing award-winning cooling products and systems.
Glenn Paxman, son of Eric Paxman and the current chairman of ‘The Paxman’ designed a scalp cooling system for his wife. She was receiving chemotherapy for breast cancer, which resulted in hair loss. The early version of the cap did not prevent the hair loss. That made Glenn realise the trauma of hair loss.
Glen and his brother Neil invested years in research and development and built the first prototype of the Paxman Scalp Cooling System. In 1997, it was installed at the Huddersfield Royal Infirmary.
In the following 10 years, several hundreds of cold cap systems were produced, which gave hope to many people across the country. It was widely embraced by doctors and nurses as well. Today, the Paxman Scalp Cooling System is used broadly across various parts of the world.
How does it work?
In the scalp cooling system, the temperature of the scalp is lowered before, during and after each chemotherapy treatment. Usually, the temperature of the scalp skin is about 34 degrees Celsius. It is reduced to between 15 to 20°C during scalp cooling. The cap has a covering that keeps the temperature constant and maintains the position of the cap.
During the scalp cooling procedure, a cold gel is circulated around a tight-fitting cap which is worn by the patient. The cap is attached to a small refrigeration machine which circulates the cold gel. Hence, the cap can be fitted only once, unlike the cooling caps that must be replaced every 30 minutes.
The circulating cold gel constricts the blood vessels of the scalp, reducing blood flow to hair follicles, thereby decreasing the amount of chemotherapy medication reaching the hair follicle cells.
The lower temperature also decreases the activity of hair follicles, which slows down cell division and reduces the effect of chemotherapy medicine.
Scalp cooling only protects the hair on the head. Body hair such as eyebrows, eyelashes and pubic hair may still be lost with chemotherapy.
Generally, the scalp cooling systems are purchased by a cancer treatment center and are rented by the patients while undergoing chemotherapy.
Who can use scalp cooling
Scalp cooling may not be recommended for all cancer patients. Patients undergoing chemotherapy for breast cancer treatment are more likely to experience hair loss. If the patient is not receiving such drugs, hair loss may be minimal and may not indicate using scalp cooling systems.
Scalp cooling is not advised for pediatric patients and patients with certain cancers or a history of some condition, including:
- blood cancers (leukemia and lymphoma)
- head and neck cancers
- scalp metastases
- central nervous system malignancies
- certain skin cancers
- cold sensitivity
- cold agglutinin disease
- cold urticaria
- post-traumatic cold dystrophy
- imminent bone marrow ablation chemotherapy
- previously received, or scheduled to undergo skull irradiation
Scalp cooling is not recommended for patients if there is a risk of tumor metastasizing into the scalp.
- Patients with advance forms of colon cancer, non-small cell lung cancer, renal cell carcinoma, are at high risk to have scalp and/or cutaneous metastases.
- The long-term effects of scalp-cooling and scalp metastasis have not been studied extensively.
Moreover, scalp cooling is not effective for all the patients. The treatment can be stopped immediately, if they are not helpful.
Patients can talk to their physicians or cancer care team about the risk of hair loss, and the benefits of scalp cooling.
How to prepare for Scalp Cooling
Patients have a lot of questions about preparing for their scalp cooling treatment. Some hospitals or healthcare providers offer the patient to take a look at the scalp cooling system, and even have a cap fitting prior to the first appointment. This allows the patient to be prepared emotionally and practically and reduce their anxiety.
Generally, the patient’s hair must be clean and tangle free for scalp cooling. Some centers may prepare the patients hair, whereas some may ask the patients to prepare their hair. In case the patient must prepare themselves after coming to the hospital on the day of the treatment, here are some guidelines:
- The patient must reach the hospital 20 minutes before the appointment, so that they have ample time to prepare their hair.
- The patient must slightly dampen their hair using a water spray to remove any air bubbles out of the hair, and to make the hair flatter to ensure a good cap fit.
- If recommended, a small amount of conditioner can be applied to ensure thin coverage and help easy removal of the cap.
- Using a wide tooth comb or a brush, the wet hair must be combed. In case the hair is too wet, it must be dried using a towel.
- The nurse may then comb the hair to cover and protect the scalp before placing the cold cap.
These guidelines may vary with different hospitals and cancer centers. However, it is recommended that you talk to your healthcare providers for the best ways to prepare. The healthcare team may also suggest the type of conditioner to be used.
