Why the Princess of Wales did not lose her hair or nails after chemotherapy - Professor Thomas explains

Hair loss and nail damage is common after chemotherapy. Although not life threatening, these side effects can have a significant impact on body image, especially for The Princess of Wales, who's every move is scrutinised when in public. However, in the poignant video, released by the Prince and Princess of Wales, it did not appear she has suffered these side effects.

There are reasons Kate doesn’t appear to be showing these common reactions though. Firstly, not all chemotherapy causes hair or nail damage.

We do not know what type of cancer the Princess had, apart from that it originated in the abdomen. If it started in the bowel, her oncologist would usually advise two types of chemotherapy called 5FU and oxaliplatin which do not usually have hair and nail consequences. If, on the other hand it originated in an ovary, the other strong candidate, it is very likely she received drugs called  taxanes and carboplatin. These are notorious for their hair and nail damaging properties, especially after six cycles of treatment over 18 gruelling weeks. 

One possibility is that she did lose her hair and she is now wearing a very good quality wig. Many of my patients invest in real-hair wigs which can be dyed and styled to the pre-chemo design. This would usually involve trimming her surviving hair, very short. The other, more likely, possibility is she wore a scalp cooling device during her chemotherapy administration and a few hours afterwards. This works by reducing the blood supply to the hair follicles when the chemotherapy levels are at their peak, shortly after the intravenous infusion.

Scalp cooling does prolong the day of chemotherapy and can be uncomfortable but can prevent hair loss in up to 40% of users. It is difficult to know who will keep their hair or not but being young with thick hair to start with certainly helps. I usually advise all patients to try out scalp cooling, at least initially. Some don't get on with it and some find it intolerable but for others it's very successful. Fortunately, cooling machines are available in most NHS or private oncology units in the UK.

Nail damage can be a visibly distressing trauma for both women and men. On top of the cosmetic impact, it can be uncomfortable and even painful. Damage, officially called onycholysis, can lead to difficultly with routine daily tasks such as dressing, washing or shopping. Other sufferers report it adversely effects mood as it is a constant visual reminder of their cancer.

The distorted nails can catch on clothing and many report trouble maintaining physical contact with their children and partners. All of these factors significantly impact on patients overall quality of life which is already impaired by the other common side effects of chemotherapy such as fatigue, nausea, mouth ulcers and brain fog, to mention but a few.

For years, patients have been advised unproven, ineffectual strategies such as wearing dark nail varnish, applying concentrated essential oils or untested balms which can irritate, dry and inflame the nail beds making matters worse. Two strategies which have been proven to help prevent nail damage include cooling gloves and a relatively new topical therapy called Polybalm.

Our cancer unit first published a report in 2010 showing, in 2010 that cooling the nail bed during chemotherapy can work, in the same way as scalp cooling is used for the hair. Since then, commercial hand cooling devices have been developed and are used in some units but they are not popular with the oncology nurses as they can restrict access to the patient and make monitoring more difficult.

Commercially available balms are marketed to people on chemotherapy but up to now, none have previously been formally evaluated for safety and effectiveness. Fortunately, scientists based in Bedford and Addenbrooke's Cambridge University Hospitals have developed a topical plant-based therapy and tested it in a national double blind randomised trial.

The balm, now known as Polybalm, contains plant extracts, waxes and oils, rich in polyphenols which have natural antioxidant properties that act as a local antidote protecting the nail bed stem cells from chemotherapy. It also has anti-microbial, moisturising and anti-inflammatory properties which prevent infection, drying, splitting or cracking of the nail. In the study, patients using the balm had virtually no damage compared to about 50% in the placebo group.

Polybalm has now been recognised in official NHS guidelines which can be followed by oncology units across the UK but unfortunately most patients have to buy it themselves because, as a natural product, it cannot be prescribed. I understand the manufacturers sent some to Kates Oncology unit so hopefully she received some benefit.

What was nice about the official video released from The Palace is that Kate is embracing self-help strategies. This is, not only highly commendable, but it re-enforces the ever increasing data which shows helping yourself can reduce the risk of side effects, including hair and nail damage, enhance recovery and reduce the risk of relapse.