GUIDANCE FOR THE MANAGEMENT OF
CYTOTOXIC CHEMOTHERAPY INDUCED ALOPECIA
Version / 4Name of responsible (ratifying) committee / Chemotherapy Governance Group
Date ratified / 26 June 2017
Document Manager (job title) / Senior Sister Haematology/Oncology
Date issued / 12 December 2017
Review date / 30 June 2019
Electronic location / Clinical Guidelines
Related Procedural Documents / -
Key Words (to aid with searching) / Hair Loss: Chemotherapy: Alopecia: Scalp Cooling:
Version Tracking
Version / Date Ratified / Brief Summary of Changes / Author4 / 26.06.2017 /
- Added Cap Crosses fitting information Page 10
- Added new cooling timings Page 13
- Added new guidance about Docetaxol and hair loss Page 15
- Added new pictures regarding cap sizes and cap fittings
3 / 17.12.2014 /
- Format of guidance changed
- 6.5 Added easy to use pictures and guidance direct from Paxman information guide
2 / 25.05.2011
CONTENTS
QUICK REFERENCE GUIDE
1.INTRODUCTION
2.PURPOSE
3.SCOPE
4.DEFINITIONS
5.DUTIES AND RESPONSIBILITIES
6.PROCESS
7.TRAINING REQUIREMENTS
8.REFERENCES AND ASSOCIATED DOCUMENTATION
9.EQUALITY IMPACT STATEMENT
10.MONITORING COMPLIANCE
EQUALITY IMPACT SCREENING TOOL
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural documents.
For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.
- Scalp cooling should be offered to all patients receiving chemotherapy that is known to cause hair loss (With the exception of Haematology Patients)
- Only staff who have received training and are deemed competent should use the scalp cooling machines
- Patients must be told to inform a member of staff if at any time they feel unwell whilst having scalp cooling.
- Before using the scalp cooling machines staff need to ensure that the patient has received both written and verbal information regarding side effects and time elements surrounding the use of the scalp cooler.
- Nursing Staff need to clean the hats in-between patient use and ensure it is ready for the next patient
- The scalp cooling machines should be switched on and ready for use before a patient arrives
1. INTRODUCTION
Chemotherapy-induced alopecia is a very distressing side effect of chemotherapy. It is the temporary loss of all body hair; this includes hair on your head, eyelashes, eyebrows, pubic hair and body hair (Dougherty 2006) All drug therapies have the potential to affect hair growth structure and loss. Alopecia is a common side effect with cytotoxic drugs occurring with varying degrees of severity. The psychological impact, which can affect both men and women, should not be underestimated (Batchelor 2001).
This scalp cooling guideline will provide guidelines on the management of Cytotoxic chemotherapy induced alopecia. The use of a mechanical device to reduce the amount of hair loss and the use of wigs.
Network wide guideline statement. The core contents of this guideline have been agreed by the (Wessex Strategic Network previously known as the Central South Coast Cancer Network to promote consistency across the network and provide up to date and effective management of Cytotoxic induced alopecia.
This policy does not cover Haematology patients who scalp cooling is not recommended
2. PURPOSE
The purpose of the guideline is to assist staff to provide good evidence based care for people who have potential to lose their hair.
3. SCOPE
This guideline has been produced to assist all health care professionals in the management of cytotoxic chemotherapy-induced alopecia. These guidelines will predominately be used on the Combined Haematology Oncology Day Unit at Queen Alexandra Hospital. This guideline is for the use in all adult patients who are receiving chemotherapy drugs that cause alopecia (except Haematology patients).
4. DEFINITIONS
4.1 Cytotoxic Chemotherapy The use of chemical treatments (Medline 2004) which are toxic in their action to cells, malignant or non-malignant (Dougherty 2004a)
4.2 Alopecia This is an abnormal loss of hair (The Penguin English Dictionary 2000). Cytotoxic chemotherapy induced alopecia may result in the loss of body hair, eyelashes and eyebrows, not simply head hair (The Royal Marsden 2004)
4.3 Scalp Cooling A system that is used to reduce the risk of Cytotoxic chemotherapy induced alopecia (Dougherty 2004b). Scalp cooling can often prevent total hair loss when used with particular Cytotoxic regimes. Scalp cooling acts by constricting blood vessels supplying the hair reducing scalp temperature, therefore reducing the circulation and uptake of the drug within the hair follicle.
