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Thermal Injury in a Patient Using a Scalp Cooling System to Prevent Chemotherapy-Induced Alopecia
Chemotherapy-induced alopecia (CIA) is an emotionally distressing complication of cancer treatment, with negative impacts on quality of life, body image, and rates of depression.1 Scalp-cooling techniques have emerged as an effective intervention to prevent CIA. These methods are thought to reduce follicular metabolism and promote scalp capillary vasoconstriction, ultimately minimizing the effects of chemotherapy on the hair follicle. Scalp cooling is well tolerated, with mild and temporary adverse effects reported.2
Manual gel-filled cold cap devices (Elasto-Gel [Southwest Technologies, Kansas City, MO], Penguin Cold Caps [Penguin Cold Caps, London, UK]) achieve temperatures of –15° to –40°C using dry ice or freezers. Scalp cooling systems (SCSs; Paxman [Paxman, Huddersfield, UK], Dignicap [Dignitana, Dallas, TX]), circulate coolant through a silicone cap at temperatures from 3° to 8°C. Ideal scalp temperature for optimal results is less than 22°C.4 Belum et al3 reported four cases of cold thermal injury (CTI) using manual cold caps, citing three potential contributory factors: lack of adequate padding between cap and skin, duration of post-infusion cooling, and preexisting CIA. Although the potential for injury related to rewarming procedures was not observed in their patients, the authors warn about it. Here we present, to our knowledge, the first reported case of CTI with an SCS and the first instance of potential reperfusion injury related to scalp hypothermia.
A 60-year-old woman with stage IA breast cancer initiated cycle 1 of intravenous (IV) docetaxel and cyclophosphamide. The patient used the Paxman SCS for 2.5 hours during pre-cooling and infusion and immediately transitioned to another machine for the 90-minute post-cooling session. After 15 minutes of post-cooling, a kink was discovered in the hose, hindering coolant flow to the cap. When remedied, the patient reported a rush of cold followed by diffuse scalp pain, burning, and prickling. After 15 minutes, symptoms resolved and she reported numbness for the remaining time. Upon cap removal, it was discovered that the protective headband had shifted off the forehead resulting in direct scalp-to-cap contact. That evening, the patient reported numbness and a blue hue on the anterior forehead.
The next day, the patient presented with facial swelling and blistering along with numbness and erythema of the forehead (Fig 1). She was treated with diphenhydramine 50 mg IV and famotidine 20 mg IV followed by diphenhydramine 50 mg by mouth once every 6 hours, mupirocin 2% ointment, and petroleum jelly. Six days later (Fig 2), two punch biopsies were performed by a dermatologist. Findings regarding the anterior forehead skin, which came in direct contact with cap, showed hyperkeratosis, vacuolar interface changes, dyskeratotic cells with dysmaturation, and focal dermal edema consistent with frostbite. The hair-bearing portion of the scalp showed no histologic abnormality.
Fig 1. Facial swelling with erythema and blistering of the anterior forehead 1 day after the first infusion of intravenous docetaxel and cyclophosphamide after using the Paxman scalp cooling system to prevent chemotherapy-induced alopecia.
Fig 2. The patient reported slightly improved but continued numbness in the area at 6 days after using the scalp cooling system. Wound weeping and peripheral hyperpigmentation were seen on examination.
The patient did not use the SCS during future infusions and developed diffuse CIA. Eight weeks after the event, she presented with post-inflammatory hyperpigmentation and reported that the numbness in her forehead had improved (Fig 3). Five months after the injury and 2 months after exposure to docetaxel, the patient presented with 1.5 cm of hair regrowth and near-normal sensation in her forehead.
Fig 3. The patient presented with no patches of hair loss at 8 weeks after using the scalp cooling system. Atrophy of anterior forehead was seen upon palpation and mild post-inflammatory hyperpigmentation was present.
To our knowledge, this is the first reported case of CTI resulting from use of an SCS. CTI may have been caused by two independent deviations from the protocol for the device: (1) movement of the protective headband, which allowed the skin to come into direct contact with the device, and (2) the introduction of a period of scalp warming, which simulated a freeze-thaw cycle. Freeze-thaw cycles are hypothesized to potentiate the extent of injury in patients with frostbite whereby skin warming causes vasodilation and reperfusion; when this is followed by abrupt freezing, rapid cell lysis occurs.5
Although SCSs offer finer control of temperature and exposure time, a risk remains for periods of warming and subsequent CTI, for example, when patients have to be disconnected so they can use the restroom. This case reinforces the need for vigilance when using scalp hypothermia devices and raises the possibility that improper use can cause lasting cosmetic and neurologic damage to patients.
Conception and design: Dina Hagigeorges, Laura J. Burns, Steven J. Isakoff, Maryanne M. Senna
Financial support: Steven J. Isakoff
Provision of study materials or patients: Steven J. Isakoff, Laura Spring
Collection and assembly of data: All authors
Data analysis and interpretation: Dina Hagigeorges, Laura J. Burns, Steven J. Isakoff, Maryanne M. Senna
Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/authors/author-center.
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Consulting or Advisory Role: Myriad Genetics, Hengrui Therapeutics, Puma Biotechnology, Immunomedics, Mylan, AbbVie, OncoPep
Research Funding: Genentech (Inst), PharmaMar (Inst), AbbVie (Inst), OncoPep (Inst), Merck (Inst), AstraZeneca/MedImmune (Inst)
Honoraria: DAVA Oncology, Clinical Care Options
Consulting or Advisory Role: Novartis, Puma Biotechnology, Lumicell
Research Funding: TESARO (Inst), Merck (Inst)
Travel, Accommodations, Expenses: TESARO, Merck
Honoraria: Concert Pharmaceuticals
Consulting or Advisory Role: Cassiopea, Arena Pharmaceuticals
Research Funding: Follica
No other potential conflicts of interest were reported.
| 1. | Choi EK, Kim IR, Chang O, et al: Impact of chemotherapy-induced alopecia distress on body image, psychosocial well-being, and depression in breast cancer patients. Psychooncology 23:1103-1110, 2014 Medline, Google Scholar |
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| 3. | Belum VR, de Barros Silva G, Laloni MT, et al: Cold thermal injury from cold caps used for the prevention of chemotherapy-induced alopecia. Breast Cancer Res Treat 157:395-400, 2016 Medline, Google Scholar |
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