Scalp Cooling to Prevent Hair Loss in Multiple Myeloma Patients Undergoing Autologous Peripheral Blood Stem Cell Transplantation
Authors: Vescio Robert Allen , Lopiccolo Christopher , Park Amanda , Castillo Rhona , Oveisi David 
Published: December 2023

The best outcomes for multiple myeloma progression-free and overall survival include the use of high-dose melphalan and autologous peripheral blood stem cell transplantation. Melphalan is given at a dose of 140 - 200 mg/m2 as a single dose two days before or in divided daily doses immediately prior to the reinfusion of stem cells. Melphalan causes nearly complete hair loss in all patients at these doses, (CTCAE v5 Grade 2). Hair typically falls out after 10-15 days and doesn't begin to grow back for 10-12 weeks. This outcome is widely expected and leads some patients to avoid doing an otherwise life sustaining procedure. In those that do proceed with the transplant, the alopecia can be emotionally harmful.
Cryotherapy is commonly used to reduce melphalan side effects in the GI tract. Melphalan typically will cause diarrhea, nausea, and mouth sores yet a randomized trial done in 2006 showed that swallowing ice chips for 6 hours starting 30 minutes before the melphalan is given can reduce these unpleasant and potentially dangerous side effects by 60% (Lilleby et. al. 2006). We at Cedars-Sinai routinely have patients do oral cryotherapy for 3.5 hours starting 30 minutes prior to each dose of melphalan. This has reduced patient side effects substantially in our experience and is considered our standard of care.
Chemotherapy drugs, such as melphalan, typically injure bone marrow, intestinal lining and other cells with high metabolism and rapid cell division. Hair follicles also have these properties and is likely why many chemotherapeutics cause hair loss when used. Scalp cooling has been used to prevent hair loss in many patients undergoing chemotherapy for solid tumors. For some women with breast cancer, this hair loss was reported to be more traumatizing than losing a breast to mastectomy (Zhang et. al. 2022). The use of cold caps during chemotherapy exposure time has helped reduce hair loss, presumably by causing vasoconstriction and reducing distribution of the drug to the hair follicle. This intervention has been effective even when drugs which have longer durations of circulation have been given. While there is a theoretical risk that scalp cooling may impair the killing of malignant cells in the scalp by the chemotherapy, there is no evidence of a heightened risk in studies. The penetration of the cold should not reach the skull bone where myeloma cells may reside and is generally to a depth of only a few millimeters. The toxicity of scalp cooling is minimal. In a study of 27 participants using scalp cooling for solid tumors, 96% reported that the procedure was worth the time, effort, cost, and discomfort and would recommend usage to others undergoing the same chemotherapy treatment (Sitarz et. al. 2022).
While scalp cooling has been used to prevent hair loss in patients undergoing chemotherapy for solid tumors, no reports were found for its usage for multiple myeloma or other hematologic malignancies. Since melphalan has a much shorter half-life, (70 minutes), than most other chemotherapy drugs used for solid tumors, it is anticipated that scalp cooling will be more efficacious when used with this drug. In fact, after 5 hours the concentration of melphalan should only be 5% of that present immediately after administration.
A 57-year-old patient with multiple myeloma undergoing high-dose chemotherapy with melphalan 200 mg/m2 opted to use the commercially available Penguin Cold Cap to prevent losing her hair. The device was started 60 minutes before and continued for 5 hours after the melphalan infusion was started at Day -2 and Day -1 prior to her autologous stem cell transplant. The procedure was well tolerated, and the patient had no signs of any hair loss after the stem cell transplant. Based upon this experience, a study was initiated to further assess the efficacy of scalp cooling with the Penguin Cold Cap device in multiple myeloma patients receiving autologous stem cell transplants. An update with results of this study will be presented at the meeting. A positive outcome may improve the percentage of people willing to undergo this life-sustaining procedure and improve the quality of life of those who do it.