Below is a list of do’s and don’ts before scalp cooling:
- The patient need not cut their hair very short. Some length of hair can help to cover the thin areas.
- Any hair extensions must be removed prior to the treatment.
- Split or dry ends must be trimmed to ensure smooth gliding of a wide tooth comb while conditioning.
- Patients can color their hair prior to the treatment, if there are no hair or scalp issues and a sensitivity test is done before coloring.
- Getting a perm or relaxing the hair before scalp cooling is not recommended, as these processes are stressful for the hair.
How should the cap fit the patient
Scalp cooling caps that are not fitted tightly have been associated with more hair loss, usually in the patches where the cap is loosely fitted. Hence, it is important to fit the cap tightly.
The cap should fit tightly all over the head. It should fit along the hairline, tightly in the crown area, without any gaps between the cap and scalp.
If it does not fit well, the patient can ask the nurse to change the size of the cap.
Although the cap must be tight, it need not be so tight that it is uncomfortable, as the patient is required to wear the cap for a long time.
How long will the treatment take
The duration of the scalp cooling treatment depends on the type of chemotherapy received. Generally, the cap is worn by the patient at least 20 to 30 minutes before the chemotherapy session, during the chemotherapy session,and also after the infusion is completed.
Additional time may be needed for the scalp cooling, which may vary based on the type of chemotherapy drug and the time required to fit the cap correctly.
Scalp cooling must be performed each time the patient undergoes chemotherapy to gain full benefits of hair preservation.
Warnings and precautions for scalp cooling
The following are some warnings and precautions for scalp cooling that one must know before undergoing the treatment:
- The efficiency of scalp cooling in patients who have received previous chemotherapy has not been studied.
- The scalp cooler or the touch screen controller should be protected from any liquids, including drips from the cooling caps.
- The ambient temperature should not be over 30°C/86°F.
- The side ventilation grills must not be touched while using the device.
Patients who use scalp cooling systems during chemotherapy, are recommended to care for their hair. Here are some tips for this.
- Hair must be combed and brushed gently.
- Hair must be washed 24-48 hours after scalp cooling.
- Hair must be washed only once a week or less, using gentle, sulfate and paraben free shampoo and cold water
- Blow drying, straightening irons or hot rollers must not be used.
- A wide-tooth comb must be used, and over-brushing should be avoided.
- Tangles must be freed using fingers. If the hair is dry, hold them above the tangles to avoid pulling the hair roots.
- Scrunchies should be preferred over hair ties.
- Satin or silk pillowcases must be used.
Side effects of scalp cooling
The common side effects of scalp cooling include:
- headaches or migraines
- extreme coldness while wearing the cap
- discomfort from the chin strap
- forehead pain from the pressure of the cap
- pruritus (severe itching)
- sinus pain
- skin tissue disorders
- skin ulceration
Benefits and the success rate of scalp cooling
Scalp cooling is intended to help prevent or reduce hair loss in cancer patients undergoing chemotherapy.
However, many people may experience total or some hair loss or hair thinning despite scalp cooling. This may be due to hair type, the type and dose of chemotherapy treatment.
Some studies suggested that people with thick hair are at higher risk of hair loss than those with thin hair, as thick hair shields the head, so that the cap cannot make close contact with the scalp.
The success rate of scalp cooling depends on various factors including chemotherapy regimen, dose, duration of drug infusion, chemotherapy drug metabolism, and concomitant comorbidities.
Scientific evidence for the effectiveness of scalp cooling is unclear as the patients included in the studies had different chemotherapy, different hair types and different cooling machines. However, some evidence is available regarding the success rate of scalp cooling.
The summaries of these studies are discussed below:
- A study suggested that the risk of significant hair loss can be lowered by 43%, and the patients need not use a wig or any other hair covering.
- The success of scalp cooling ranged from 50% to 84% among those who received taxane-based chemotherapy, 20% to 43% among those who were treated with anthracycline-based chemotherapy, about 16% among those who received a taxane followed by an anthracycline, and 100% among patients who were treated with a weekly Taxol.
On an average, scalp cooling costs about $1,500 to $3,000 per patient. This cost may vary depending on the number of cycles of chemotherapy. In India, the additional cost of scalp cooling ranges between Rs 3,000 to Rs 4,000.