5. DUTIES AND RESPONSIBILITIES
The maintenance of the machinery: Portsmouth Hospitals NHS Trust has a contract with Paxman who attend the unit and service the machinery at Queen Alexandra Hospital, Portsmouth.
Each person using the machine has a responsibility to ensure it is running safely and report any problems or concerns to the nurse in charge or the senior nurse in order for them to contact Paxman to report and problems.
The Haematology/Oncology Day Unit Manager is responsible for ensuring the machines are maintained and serviced regularly.
The Haematology/Oncology Day Unit Manager is also responsible for ensuring training and education is completed to all new staff and that competencies are maintained. The Manager will ensure that the scalp cooling machines are audited yearly.
6. PROCESS
6.1 Psychological Aspects
Hair is often seen as an indicator of health and attractiveness. Alopecia has been found to be one of the most distressing anticipated side effects of cytotoxic chemotherapy with some patients refusing to have chemotherapy rather than risk losing their hair.
Chemotherapy induced alopecia is nearly always reversible, but sometimes permanent. Permanent chemotherapy induced alopecia is defined as an absence of, or incomplete hair growth, 6 months beyond the completion of chemotherapy. Why some patients develop permanent alopecia rather than temporary, is unknown. (Trueb 2009)
Not all chemotherapy drugs will cause alopecia. Cytotoxic chemotherapy causes differing degrees of alopecia. The degree of alopecia will be increased when a combination of drugs are used and the condition and type of hair.
Chemotherapy induced alopecia is still one of the most common and most emotionally distressing side effects of cancer therapy. It may lead to a negative body image, depression and anxiety (Hurk 2010)
Hair loss for people from Sikh culture is particularly relevant because one of the five symbols of the Sikh religion is Kesh, the uncut hair and beard which symbolizes spirituality. Many devout Sikh men and women never cut their hair, and men never shave or trim their beards.
6.2 Rationale for Scalp Cooling
Cooling the scalp throughout the administration of chemotherapy and for a period of time afterwards, constricts the small blood vessels surrounding the hair follicles, reducing the uptake of cytotoxic drugs thereby reducing the risk of damage to the hair follicle and subsequent hair loss. Epithelial cells concerned with hair formation are among the most rapidly dividing cells of the body and are highly susceptible to drugs that influence cell division.
Hair fibres originate in the flask shaped hair follicles in the skin. At the base of each follicle is a matrix of epithelial cells from which the hair fibre develops.
Each fibre consists of three elements.
- Medulla of soft keratin
- A cortex of closely packed keratinised cells containing melanin and other pigments
- An outer layer overlapping horny keratinised cells (the structure evokes an image of the manner in which roof tiles are laid)
ANAGEN PHASE – Initial stage, hair growth at the follicle base, approximate rate of 0.3mm a day
CATAGEN – Intermediate, short phase, resting phase lasting approximately 2 weeks
TELEGAN PHASE –Hairs gradually loose anchorage in the hair follicle and are slowly shed of a period of about three months (Hopkins 1993)
A new cycle of hair growth then begins
With an average of 85% hair follicles in the anagen phase at any one time, the most common site of hair loss is the scalp.
The majority of other body hair follicles e.g. eyebrows, axilla, pubic hair are in the Catagen and Telegan phase and therefore not initially affected however with multiple exposures these hairs may also be lost as the percentage of hairs entering the anagen phase increases (Dougherty 1996).
Cooling the scalp constricts the small blood vessels that surround the hair follicles therefore reducing the uptake of chemotherapy by these cells. During the infusion time and for a period after the drug concentration reaches a peak plasma level. This is the time when hair follicles are most vulnerable.
Scalp cooling reduces the peak concentration to the scalp but secondary circulation of the chemotherapy agent at a time when drug levels are constant ensure that chemotherapy does reach the scalp.
6.3 The World Health Organization Common Toxicity Criteria
Grade / 0 / 1 / 2 / 3 / 4Alopecia / No Change / Minimal Hair Loss / Moderate, Patchy Hair Alopecia / Complete but reversible Alopecia / Non Reversible Alopecia
(WHO 1998)
6.4 Exceptions and Contradictions The length of the treatment could be a deciding factor as to whether scalp cooling is suitable.
