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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Alopecia can have a substantial social and psychological impact on patients who receive chemotherapy&#46; The side effect is considered the most concerning aspect of treatment for between 47&#37; and 58&#37; of treated patients and it can influence the choice of treatment in up to 8&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> Not all treatments cause alopecia&#44; and the risk varies for the different agents&#46; The onset of alopecia usually occurs within 1&#8211;2 weeks of starting treatment&#44; and is complete in the first to second month&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> In most cases&#44; but not always&#44; it is reversible&#44; and often when hair does grow back it is with changes in form&#44; color&#44; and quantity&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> Although in recent years certain strategies have been studied and implemented&#44; such as the use of scalp cooling systems&#44; in daily practice&#44; there is still uncertainty regarding their effectiveness and even some debate about whether these strategies may be harmful&#46; The aim of this review is to analyze the available evidence on the effects&#44; effectiveness&#44; and safety of these techniques&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Chemotherapy and Alopecia</span><p id="par0010" class="elsevierStylePara elsevierViewall">Hair is a skin appendage with several different functions &#40;temperature regulation&#44; protection&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> Every hair is comprised of 3 layers &#40;medulla&#44; cortex&#44; and cuticle&#41;&#44; and is the product of the hair follicle&#46; The base of the hair follicle is composed of the hair bulb&#44; made up of the dermal papilla and hair matrix &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The dermal papilla controls the number of keratinocytes of the matrix&#44; which is what determines the size of the hair shaft&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> Damage to this part of the hair leads to nonscarring alopecias&#46; The epithelial stem cells reside in the matrix of the hair follicle bulge &#40;in the medial part of the follicle&#41;&#59; damage to this structure can lead to irreversible alopecia&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Once formed&#44; the hair follicles follow life cycles characterized by periods of growth &#40;anagen&#41;&#44; regression &#40;catagen&#41;&#44; and rest &#40;telogen&#41;&#44; after which shedding occurs &#40;exogen&#41;&#46; At a given time&#44; between 80&#37; and 90&#37; of hairs are in the anagen phase&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> During this phase&#44; mitotically active cells of the matrix in the hair bulb differentiate and divide&#44; leading to a rate of hair growth of approximately 0&#46;35<span class="elsevierStyleHsp" style=""></span>mm per day in the case of scalp hair&#44; for a period of 2&#8211;6 years&#46; Between 1&#37; and 3&#37; are in catagen&#44; the transition phase&#44; where growth stops and the follicle regresses with apoptosis&#46; Between approximately 5&#37; and 10&#37; of the remaining follicles are in telogen&#44; during which all mitotic activity stops and the hair acquires a characteristic aspect of the phase&#44; fully keratinized&#44; and ready to be shed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The term alopecia refers to the partial or total absence of hair in any area where hair normally grows&#46; Chemotherapy-induced alopecia is most prominent on the scalp&#44; with a predilection for areas with low total hair density&#44; such as the crown and frontal areas&#44; where hair recovery is slower&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Cytotoxic chemotherapy causes death by apoptosis in cells that are in the process of mitotic division&#44; and this includes the keratinocytes proliferating in the hair bulb&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> This causes alopecia essentially through 3 mechanisms &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">If keratinocyte proliferation in the matrix of the hair follicle is severely inhibited&#44; the hair can separate in the bulb and shed&#44; in a process denoted anagen effluvium&#44; with abrupt loss of hair in the growth phase&#46; Less common is dystrophic anagen effluvium&#44; in which alopecia is less severe&#46; In this case&#44; there is essentially a delay in hair growth due to delayed keratinocyte proliferation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand&#44; constrictions may arise that result in breakage of the hair stem at the follicular orifice during the resting or telogen phase&#44; known as telogen effluvium&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> Nonlethal damage to the proliferating keratinocytes may generate proliferative responses as a defense mechanism in some sectors&#44; which explains patched or uneven alopecia observed in some cases&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Whether alopecia is reversible or not depends on the extent of damage to stem cells in the bulge&#46; Given that most are in a quiescent state while treatment is applied&#44; not all cells are affected&#44; and chemotherapy-induced alopecia can be reversible&#46; The hair follicle restarts a normal cycle with the surviving keratinocytes once treatment has been discontinued&#44; and hair growth becomes evident in 3 to 6 months&#46; The regrowing hair often has different characteristics to the original hair&#46; Overall&#44; 