Cold thermal injury from cold caps used for the prevention of chemotherapy-induced alopecia

Abstract

Introduction: The use of scalp cooling for the prevention of chemotherapy-induced alopecia (CIA) is increasing. Cold caps are placed onto the hair-bearing areas of the scalp for varying time periods before, during, and after cytotoxic chemotherapy. Although not yet reported, improper application procedures could result in adverse events (AEs). At present, there are no evidence-based scalp cooling protocols, and there is no regulatory oversight of their use.

Objective: To report the occurrence of cold thermal injury (frostbite) on the scalp, following the use of cold caps for the prevention of CIA.

Materials and methods: We identified four patients who developed cold thermal injuries on the scalp following the application of cold caps. Medical records were analyzed to retrieve the demographic and clinical characteristics.

Results: The cold thermal injuries in our patients were grade 1/2 in severity and improved with topical interventions and interruption of cold cap use, although grade 1 persistent alopecia ensued in 3 patients. The true incidence of such injuries in this setting, however, remains unknown.

Conclusions: Cold thermal injuries are likely infrequent and preventable AEs that may result from improper device application procedures during cold cap use. Although these untoward events are usually mild to moderate in severity, the potential occurrence of long-term sequelae (e.g., permanent alopecia and scarring) or the need to discontinue cold cap use, are not known. Prospective studies are needed to further elucidate the risk and standardize healthcare delivery methods, and to improve patient/supportive/healthcare provider education.

Keywords: Chemotherapy-induced alopecia; Cold caps; Cryotherapy; Frostbite; Scalp hypothermia; Thermal injury.

Figure 1A

Scalp changes in a 49-year-old woman with stage IIA invasive ductal carcinoma, following improper cold cap application procedures for the prevention of CIA (adjuvant TCHP). Post-inflammatory hyperpigmentation over the upper mid-forehead (distal to the frontal hairline), 1 week after the 3^rd chemotherapy cycle/cold cap use. Note the arcuate violaceous patch with sharply demarcated borders and localized alopecia. (Inset) Large patch of alopecia on the frontal scalp, approximately 4 weeks after the 3^rd chemotherapy cycle/cold cap use.

Figure 1B

Cold thermal injury in a 55-year-old woman with triple-negative stage IIA invasive ductal carcinoma, following the use of cold caps for the prevention of further alopecia (adjuvant AC-T). Note the fluid-filled bulla (~4 cm) over an erythematous and edematous plaque (10 cm) on the left parietal scalp, appearing after the 3^rd chemotherapy cycle (paclitaxel)/cold cap use.

Figure 1C

Localized alopecia (white dotted lines) on the background of diffuse hair thinning in a 58-year-old woman with ER+/PR+/Her2−, metastatic breast cancer—approximately 3 weeks after the first cold thermal injury (blistering and crusting). The localized alopecia occurred after one instance of cold cap use on a scalp that had already developed diffuse paclitaxel-induced alopecia.

Figure 1D

Mild persistent alopecia due to cold thermal injury in a 50-year-old female with stage IA, invasive ductal carcinoma, following the improper application of Penguin cold caps to prevent chemotherapy-induced alopecia. Note the hair thinning in a localized area of the scalp (crown), at 6 months after the 1st chemotherapy infusion/cold cap use.