For some patients scalp cooling is contraindicated
Patients receiving continuous chemotherapy are unsuitable due to the time element.
Patients with Haematological malignancies are advised not to have scalp cooling, as there is a possibility of circulating cancer cells within the scalp (Dougherty 2004, Dean et 1l 1979 cited Batchelor 2001).
Patients who have also received cranial radiation/Haematological patients or where there is existing scalp tumours should also not be offered scalp cooling.
The use of scalp cooling is not recommended for patients who suffer from Migraines.
The use of scalp cooling needs to be assessed on an individual basis
6.5 Clinical Practice Guidelines / RATIONALE.
The Paxman scalp cooling system (model Orbis) consists of a small compact refrigeration unit containing a coolant which maintains the temperature between -3.5 and -4°C through coolant lines to specially designed cooling caps. The coolant is pumped through the cooling cap and returned to the coolant tank. The cap is placed on the patient’s head, which reduces the temperature of the scalp to approximately +18°C.Temperature varies over the scalp between +16°C and +19°C
It is simple to operate with no complicated dials or controls, easy to read display, allowing instant visual monitoring. The compact nature and maneuverability of the system ensures an efficient use of space. In confined areas, the cooling unit can be easily placed near to chairs or beds. In large chemotherapy suites, several machines can be working at the same
6.6 Side effects of scalp cooling
Any side effects related to scalp cooling are usually associated with tolerance to the procedure.
Feeling cold, dizziness and headaches appear to be the most common side effects. Patients are usually offered a blanket and given warm drinks to ensure they are kept warm and comfortable. There is the suggestion (Tierney 1987.Macduff et al 2003, Batchelor 2001, Massey 2004 and Belleau 1987) that patients with a history of migraines should not be offered scalp cooling.
The above side effects are worth noting but the major issue that is normally the deciding factor is the increased time of the visit to hospital, which is not always acceptable to the patient.
6.7 Efficacy
The efficacy of scalp cooling is very difficult to predict. There are many varying factors such a liver function, temperature of the scalp cooling system, type and structure of the hair and the drug or combination of drugs used.
Even though Cytotoxic chemotherapy induced alopecia is usually reversible (Arzouman et al 1991 cited Bachelor 2001). The psychological impact is still great.
It is possible to rationalize the onset of alopecia and its affects. However, many patients find difficulty in dealing with the emotional impact (Clement Jones 1985).
Doctors and nurses working in Haematology and Oncology commonly see patients without hair. Therefore it is easy to become accustomed to the concept and view it is small price to pay for acceptance of treatment.
Although hair loss and short hair is more acceptable for men within our society (Batchelor 2001) we as health care professionals should not assume that male patients do not suffer the same psychological trauma in losing their hair and must ensure that all patients receive psychological care not just those demonstrating obvious distress.
Not all chemotherapy drugs cause hair loss. Below is a list of commonly used chemotherapy regimes and a table of the likelihood of hair loss
Drugs which usually do cause hair loss / Drugs which sometimes cause hair loss / Drugs which usually don't cause hair lossAdriamycin / Amsacrine / Methotrexate
Daunorubicin / Cytarabine / Carmustine(BCNU)
Etoposide / Bleomycin / Mitroxantrone
Irinotecan (Campto) / Busulphan / Mitomycin C
Cyclophosphamide / 5 Fluorouracil / Carboplatin
Epirubicin / Melphalan / Cisplatin
Docetaxel, (Taxotere) / Vincristine / Procarbazine
Paclitaxel, (Taxol) / Vinblastine / 6-Mercaptopurine
Ifosphamide / Lomustine(CCNU) / Sreptozotocin
Vindesine / Thiotepa / Fludarabine
Vinorelbine / Gemcitabine / Raltitrexate (Tomudex)
Topotecan / Capecitabine
Recent evidence with the administration of Docetaxol have shown long term significant scalp alopecia (lasting for up to 3.5 years following completion of chemotherapy) may affect 10-15% of patients following docetaxel. This rate is higher than previous estimates. Long term hair loss to other parts of the body was also widely reported.
This risk should be discussed routinely (as part of the process of informed consent) with all patients embarking upon docetaxel (Thorp 2015)
6.8 Record Keeping
All nursing interventions must be documented and although scalp cooling and ordering of wigs may not seem as important as other nursing interventions it is vital that any action is recorded in order for there to be an accurate record.
