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Scalp cooling

What is it and how does it work?

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Scalp cooling or cold cap therapy is a therapy that can be used to help avoid or lessen the hair loss associated with chemotherapy.

Some chemotherapy drugs can damage hair follicles and cause hair to fall out. Scalp cooling technology involves wearing a cap, which is kept cold during a chemotherapy infusion session. For some people, keeping the scalp cold reduces chemotherapy’s impact on the hair follicles.

Research shows that scalp cooling therapy works in some people and that many who try it are happy with their results.

Still, some people who start using scalp cooling decide to stop for reasons including hair loss, logistical issues, and difficulty tolerating side effects such as headache or dizziness.

If your healthcare team has recommended chemotherapy but you haven’t yet started it, now is the time to consider whether scalp cooling is right for you. Whether you’re using scalp cooling or cold cap therapy, it should start at the first chemotherapy infusion session.

In the video below, LBBC CEO Jean Sachs, MSS, MLSP talks with Vered Stearns, MD, director of the Women’s Malignancies Disease Group at Johns Hopkins University about:

  • The pros and cons of scalp cooling
  • What to know about hair types and processing
  • The costs of scalp cooling therapy
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What is scalp cooling or cold cap therapy?


Scalp cooling is a technology that helps to reduce the risk of hair loss in some people during chemotherapy treatment.

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How does scalp cooling work?


With scalp cooling technology, a person receiving a chemotherapy infusion wears a cap that contains liquid coolant or cold gel. The cold temperature constricts the blood vessels in the scalp. When the blood vessels constrict, it’s more difficult for chemotherapy to reach and potentially damage hair follicles, the tiny skin openings through which hairs grow.

There are a few different scalp cooling systems available in the United States, but the way they work to prevent hair loss is similar: Cooling the scalp and hair follicles during a chemotherapy infusion session is thought to slow blood flow to the scalp so that the scalp is less exposed to chemotherapy.

Another theory is that the low temperatures cause the cells of the hair follicle to slow their activity, making them a less likely target for chemotherapy. Chemotherapy targets rapidly dividing cells.

Scalp cooling is performed just before, during, and just after each chemotherapy appointment. Usually, people put the cap on 30 minutes before their chemotherapy infusion starts and continue to wear it throughout the infusion and for some time after it ends.

How long a person wears the cap after the infusion is over depends on what the equipment manufacturer recommends. One example is 90 minutes.

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Types of scalp cooling systems


There are two of methods of scalp cooling available today:

  • Refrigerated scalp cooling systems
  • Cold caps

Refrigerated scalp cooling systems


Refrigerated scalp cooling systems use a refrigeration unit to keep the cap cold throughout your treatment session. The unit has coolant inside that connects to the cap through a line and circulates through channels inside the cap to keep your scalp cold.

This type of scalp cooling usually requires the cancer center to have one of these systems in their infusion rooms. Depending on the machine used and the policies of your treatment center, you may have the cap placed on your head with the help of staff or you may have to place the cap yourself.

Cold caps


Cold caps are another method of scalp cooling. Cancer centers usually do not keep cold caps on hand. Instead, the caps can be rented from the manufacturing company and are shipped directly to you. It’s up to you to bring all the caps with you to each chemo infusion session in a cooler filled with dry ice.

In some centers, the caps can be stored in a freezer for you. Each cap contains a liquid or a gel that stays cold for a limited period — about 30 minutes — and slowly warms once the cap is on your head.

When the cold cap warms up, you’ll need to remove the cap from your head and replace it with a cold one from the cooler or freezer. Many people find it helpful to bring a friend or family member to treatment to help them place and change the caps correctly.

Some manufacturers offer cold cap training sessions for people undergoing treatment and the people supporting them. Training may be offered in-person at the cancer center or via Zoom. Each manufacturer is different, so be sure to talk with your healthcare team to find out if the cancer center works with any cold cap companies, and what resources are available to you.

If you decide to use cold caps, you’ll need to order them before your first chemotherapy session to make sure there’s time for the company to ship them to you.

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How effective is scalp cooling at preventing hair loss?


