Westbury, C., Hines, F., Hawkes, E., Ashley, S., & Brada, M. (2000). Advice on hair and scalp care during cranial radiotherapy: A prospective randomized trial. Radiotherapy and Oncology, 54, 109–116.

To establish whether standard scalp care, as usually practiced by the patient, affects severity and course of acute skin radiation side effects, and to what extent advice on changing normal routine of hygiene causes distress

Patients receiving cranial radiation therapy were randomized to two groups. Group 1 patients were advised to continue normal scalp care. Group 2 patients were advised to avoid washing the irradiated area. Hair washing was not prohibited, but patients were advised to avoid it. Patients were assessed weekly over 10 weeks from the start of treatment, with recording of symptoms by patients and clinical assessment by an observer.

• The study sample was comprised of 59 male and 48 female patients (N = 107) who were randomized to group 1 (normal scalp care [n = 55]) or group 2 (no washing [n = 52]).
• Median age was 52 years in group 1 and 48 years in group 2.
• All patients had primary brain tumors or were receiving prophylactic cranial irradiation
• Patients received high (more than 30 Gy [n = 23]) or low-dose (less than 30 Gy [n = 84]) radiation therapy.

The study took place at The Royal Marsden NHS Trust in London, England.

The study used a randomized controlled trial design.

• Pain and itching were recorded by patients using a modified RTOG/EORTC acute skin reaction scoring on a scale of 0–3.
• Skin reaction was assessed using RTOG/EORTC scale for erythema/desquamation, on a scale of 0–4.
• Frequency of hair washing and distress of changing practice of normal hygiene were recorded on a self-completed diary card.
• Degree of distress was assessed on a four-point scale by group 2.
• Differences between area under the curve of male and female patients were assessed by t-test.
• Use of topical applications for treatment of skin reactions was recorded.
• Mann-Whitney Test was used to investigate differences between treatment groups at each time points.

No differences were reported between scores of skin reaction in the two groups. Itching was the main local symptom experienced by both groups, with no significant differences. A marginal difference occurred between patient groups at six weeks, with the patients in group 2 having more severe symptoms.

The practice of normal hair washing is not associated with increased severity of adverse skin reaction caused by megavoltage cranial radiation therapy. The time course of skin reaction was also not affected by the different practice of hair washing. Mild-to-moderate skin reaction is not exacerbated in patients continuing their usually regimen of hair care.

• After six weeks, completion of skin reaction assessments declined, and interpretation of results became more difficult.
• Patients did not stop hair washing completely and, therefore, the study assessed acute skin reaction for different hair-washing frequencies.
• The small trial size meant that statistical power of results was limited, particularly when stratifying by dose of radiation therapy.
• There is no discussion of validity and reliability symptom scoring used.
• Patients were not instructed to use any creams or lotions unless prescribed by their physician.