65&#37; experience greying&#44; curling&#44; or straightening&#44; probably due to the differential effects of chemotherapy on follicular melanocytes and the epithelium of the inner root sheath&#44; and these effects often resolve with time&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> Prolonged and even irreversible alopecia has been reported with some agents such as taxanes&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The risk of chemotherapy-induced alopecia varies according to the agent used&#44; and often depends on the dosing regimen &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Several studies have assessed pharmacological interventions with a view of preventing hair follicle damage caused by chemotherapy&#44; but to date&#44; none of these have been approved by regulatory agencies&#46; Topical minoxidil is known for use in androgenic alopecia&#46; Studies have also evaluated this agent in preventing chemotherapy-induced alopecia&#44; with application of 2&#37; solution twice a day&#44; but without showing any preventive effect for severe alopecia&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a> Likewise&#44; other drugs such as finasteride&#44; spironolactone&#44; and topical calcitriol have not shown satisfactory results&#44; and there are safety concerns due to estrogen elevations in many cases &#40;which we know are harmful for breast cancer cells&#44; and breast cancer would be one of the most frequent indications for alopecia prevention&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Alopecia Prevention with Cooling Caps</span><p id="par0055" class="elsevierStylePara elsevierViewall">In the absence of pharmacological strategies&#44; therapeutic approaches have aimed at physically reducing the amount of drug reaching the hair bulb&#46; One of these consists of cooling the scalp using a variety of different strategies&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Scalp cooling is thought to act by causing vasoconstriction of blood vessels&#44; reducing the amount of cytostatic agents reaching the scalp&#44; decreasing the metabolic ratio of the follicle cells&#44; and also decreasing absorption of chemotherapy agents by the cells&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Different types of cold therapy or scalp cooling have been used in different scenarios&#44; and with different chemotherapy regimens&#46; The use of these scalp cooling systems is recommended in the National Comprehensive Cancer Network guidelines with a level of evidence IIA<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a> and also in the new guidelines for management of adverse effects issued by theEuropean Society for Medical Oncology&#44; with a level of evidence IIB&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">There are 2 automatic devices approved by the US Food and Drug Administration for treatment with polychemotherapy in solid tumors&#44; based on prospective clinical trials in patients with breast cancer&#46; Efficacy is variable and depends on the type and intensity of chemotherapy&#44; with significantly lower hair preservation in patients who receive anthracycline-based regimens compared with regimens not based on anthracyclines&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The approved automatic devices use a portable cooling unit that circulates a refrigerant to maintain the scalp temperature within a narrow range&#46; Other unapproved devices are also available &#40;for example frozen gel caps&#41; which are thought to lower the temperature more than automatic ones&#46; The caps are changed once they have lost their coldness&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Regardless of the specific device used&#44; it should be put in place approximately 30&#8211;45<span class="elsevierStyleHsp" style=""></span>min before the chemotherapy infusion begins to allow gradual cooling of the scalp&#46; The cooling is maintained for a period of time after the end of the infusion&#44; generally at least 90<span class="elsevierStyleHsp" style=""></span>min&#44; depending on the regimen and agents&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Several prospective studies have assessed automatic devices for cooling the scalp in women with early-stage breast cancer&#46; There are no prospective studies available to evaluate the efficacy of nonautomatic devices&#44; or in other types of tumor&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In a prospective multicenter cohort study published in JAMA in 2017&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> 101 patients with early-stage breast cancer who received taxane-based chemotherapy without anthracyclines and who used the DigniCap device were compared with 16 controls&#46; Alopecia of less than 50&#37; was observed in 66&#46;3&#37; in the intervention group compared with none in the contol group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; In addition&#44; the perception of hair loss&#44; sense of being bothered by hair loss&#44; and feeling less physically attractive improved&#46; The most frequent adverse effect was mild headache&#44; and 3 patients stopped using the device due to feeling cold&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">A second randomized study&#44; also published in JAMA in 2017 &#40;the SCALP trial<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a>&#41; randomized 182 patients in a 2&#58;1 ratio to use of the Paxman&#174; device or no intervention during chemotherapy for breast cancer&#46; Overall&#44; 36&#37; received anthracycline-based chemotherapy&#44; whereas the rest received taxane monotherapy