Research shows that scalp cooling works in some cases, but not in others. Factors that might impact the success of scalp cooling include:

Chemotherapy type and dose

The SCALP trial looked at the success of one cooling system available in the U.S.: the Paxman Scalp Cooling System. In the trial, half the participants using it reported that the Paxman Scalp Cooling System was successful. But there was a large difference in success depending on which chemotherapy medicine a person was given.

In this trial, scalp cooling was successful in 59 percent of people given taxane-based chemotherapy and only 16 percent of people given an anthracycline.

A similar trial using the DigniCap System found scalp cooling was successful in 66 percent of participants, but that study did not include anyone given anthracycline chemotherapy. Higher doses of chemotherapy were also linked to lower rates of success with scalp cooling in this trial.

Even when scalp cooling was successful, most people lost some hair, but they didn’t lose enough hair to feel the need to wear a wig. The studies defined success as either “not needing a wig” or keeping at least 50 percent of their hair after chemotherapy.

Hair type


So far, no formal research has looked at hair type as a factor in whether scalp cooling will prevent hair loss. But many healthcare teams have noticed that hair type does seem to matter in the clinic. At Johns Hopkins, Dr. Stearns’ team saw that in general, scalp cooling seems to work better on naturally thinner, straighter hair than it does on naturally thicker, wavy, or curly hair.

Age

A large observational study completed in the Netherlands in 2012 found that scalp cooling worked better in younger people than in older people. Their research team theorized that this is because hair is naturally more brittle and likely to break in older people than in younger people.

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Caring for your hair during scalp cooling therapy

Many companies and experts say to avoid dyeing, waving, and using other harsh processes in your hair while undergoing chemotherapy and scalp cooling therapy. If you have hair extensions, Dr. Stearns suggests removing them before you begin scalp cooling.

Some experts recommend being as gentle as possible with your hair, starting at the first chemotherapy infusion and continuing up to 2 months after the final infusion. This includes using gentle shampoos and conditioners and treating your hair delicately when brushing it.

Beyond these recommendations, there is little agreement about how to care for your hair. There are no studies that show the effect hair care methods have on the success of scalp cooling.

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FDA oversight of scalp cooling therapy

FDA has oversight on treatments that manage side effects of cancer treatments as well as cancer treatments themselves. Medical devices such as refrigerated scalp cooling systems need FDA clearance before they can be marketed in the US. Several refrigerated systems including Paxman, DigniCap, and Amma have FDA clearance.

Cold caps you rent from the manufacturer and bring to your appointments do not yet have FDA clearance, which is why cancer centers can’t keep them on site for you to use. This does not mean that these types of cold caps don’t work, or that they work less well than on-site systems.

National Comprehensive Cancer Network (NCCN) guidelines on scalp cooling therapy

Another organization involved in side effect treatments is the National Comprehensive Cancer Network, or NCCN. The NCCN maintains guidelines for the treatment of breast cancer and gives recommendations about managing side effects.

In 2022, the NCCN added scalp cooling to their guidelines as a Category 2A Treatment. Category 2A treatments may not have very strong research findings yet, but the doctors and researchers on the NCCN panel in charge of the guidelines agree that the treatment works and should be available to patients.

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Side effects of scalp cooling therapy


The most common reported side effects of scalp cooling are:

  • Headache
  • Feeling very cold
  • Nausea
  • Stiff neck and shoulders from the weight of the cap
  • Feeling dizzy

Some people find using the cold cap to be uncomfortable, but most people do not stop using the caps because of discomfort. Reported rates of stopping scalp cooling due to side effects range from 3 percent to 12 percent.

Some people also worry that slowing the flow of chemotherapy to the scalp will raise the risk of breast cancer cells traveling to the scalp, causing a recurrence or metastatic breast cancer. There is no research evidence that this happens. An analysis of multiple studies involving over 3,000 participants found no difference in the rates of scalp metastasis in people who used scalp cooling versus people who didn’t.

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Paying for scalp cooling treatment

In 2022, the Centers for Medicare and Medicaid Services approved insurance reimbursement for scalp cooling. There are now two Current Procedural Terminology codes, or CPT codes, for scalp cooling with refrigeration units at infusion centers. CPT codes are used by healthcare providers across the U.S. to bill insurance companies for medical services. Below, we share the current scalp cooling reimbursement codes.