Written communication should be accurate and not include abbreviations or medical jargon, speculation or be subjective (NMC 2002). Scalp cooling audits are carried out yearly (See Appendix 1).
6.9. Hair Care for all patients
The hair should be washed using a shampoo with a neutral pH, and allowed to dry naturally: Hairdryers and hair care products should be avoided (Macmillian.org). Any treatment such as hair dyes, perming lotions, and colours should not be used. It is normally advised that if people have long hair it is advisable to have it cut shorter to avoid stress to the roots. Cutting the hair short may improve the success of scalp cooling, as there is less weight of hair pulling on the roots.
Browns are currently Portsmouth Hospitals NHS Trust main supplier of wigs. All patients who are receiving chemotherapy that could potentially cause hair loss are entitled to obtain one wig on prescription. A wig request form needs to be completed with all the patient’s details. This should be completed and faxed through to Browns as soon as a decision is made to commence chemotherapy. Ideally, the patient will have an appointment for a wig prior to commencing chemotherapy or within a week of commencing the first treatment. The Macmillan unit at Queen Alexandra Hospital Portsmouth holds a fitting service and has visits from Browns to discuss and support patients.
7. TRAINING REQUIREMENTS
All staff that work within the Combined Oncology/Haematology Day Unit will receive training and competency. This will be from both senior staff on the unit and from Paxman representatives. The training will be done on a yearly basis and will be a competency based assessment.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Allen R 2000 The new Penguin English Dictionary. Penguin Books. London
Arzouman J, Dudas S, Estwing Ferrans C et al 1991quality of life of patients with sarcoma post chemotherapy. Oncology Nursing Forum.18 (5), 889-894
Batchelor D 2001 Hair and cancer chemotherapy: Consequences and nursing care-a literature study. European journal of cancer care. 10,147-163.
Belleau F 1987 Chimiotherapie: Prevenir l’ alopecie. Nursing quebec. 7 (5), 20-23
Bulow J et al 1985 Frontal subcutaneous blood flow and epiand subcutaneous temperatures during scalp cooling in normal man. Scand J Clin Lab Invest.45, 505-8
Cancer BACUP 2004 Possible side effects of some chemotherapy drugs-your hair.
side effects# 1615 10.11.04
Clement –Jones V 1985 cancer and beyond: The formation of BACUP. British Medical Journal.291, 1021-1023.
David J & Speechley V. 1987 Scalp cooling to prevent alopecia. Nursing times. Vol 83, No 32.Pg 36-37
Dougherty L 2006,Alopecia (eds Brighton D & Wood M). In: The royal Marseden Hospital Handbook of Cancer Chemotherapy. Elsevier Churchill Livingstone, Edinghburgh.Chapter 23,pp.197-203
Dougherty L 1996.Scalp cooling to prevent hair loss in chemotherapy. Professional nurse. Vol 11.No 12. Pg 507-509
Dougherty L 2004a drug administration: Cytotoxic drugs. In the royal Marsden Hospital Manual of nursing +proceudures.6th edition. Dougherty L and Lister S (eds). Blackwell Publishing. Oxford.
Dougherty L 2004b Scalp Cooling. In the Royal Marsden of Nursing Procedures. 6th Edition. Dougherty L and Lister S (eds). Blackwell Publishing. Oxford.
Franssen C and Hillen H 1991 Haaruitval door cytostatica. Nederlands Tydschrift Geneeskunde. 135 (24), 1070-1073.
Hopkins S.J 1993 Investigating drug induced alopecia. Nursing Standard. Vol 7. No 20. Pg 38-39.
Van den HurkCJ, Mols F, Vingerhoets AJ,Breed WP. Impact of alopecia and scalp cooling on the well being of breast cancer patients. Psychooncology 19(7),701-709(2010)
MacDuff C, MacKenzie T, Hutcheon A ,Melville L and Archiblad H 2003 The effectiveness of scalp cooling in preventing alopecia for patients receiving Epirubicin and Docetaxol. European journal of cancer care. 12, 154-161
Massey C 2004 A multicentre study to determine the efficacy and patient acceptability of the Paxman scalp cooler to prevent hair loss in patients receiving chemotherapy. European Journal of oncology nursing. 8, 121-130