or taxane in combination with carboplatin&#44; cyclophosphamide&#44; pertuzumab&#44; and&#47;or trastuzumab&#46; A successful outcome was defined as less than 50&#37; hair loss with a wig not required at the end of chemotherapy&#46; This outcome measure was assessed by a physician who was not aware of the group to which the patient had been randomized&#46; The device was considered successful in 50&#46;5&#37; of patients&#44; while no success was reported in the control group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0061&#41;&#46; Adverse events were all grade 1 and 2&#44; and were mainly headache or feeling cold&#46; A post-hoc exploratory analysis indicated that only 16&#37; of the patients who received anthracycline-based chemotherapy reported a successful outcome&#44; in comparison with 59&#37; of those who had taxane-based one&#44; although the confidence intervals were very broad&#46; This analysis is therefore considered to support the hypothesis that efficacy is lower in anthracycline-based regimens &#40;hypothesis generating&#41;&#46; A Japanese study used the same device and reported similar results&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The COOLHAIR study also evaluated the DigniCap&#174; in 79 patients with early-stage breast cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> Hair was preserved in 39&#46;3&#37; of patinets in the group who used cold caps compared with none in the control group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; Wig use was significantly lower &#40;40&#46;7&#37; vs&#46; 95&#46;5&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; In 2019&#44; a fourth study was published&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> This study evaluated the DigniCap&#174; device in 139 patients with early-stage breast cancer who received chemotherapy&#46; Most patients &#40;95&#37;&#41; received at least 4 cycles of anthracycline-based chemotherapy&#44; and then sequential taxanes&#46; When the device could be used in all chemotherapy cycles&#44; 43&#37; lost less than 50&#37; of their hair&#46; Nine patients discontinued treatment due to adverse events&#46; In 2020&#44; DigniCap&#174; was studied in 135 patients with early-stage breast cancer &#40;adjuvant therapy in 74&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> The success rate in preventing alopecia was 60&#37; &#40;81&#47;135&#41; at 3 weeks after the end of treatment&#46; Higher success rates were reported with anthracycline-free regimens &#40;taxane plus cyclophosphamide&#41; &#40;71&#37;&#41; in comparison with anthracycline-containing regimens &#40;54&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A metaanalysis in 2015 included the 3 aforementioned randomized clinical trials&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> The authors concluded that scalp cooling was the only intervention that significantly reduced the risk of chemotherapy-induced alopecia &#40;RR of 0&#46;38&#44; 95&#37; CI 0&#46;32&#8211;0&#46;45&#41;&#46; No significant adverse events were reported associated with the intervention&#44; although the studies did not always conduct long-term follow-up of toxicity&#46; A subgroup analysis suggested a similar degree of efficacy for scalp cooling regardless of the type of tumor&#44; but most of the patients included had breast cancer and data for other types of tumor were not presented by tumor type&#46; Another metaanalysis published in 2018<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> in 654 patients &#40;66&#37; with breast cancer&#41; concluded&#44; with a moderate level of evidence&#44; that cooling caps can significantly reduce alopecia &#40;greater than 50&#37;&#41; compared with control &#40;RR 0&#46;57 95&#37; CI 0&#46;45&#8211;0&#46;72&#59; <span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;00001&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Adverse events reported with scalp cooling are generally mild and include discomfort for the patient&#44; for example&#44; a feeling of cold&#44; headache&#44; nausea&#44; dry skin&#44; and claustrophia&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">23&#8211;25</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In the literature&#44; there are reports of concern over the possibility of increased risk of scalp metastasis with the use of these devices&#46; The incidence of metastasis has been most extensively studied in breast cancer&#44; where the risk was reported as very low&#46; The aforementioned studies have not reported a significant association&#46; In a systematic review and metaanalysis in 2017&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> among the 1959 patients who used cooling caps&#44; with a follow-up of 43&#46;1 months&#44; there was a rate of scalp metastasis of 0&#46;61&#37; &#40;95&#37; CI&#44; 0&#46;32&#8211;1&#46;1&#41; compared with 0&#46;41&#37; in the control group of 1238 patients &#40;95&#37; CI&#44; 0&#46;13&#8211;0&#46;94&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;43&#41;&#46; In the prospective DigniCap study described above&#44; no patient developed scalp metastasis with a median follow-up of 4 years&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">As we have discussed above&#44; the main body of evidence comes from patients with localized breast cancer treated with anthracyclines and taxanes&#44; but these devices have been used with other chemotherapy regimens and in other tumors&#44; as well as in patients receiving palliative care&#44; in whom alopecia has a major impact on quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">It is important to remember that the strategy