Scalp Cooling and Alopecia
Appraised by:
Kristi Erickson SN, Megan Hilzendeger SN, Lauren Ritter SN
NDSU College of Nursing at Sanford Health, Bismarck, ND
Clinical Question:
Does scalp-cooling reduce alopecia in cancer patients receiving chemotherapy?
Articles:
Betticher, D. C., Delmore, G., Breitenstein, U., Anchisi, S., Zimmerli-Schwab, B., Müller, A., &
Trueb, R. R. (2013). Efficacy and tolerability of two scalp cooling systems for the
prevention of alopecia associated with docetaxel treatment. Supportive Care In
Cancer. 21(9), 2565-2573. doi:10.1007/s00520-013-1804-9
Kargar, M., Sarvestani, R. S., Khojasteh, H. N., & Heidari, M. T. (2011). Efficacy of penguin
cap as scalp cooling system for prevention of alopecia in patients undergoing
chemotherapy. Journal Of Advanced Nursing. 67(11), 2473-2477.
doi:10.1111/j.13652648.2011.05668.x
Mols, F., van den Hurk, C., Vingergoets, A., Breed, W. (2008). Scalp cooling to prevent
chemotherapy- induced hair loss: practical and clinical considerations. Support Care
Cancer, 17, 181-189. doi: 10.1007/s00520-008-0475-4
Synthesis of Conclusions:
Betticher, et. al. (2013) conducted a non-randomized prospective controlled study at
twenty-seven sites in Switzerland. Two hundred thirty eight cancer patients receiving
chemotherapy infusions were studied. Participants in the study were given the ability to choose
which of the three treatments that they preferred from the options of 1) PAX (Paxman electric
cooling device), 2) CC (gel-filled cooling caps), and 3) no scalp cooling treatment (the control
group). There were 39 participants who received no treatment in the control group. The cooling
caps were placed on the participants for 30 minutes before chemotherapy infusion start time, the
duration of the chemotherapy infusion, and for either 45 or 90 minutes post-infusion end time.
There was no significant difference whether patients wore the scalp cooling treatment for 45 or
90 minutes after the infusion was finished. For this reason, it is recommended that post infusion
cooling cap time is 45 minutes as there was no significant difference in alopecia when the cap
was applied for the extra 45 minutes totaling 90 minutes. The findings in this study show that
patients receiving docetaxel therapy with both PAX and CC devices substantially reduces
alopecia compared to patients receiving docetaxel and no scalp-cooling technique. The
participants who received the scalp cooling treatments were asked to fill out a short questionnaire
after each treatment. The survey showed patient satisfaction and that there were minimal side
effects of the cooling cap. Side effects included minor headaches and a small bout of chills
which were relieved by warm blankets. This study has sufficient sample size for the study
design. The researchers also had adequate control. The research included a definitive conclusion
that supports scalp cooling during chemotherapy infusion reduces the risk of alopecia. The
limitations of this study include the non-randomization, thus making it prone to selection and
allocation biases because patients were free to choose their preferred treatment method. Also,
the number of patients participating in the cooling cap was lower than expected due to preference
to the packs treatment.
Kargar, Sabet, Khojeasteh, and Heidari (2011) conducted a non-randomized quasiexperimental study at Namazi hospital. The study included 63 patients undergoing IV
chemotherapy that included six cycles of chemotherapy at intervals of 3 weeks. Thirty-one
participants who accepted the scalp-cooling system were selected non-randomly and compared
to 32 participants who refused the device. Interventions included Penguin caps previously kept
at -20 degrees Celsius for 24 hours. They were applied to the scalp 15 minutes before
chemotherapy and maintained “in situ” (Kargar, et. al. 2011) throughout the treatment period.
As a result, each cap was used for an estimated 45 minutes. A check list and demographics were
performed during the treatment and a nurse recorded the data. Post-procedure, the patients were
assessed by a physician and the degree of alopecia was determined according to World Health
Organization guidelines. The results of this study “clearly demonstrated the efficacy of the
Penguin Cap to reduce alopecia.” (Kargar et. al. 2011). According to the study by Kargar et al.
(2011), “24 participants treated by chemotherapy drugs and the penguin caps had alopecia of
first and second degrees; significantly less severe than those receiving chemotherapy treatment
without the Penguin caps” (p. 2475). This study has generalizable results and the researchers had
adequate control. The sample size, however, was small and therefore limited the results.
Floortje, van den Hurk, Vingerhoets, and Breed (2008) conducted a nonrandomized,
quasi-experimental study using 13 different hospitals in the Netherlands. The purpose of this
study was to determine the effectiveness of scalp-cooling in patients undergoing chemotherapy
as well as the burden of patients losing their hair and how it effects their body image. The study
was conducted between October 2004 and February 2007. Of the thirteen hospital locations, 6
offered scalp-cooling, while the other 7 did not. Patients that decided to participate in the study
receive a set of questionnaires, before the start of chemotherapy, 3 weeks after the last
chemotherapy cycle, and 6 months after the last chemotherapy cycle. Ninety-eight patients
received scalp-cooling while 168 control patients included were treated in hospitals with no
scalp-cooling. Scalp-cooling showed to be effective in reducing chemotherapy induced alopecia
in 32-62 evaluable patients while all patients in the control group not receiving scalp-cooling
needed to wear a wig or head cover after completing chemotherapy. When answering questions
on the questionnaire, 71% of patients didn’t feel attractive because of their hair loss. (Floortje et.
al. 2008). The results of this study showed that hair loss can be stressful and this method is
effective and is well tolerated.
All three studies showed evidence that scalp-cooling can reduce chemotherapy induced
alopecia. Each study used a type of survey or questionnaire, and two studies used the guidelines
from the WHO to determine alopecia severity.
little evidence was found regarding the negative effects of scalp-cooling. Side effects to
the scalp-cooling systems were possibility of headaches and overall feeling of being cold, and
the fact that it might not be effective. Only one of the three studies used a physician assessment.
Sample sizes varied among the studies which limited information due to small sample sizes, but
they still came to similar conclusions: scalp-cooling is effective in the reduction of alopecia in
patients receiving chemotherapy.
Bottom Line:
Evidence based research shows that scalp-cooling therapy during chemotherapy infusions
is found to be a safe and effective treatment for the reduction of alopecia that is a common side
effect. By reducing alopecia, cancer patients receiving chemotherapy have a greater self-esteem
and self-worth that is sometimes lost due to the outward physical symptoms caused by the
chemotherapy.
Implications for Nursing Practice:
Nurses and Oncology staff will be able to offer scalp-cooling as an adjunctive treatment
therapy for cancer patients receiving chemotherapy. By accepting this treatment modality,
patients will have the option to reduce the risk of alopecia, which is a common side effect of
chemotherapy. By reducing alopecia, cancer patients are able to experience a greater self-esteem,
which is sometimes lost related to the alopecia. The studies appraised suggested that scalpcooling an effective intervention.