0662T is a CPT code that applies to:

  • Initial cap measurement and fitting
  • Cooling unit time and intensity calibration, based on individual chemotherapy regimen

0662T enables a one-time reimbursement of $1,850.50 that covers all the planned treatment sessions. For example, if the treatment plan is four doses of docetaxel (Taxotere) plus cyclophosphamide (Cytoxan), there would be one single charge and reimbursement that would cover all four of the planned sessions. (This does not apply to gel caps.)

0663T is a CPT code that applies to placement, monitoring, and removal of the cap.

As of 2023, many infusion centers with refrigerated scalp cooling systems are still transitioning into a new billing process using these CPT codes. The codes ensure coverage for people using Medicare, but private insurers may or may not be using these codes to offer coverage. It’s important to talk with your insurance company about whether they offer coverage, and to talk with your infusion center about their billing and payment process for scalp cooling.

Rented cold caps that you bring to the infusion center yourself can cost about $500 per month. Some organizations, such as Hair to Stay, offer assistance to people who have financial need.

If you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA) through your employer, you may be able to use funds in that account to pay your portion of the bill.

Learn more about paying for using the DigniCap System here, and the Paxman System here.

Rented cold caps that you bring along to appointments do not have a CPT code. Still, it may be possible to get some cost coverage through your insurance. Some common brands of cold cap are:

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Scalp cooling FAQs

Here are answers to some frequently asked scalp cooling questions.

How do I know if scalp cooling will work for me?

A great place to start is talking with your oncologist about what type of breast cancer treatment you’ll need. Scalp cooling only works for some types of chemotherapy, not all.

Your hair type may also affect how well cold caps work. The company that provides the Paxman Cooling System has a decision making guide that can help.

Where can I buy a cold cap for chemo?

Cold caps can be rented from the companies that make them. Many of these companies offer plans that can include the cooler, a hand truck to move it, the caps, video or in-person training, and resources to make using the caps easier.

Consider the brands listed above or ask your cancer center which brand they recommend. The Rapunzel Project makes recommendations on cold caps and may also be a good resource.

If you search for cold caps online, chances are you’ll find products on Amazon or other low-cost sites making claims that their caps are useful during chemotherapy. It’s important to choose a cap that has been vetted by a professional and that your cancer treatment center is OK with you using a certain cap.

Before you buy products from any company, talk to your care team about whether it will work for you.

What is the best cold cap or scalp cooling system available?

No one scalp cooling system can be called the “best,” but some research has suggested that refrigerated scalp cooling systems such as Paxman and DigniCap are both easier to use and can be more effective than cold caps in some people.

How well do cold caps actually work for preventing hair loss?

Scalp cooling therapy includes:

  • Refrigerated scalp cooling systems offered at cancer centers, such as Paxman, DigniCap, and Amma
  • Cold caps that you rent and bring with you to chemotherapy sessions, such as Penguin Cold Caps, Arctic Cold Caps, Chemo Cold Caps, and Wishcaps

Scalp cooling works by slowing blood flow to the hair follicles, helping to protect it from the effects of chemotherapy.

Effectiveness of refrigerated scalp cooling systems: The SCALP trial looked at how effective the Paxman Scalp Cooling System is in preventing hair loss during chemotherapy. Half the participants reported that the Paxman Scalp Cooling System was successful in 59 percent of people given taxane-based chemotherapy and only 16 percent of people given an anthracycline.

A trial using the DigniCap System found scalp cooling was successful in 66 percent of participants, but no one in this study was given anthracycline chemotherapy. The study results also showed that higher doses of chemotherapy were linked to lower rates of success.

Even when scalp cooling was successful, most people lost some hair. However, they didn’t lose enough hair to feel the need to wear a wig. The studies defined success as either “not needing a wig” or keeping at least 50 percent of their hair.

Effectiveness of cold caps: A small study of Penguin Cold Caps showed that overall, 61 percent of study participants avoided chemotherapy-induced hair loss, but how well the caps worked was linked to the type of chemotherapy used.

For example, people who received anthracycline chemotherapy were less likely to experience hair loss prevention while using these cold caps.

Are cold caps painful?

A possible side effect of cold caps is scalp pain caused by the extreme cold.

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Reviewed and updated: August 5, 2023

Reviewed by: Mikel Ross, MSN, RN, AGPCNP-BC, OCN, CBCN

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