may not be appropriate in all cases&#46; It is not recommended in pediatric patients&#44; given that it has not been studied in this population&#46; Those who receive continuous infusions lasting for 24<span class="elsevierStyleHsp" style=""></span>h or more and those who receive head radiotherapy are not considered good candidates &#40;lack of evidence&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a> The intervention is contraindicated in patients with diseases caused by cryglobulins&#44; cryoglobulinemia&#44; and post-traumatic dystrophy caused by cold&#44; and its use is not recommended in patients with hematologic neoplasms&#44; including leukemia and some forms of lymphoma&#44; and in those who undergo bone marrow or stem cell transplantation with myelosuppressive doses of chemotherapy and&#47;or radiotherapy&#46; It is important to consider that safety data are not available for scalp metastasis in any of the tumor types with a high propensity for cutaneous metastasis &#40;such as some lung cancers or skin cancers&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Recently&#44; both approved devices &#40;DigniCap&#174; and Paxman&#174;&#41; were available in several oncology departments in Europe&#44; including in Spain&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0135" class="elsevierStylePara elsevierViewall">The use of automatic cooling caps is an approved option and generally well tolerated for preventing alopecia&#44; essentially in adjuvant treatment for breast cancer&#44; although it has been extrapolated to other tumors and scenarios with certain caveats&#46; There are no prospective studies with other types of cooling caps &#40;for example&#44; gel&#41; and so it is not known whether the results can be extrapolated&#46; In anthracycline-based regimens&#44; success rates are lower&#46; The technique does not appear to increase the risk of cutaneous metastasis in the scalp in patients with early-stage breast cancer or compromise the oncological outcomes &#40;although longer follow-up is required&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chemotherapy-induced hair loss in cancer is usually temporary but can take a significant emotional toll on patients and lead to treatment refusal in many cases&#46; Although hair loss is usually reversible&#44; regrowth can take months&#44; causing greater psychological distress&#46; Recent years have seen the emergence of cold caps&#44; or scalp cooling systems&#44; designed to prevent or at least reduce chemotherapy-induced hair loss&#46; The results to date are encouraging&#46; We review the evidence on the effects and effectiveness of these systems&#44; which are making their way into routine clinical practice&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La alopecia es un efecto generalmente transitorio del tratamiento con citost&#225;ticos&#44; generador de una importante repercusi&#243;n emocional en el tratamiento contra el c&#225;ncer&#44; muchas veces responsable de rechazo de distintas maniobras terap&#233;uticas&#46; Si bien en la mayor&#237;a de los casos es reversible&#44; esto puede involucrar meses&#44; amplificando el impacto&#44; sobre todo psicol&#243;gico&#44; de los tratamientos&#46; En los &#250;ltimos a&#241;os han surgido estrategias con gorras de fr&#237;o&#44; o &#8220;scalp cooling system&#8221; que buscan prevenir&#44; o al menos limitar&#44; este efecto adverso&#44; con resultados que se han mostrado promisorios&#46; El objetivo de esta revisi&#243;n es analizar la evidencia con la que contamos respecto a los efectos y eficacia de este tipo de t&#233;cnicas que han empezado a inmiscuirse dentro de nuestra pr&#225;ctica cl&#237;nica diaria&#46;</p></span>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Chon et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleInterRef" id="intr0005" href="http://www.bccancer.bc.ca/drug-database-site">http&#58;&#47;&#47;www&#46;bccancer&#46;bc&#46;ca&#47;drug-database-site</span>&#46;</p>"
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                  \t\t\t\t">- Doxorubicin<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> &#40;100&#37;&#41;- Epirubicin<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> &#40;70&#8211;96&#37;&#41;- Paclitaxel every 3 weeks &#40;83&#8211;93&#37;&#41;- Docetaxel &#40;76&#8211;85&#37;&#41;- Ifosfamide &#40;1&#8211;83&#37;&#41;- Cyclophosphamide iv &#40;&#62;300<span class="elsevierStyleHsp" style=""></span>m&#47;m<span class="elsevierStyleSup">2</span>&#41; &#40;40&#8211;60&#37;&#41;- Etoposide &#40;8&#8211;66&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">- Methotrexate &#40;1&#8211;10&#37;&#41;- Carboplatin AUC 5&#8211;6 &#40;2&#8211;3&#37;&#41;- Weekly paclitaxel &#40;10&#8211;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">- Bleomycin&nbsp;\t\t\t\t\t\t\n
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Practical Dermatology
Chemotherapy, Alopecia, and Scalp Cooling Systems
Alopecia, quimioterapia y gorras de frío o «scalp cooling system»
D. Amarilloa,b,
Corresponding author
, D. De Bonic, M. Cuellod
a Servicio de Oncología Clínica, Hospital de Clínicas, Facultad de Medicina, Universidad de La Republica, Montevideo, Uruguay
b Departamento Básico de Medicina, Hospital de Clínicas, Facultad de Medicina, Universidad de La Republica, Montevideo, Uruguay
c Dermatóloga en Instituto Nacional del Cáncer, Montevideo, Uruguay, Integrante de Unidad de Oncología Cutánea, Servicio de Oncología Clínica, Hospital de Clínicas, Facultad de Medicina, Universidad de La Republica, Montevideo, Uruguay
d Servicio de Oncología Clínica, Hospital de Clínicas, Facultad de Medicina, Universidad de La Republica, Montevideo, Uruguay
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Alopecia and chemotherapy&#46; Main sites where chemotherapy affects the hair cycle and generates alopecia &#40;image created with BioRender&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Alopecia can have a substantial social and psychological impact on patients who receive chemotherapy&#46; The side effect is considered the most concerning aspect of treatment for between 47&#37; and 58&#37; of treated patients and it can influence the choice of treatment in up to 8&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> Not all treatments cause alopecia&#44; and the risk varies for the different agents&#46; The onset of alopecia usually occurs within 1&#8211;2 weeks of starting treatment&#44; and is complete in the first to second month&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> In most cases&#44; but not always&#44; it is reversible&#44; and often when hair does grow back it is with changes in form&#44; color&#44; and quantity&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> Although in recent years certain strategies have been studied and implemented&#44; such as the use of scalp cooling systems&#44; in daily practice&#44; there is still uncertainty regarding their effectiveness and even some debate about whether these strategies may be harmful&#46; The aim of this review is to analyze the available evidence on the effects&#44; effectiveness&#44; and safety of these techniques&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Chemotherapy and Alopecia</span><p id="par0010" class="elsevierStylePara elsevierViewall">Hair is a skin appendage with several different functions &#40;temperature regulation&#44; protection&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> Every hair is comprised of 3 layers &#40;medulla&#44; cortex&#44; and cuticle&#41;&#44; and is the product of the hair follicle&#46; The base of the hair follicle is composed of the hair bulb&#44; made up of the dermal papilla and hair matrix &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The dermal papilla controls the number of keratinocytes of the matrix&#44; which is what determines the size of the hair shaft&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> Damage to this part of the hair leads to nonscarring alopecias&#46; The epithelial stem cells reside in the matrix of the hair follicle bulge &#40;in the medial part of the follicle&#41;&#59; damage to this structure can lead to irreversible alopecia&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Once formed&#44; the hair follicles follow life cycles characterized by periods of growth &#40;anagen&#41;&#44; regression &#40;catagen&#41;&#44; and rest &#40;telogen&#41;&#44; after which shedding occurs &#40;exogen&#41;&#46; At a given time&#44; between 80&#37; and 90&#37; of hairs are in the anagen phase&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> During this phase&#44; mitotically active cells of the matrix in the hair bulb differentiate and divide&#44; leading to a rate of hair growth of approximately 0&#46;35<span class="elsevierStyleHsp" style=""></span>mm per day in the case of scalp hair&#44; for a period of 2&#8211;6 years&#46; Between 1&#37; and 3&#37; are in catagen&#44; the transition phase&#44; where growth stops and the follicle regresses with apoptosis&#46; Between approximately 5&#37; and 10&#37; of the remaining follicles are in telogen&#44; during which all mitotic activity stops and the hair acquires a characteristic aspect of the phase&#44; fully keratinized&#44; and ready to be shed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The term alopecia refers to the partial or total absence of hair in any area where hair normally grows&#46; Chemotherapy-induced alopecia is most prominent on the scalp&#44; with a predilection for areas with low total hair density&#44; such as the crown and frontal areas&#44; where hair recovery is slower&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Cytotoxic chemotherapy causes death by apoptosis in cells that are in the process of mitotic division&#44; and this includes the keratinocytes proliferating in the hair bulb&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> This causes alopecia essentially through 3 mechanisms &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">If keratinocyte proliferation in the matrix of the hair follicle is severely inhibited&#44; the hair can separate in the bulb and shed&#44; in a process denoted anagen effluvium&#44; with abrupt loss of hair in the growth phase&#46; Less common is dystrophic anagen effluvium&#44; in which alopecia is less severe&#46; In this case&#44; there is essentially a delay in hair growth due to delayed keratinocyte proliferation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand&#44; constrictions may arise that result in breakage of the hair stem at the follicular orifice during the resting or telogen phase&#44; known as telogen effluvium&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> Nonlethal damage to the proliferating keratinocytes may generate proliferative responses as a defense mechanism in some sectors&#44; which explains patched or uneven alopecia observed in some cases&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Whether alopecia is reversible or not depends on the extent of damage to stem cells in the bulge&#46; Given that most are in a quiescent state while treatment is applied&#44; not all cells are affected&#44; and chemotherapy-induced alopecia can be reversible&#46; The hair follicle restarts a normal cycle with the surviving keratinocytes once treatment has been discontinued&#44; and hair growth becomes evident in 3 to 6 months&#46; The regrowing hair often has different characteristics to the original hair&#46; Overall&#44; 65&#37; experience greying&#44; curling&#44; or straightening&#44; probably due to the differential effects of chemotherapy on follicular melanocytes and the epithelium of the inner root sheath&#44; and these effects often resolve with time&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> Prolonged and even irreversible alopecia has been reported with some agents such as taxanes&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The risk of chemotherapy-induced alopecia varies according to the agent used&#44; and often depends on the dosing regimen &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Several studies have assessed pharmacological interventions with a view of preventing hair follicle damage caused by chemotherapy&#44; but to date&#44; none of these have been approved by regulatory agencies&#46; Topical minoxidil is known for use in androgenic alopecia&#46; Studies have also evaluated this agent in preventing chemotherapy-induced alopecia&#44; with application of 2&#37; solution twice a day&#44; but without showing any preventive effect for severe alopecia&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a> Likewise&#44; other drugs such as finasteride&#44; spironolactone&#44; and topical calcitriol have not shown satisfactory results&#44; and there are safety concerns due to estrogen elevations in many cases &#40;which we know are harmful for breast cancer cells&#44; and breast cancer would be one of the most frequent indications for alopecia prevention&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Alopecia Prevention with Cooling Caps</span><p id="par0055" class="elsevierStylePara elsevierViewall">In the absence of pharmacological strategies&#44; therapeutic approaches have aimed at physically reducing the amount of drug reaching the hair bulb&#46; One of these consists of cooling the scalp using a variety of different strategies&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Scalp cooling is thought to act by causing vasoconstriction of blood vessels&#44; reducing the amount of cytostatic agents reaching the scalp&#44; decreasing the metabolic ratio of the follicle cells&#44; and also decreasing absorption of chemotherapy agents by the cells&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Different types of cold therapy or scalp cooling have been used in different scenarios&#44; and with different chemotherapy regimens&#46; The use of these scalp cooling systems is recommended in the National Comprehensive Cancer Network guidelines with a level of evidence IIA<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a> and also in the new guidelines for management of adverse effects issued by theEuropean Society for Medical Oncology&#44; with a level of evidence IIB&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">There are 2 automatic devices approved by the US Food and Drug Administration for treatment with polychemotherapy in solid tumors&#44; based on prospective clinical trials in patients with breast cancer&#46; Efficacy is variable and depends on the type and intensity of chemotherapy&#44; with significantly lower hair preservation in patients who receive anthracycline-based regimens compared with regimens not based on anthracyclines&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The approved automatic devices use a portable cooling unit that circulates a refrigerant to maintain the scalp temperature within a narrow range&#46; Other unapproved devices are also available &#40;for example frozen gel caps&#41; which are thought to lower the temperature more than automatic ones&#46; The caps are changed once they have lost their coldness&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Regardless of the specific device used&#44; it should be put in place approximately 30&#8211;45<span class="elsevierStyleHsp" style=""></span>min before the chemotherapy infusion begins to allow gradual cooling of the scalp&#46; The cooling is maintained for a period of time after the end of the infusion&#44; generally at least 90<span class="elsevierStyleHsp" style=""></span>min&#44; depending on the regimen and agents&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Several prospective studies have assessed automatic devices for cooling the scalp in women with early-stage breast cancer&#46; There are no prospective studies available to evaluate the efficacy of nonautomatic devices&#44; or in other types of tumor&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In a prospective multicenter cohort study published in JAMA in 2017&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> 101 patients with early-stage breast cancer who received taxane-based chemotherapy without anthracyclines and who used the DigniCap device were compared with 16 controls&#46; Alopecia of less than 50&#37; was observed in 66&#46;3&#37; in the intervention group compared with none in the contol group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; In addition&#44; the perception of hair loss&#44; sense of being bothered by hair loss&#44; and feeling less physically attractive improved&#46; The most frequent adverse effect was mild headache&#44; and 3 patients stopped using the device due to feeling cold&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">A second randomized study&#44; also published in JAMA in 2017 &#40;the SCALP trial<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a>&#41; randomized 182 patients in a 2&#58;1 ratio to use of the Paxman&#174; device or no intervention during chemotherapy for breast cancer&#46; Overall&#44; 36&#37; received anthracycline-based chemotherapy&#44; whereas the rest received taxane monotherapy or taxane in combination with carboplatin&#44; cyclophosphamide&#44; pertuzumab&#44; and&#47;or trastuzumab&#46; A successful outcome was defined as less than 50&#37; hair loss with a wig not required at the end of chemotherapy&#46; This outcome measure was assessed by a physician who was not aware of the group to which the patient had been randomized&#46; The device was considered successful in 50&#46;5&#37; of patients&#44; while no success was reported in the control group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0061&#41;&#46; Adverse events were all grade 1 and 2&#44; and were mainly headache or feeling cold&#46; A post-hoc exploratory analysis indicated that only 16&#37; of the patients who received anthracycline-based chemotherapy reported a successful outcome&#44; in comparison with 59&#37; of those who had taxane-based one&#44; although the confidence intervals were very broad&#46; This analysis is therefore considered to support the hypothesis that efficacy is lower in anthracycline-based regimens &#40;hypothesis generating&#41;&#46; A Japanese study used the same device and reported similar results&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The COOLHAIR study also evaluated the DigniCap&#174; in 79 patients with early-stage breast cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> Hair was preserved in 39&#46;3&#37; of patinets in the group who used cold caps compared with none in the control group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; Wig use was significantly lower &#40;40&#46;7&#37; vs&#46; 95&#46;5&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; In 2019&#44; a fourth study was published&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> This study evaluated the DigniCap&#174; device in 139 patients with early-stage breast cancer who received chemotherapy&#46; Most patients &#40;95&#37;&#41; received at least 4 cycles of anthracycline-based chemotherapy&#44; and then sequential taxanes&#46; When the device could be used in all chemotherapy cycles&#44; 43&#37; lost less than 50&#37; of their hair&#46; Nine patients discontinued treatment due to adverse events&#46; In 2020&#44; DigniCap&#174; was studied in 135 patients with early-stage breast cancer &#40;adjuvant therapy in 74&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> The success rate in preventing alopecia was 60&#37; &#40;81&#47;135&#41; at 3 weeks after the end of treatment&#46; Higher success rates were reported with anthracycline-free regimens &#40;taxane plus cyclophosphamide&#41; &#40;71&#37;&#41; in comparison with anthracycline-containing regimens &#40;54&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A metaanalysis in 2015 included the 3 aforementioned randomized clinical trials&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> The authors concluded that scalp cooling was the only intervention that significantly reduced the risk of chemotherapy-induced alopecia &#40;RR of 0&#46;38&#44; 95&#37; CI 0&#46;32&#8211;0&#46;45&#41;&#46; No significant adverse events were reported associated with the intervention&#44; although the studies did not always conduct long-term follow-up of toxicity&#46; A subgroup analysis suggested a similar degree of efficacy for scalp cooling regardless of the type of tumor&#44; but most of the patients included had breast cancer and data for other types of tumor were not presented by tumor type&#46; Another metaanalysis published in 2018<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> in 654 patients &#40;66&#37; with breast cancer&#41; concluded&#44; with a moderate level of evidence&#44; that cooling caps can significantly reduce alopecia &#40;greater than 50&#37;&#41; compared with control &#40;RR 0&#46;57 95&#37; CI 0&#46;45&#8211;0&#46;72&#59; <span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;00001&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Adverse events reported with scalp cooling are generally mild and include discomfort for the patient&#44; for example&#44; a feeling of cold&#44; headache&#44; nausea&#44; dry skin&#44; and claustrophia&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">23&#8211;25</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In the literature&#44; there are reports of concern over the possibility of increased risk of scalp metastasis with the use of these devices&#46; The incidence of metastasis has been most extensively studied in breast cancer&#44; where the risk was reported as very low&#46; The aforementioned studies have not reported a significant association&#46; In a systematic review and metaanalysis in 2017&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> among the 1959 patients who used cooling caps&#44; with a follow-up of 43&#46;1 months&#44; there was a rate of scalp metastasis of 0&#46;61&#37; &#40;95&#37; CI&#44; 0&#46;32&#8211;1&#46;1&#41; compared with 0&#46;41&#37; in the control group of 1238 patients &#40;95&#37; CI&#44; 0&#46;13&#8211;0&#46;94&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;43&#41;&#46; In the prospective DigniCap study described above&#44; no patient developed scalp metastasis with a median follow-up of 4 years&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">As we have discussed above&#44; the main body of evidence comes from patients with localized breast cancer treated with anthracyclines and taxanes&#44; but these devices have been used with other chemotherapy regimens and in other tumors&#44; as well as in patients receiving palliative care&#44; in whom alopecia has a major impact on quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">It is important to remember that the strategy may not be appropriate in all cases&#46; It is not recommended in pediatric patients&#44; given that it has not been studied in this population&#46; Those who receive continuous infusions lasting for 24<span class="elsevierStyleHsp" style=""></span>h or more and those who receive head radiotherapy are not considered good candidates &#40;lack of evidence&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a> The intervention is contraindicated in patients with diseases caused by cryglobulins&#44; cryoglobulinemia&#44; and post-traumatic dystrophy caused by cold&#44; and its use is not recommended in patients with hematologic neoplasms&#44; including leukemia and some forms of lymphoma&#44; and in those who undergo bone marrow or stem cell transplantation with myelosuppressive doses of chemotherapy and&#47;or radiotherapy&#46; It is important to consider that safety data are not available for scalp metastasis in any of the tumor types with a high propensity for cutaneous metastasis &#40;such as some lung cancers or skin cancers&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Recently&#44; both approved devices &#40;DigniCap&#174; and Paxman&#174;&#41; were available in several oncology departments in Europe&#44; including in Spain&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0135" class="elsevierStylePara elsevierViewall">The use of automatic cooling caps is an approved option and generally well tolerated for preventing alopecia&#44; essentially in adjuvant treatment for breast cancer&#44; although it has been extrapolated to other tumors and scenarios with certain caveats&#46; There are no prospective studies with other types of cooling caps &#40;for example&#44; gel&#41; and so it is not known whether the results can be extrapolated&#46; In anthracycline-based regimens&#44; success rates are lower&#46; The technique does not appear to increase the risk of cutaneous metastasis in the scalp in patients with early-stage breast cancer or compromise the oncological outcomes &#40;although longer follow-up is required&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Chemotherapy and Alopecia"
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              "titulo" => "Alopecia Prevention with Cooling Caps"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chemotherapy-induced hair loss in cancer is usually temporary but can take a significant emotional toll on patients and lead to treatment refusal in many cases&#46; Although hair loss is usually reversible&#44; regrowth can take months&#44; causing greater psychological distress&#46; Recent years have seen the emergence of cold caps&#44; or scalp cooling systems&#44; designed to prevent or at least reduce chemotherapy-induced hair loss&#46; The results to date are encouraging&#46; We review the evidence on the effects and effectiveness of these systems&#44; which are making their way into routine clinical practice&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La alopecia es un efecto generalmente transitorio del tratamiento con citost&#225;ticos&#44; generador de una importante repercusi&#243;n emocional en el tratamiento contra el c&#225;ncer&#44; muchas veces responsable de rechazo de distintas maniobras terap&#233;uticas&#46; Si bien en la mayor&#237;a de los casos es reversible&#44; esto puede involucrar meses&#44; amplificando el impacto&#44; sobre todo psicol&#243;gico&#44; de los tratamientos&#46; En los &#250;ltimos a&#241;os han surgido estrategias con gorras de fr&#237;o&#44; o &#8220;scalp cooling system&#8221; que buscan prevenir&#44; o al menos limitar&#44; este efecto adverso&#44; con resultados que se han mostrado promisorios&#46; El objetivo de esta revisi&#243;n es analizar la evidencia con la que contamos respecto a los efectos y eficacia de este tipo de t&#233;cnicas que han empezado a inmiscuirse dentro de nuestra pr&#225;ctica cl&#237;nica diaria&#46;</p></span>"
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                  \t\t\t\t">- Methotrexate &#40;1&#8211;10&#37;&#41;- Carboplatin AUC 5&#8211;6 &#40;2&#8211;3&#37;&#41;- Weekly paclitaxel &#40;10&#8211;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Association Between Different Chemotherapy Agents and Risk of Alopecia&#46;</p>"
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        0 => array:2 [
          "identificador" => "bibs0015"
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                          "etal" => false
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                            0 => "E&#46;L&#46; Mc Garvey"
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                          ]
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                      "titulo" => "Chemotherapy-induced alopecia&#58; psychosocial impact and therapeutic approaches"
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                      "titulo" => "The biology of hair follicles"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "M&#46;D&#46; Ralf Paus"
                            1 => "M&#46;D&#46; George Cotsarelis"
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                    0 => array:2 [
                      "titulo" => "Functional hair follicle regeneration&#58; an updated review"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
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ISSN: 00017310
Original language: English
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