For many people, hair loss as part of cancer treatment can feel almost as devastating as their cancer diagnosis. In fact, research suggests that for many patients, chemotherapy-related hair loss is associated with depression, negative body image, lowered self-esteem, and a reduced sense of well-being.
“Chemotherapy works by targeting fast-growing cancer cells, but unfortunately also impacts other fast-growing cells such as the cells in hair follicles,” says Anne Peled, MD, a breast cancer surgeon based in San Francisco.
For some cancers and chemotherapies, a technology called cold cap therapy, also known as scalp cooling, might reduce your chances of losing your hair during cancer treatment.
What Is Cold Cap Therapy?
Cold cap therapy describes the process of lowering your scalp’s temperature before, during, and after chemotherapy treatment. “Cold caps work by constricting the blood vessels in the scalp, which decreases the amount of chemotherapy drugs getting to the hair follicles,” says Dr. Peled.
Although chemo damages hair follicles (structures in your skin that grow hair) right away, hair loss usually starts three to four weeks after your first chemotherapy treatment.
By blocking chemo from reaching your hair follicles, cold caps can lessen hair loss
During cold cap therapy, patients wear a cap (or set of caps) designed to lower the temperature of the scalp and its hair follicles. Depending on the type of cap used, cold cap therapy can start 30 minutes to an hour before chemotherapy administration, and may continue for several hours after your treatment finishes.
Types of Cold Caps
Currently, people receiving chemotherapy can choose between two types of cold caps: automated and manual.
Automated cold caps, which are regulated by the U.S. Food and Drug Administration (FDA), connect to a machine that circulates constantly cooled liquid, so you can wear the same cap throughout treatment and maintain a constant temperature.
These three automated cold caps are FDA approved for preventing hair loss with chemotherapy:
Manual cold caps are not approved by the FDA and must be cooled in the freezer or with dry ice. Because the cap warms up as soon as you put it on, you typically have to start out at a much cooler temperature than with automatic caps.
Manual cold caps also have to be switched out every 20 to 30 minutes to maintain scalp temperature.
Manual cold cap brands include:
- Arctic Caps
- Chemo Cold Caps
- Penguin
Cold Cap Cost
Your total out-of-pocket expenses for cold cap therapy depends on a lot of variables, like insurance coverage and product type. In 2022, Medicare decided to cover automated scalp cooling up to $1,850 per person.
Some private insurance plans cover automated cold caps, but most won’t cover manual types that aren’t FDA-approved.
On average, cold cap therapy costs $415 per month, but this can vary based on type and length of treatment.
Penguin Cold Caps cost $450 a month, so depending on how many cycles of chemo you need, it can add up. Paxman costs $500 for the cap, plus $100 to $350 per chemo cycle (total patient cost is capped at $2,400), and DigniCap pricing varies across the country.
You can best assess what your cost will be by checking your insurance coverage and talking to your provider about what kind of chemotherapy you will receive and how many rounds you will get. Some nonprofit organizations like the HairToStay Foundation and the Rapunzel Project can also help with the cost.
How Effective Is Cold Cap Therapy?
Cold cap therapy has been getting more attention as research suggests it may be a great option for reducing hair loss with chemotherapy.
Peled tells her patients that even though they may still lose some hair using cold caps, lots of people keep enough of their hair to avoid unwanted questions about what they’re going through, maintaining more privacy about their diagnosis.
What the Research Says
Most cold cap studies involve small groups of people with breast cancer, which may not offer a full picture of its benefits, but these studies have shown promising results.
In one small study on Penguin caps, for example, over 90 percent of patients kept over half their hair throughout chemo treatment.
Another study on Paxman caps found 50 percent of their participants kept more hair than the group who didn’t use the caps.
A third study of 91 people with breast cancer found that 81 percent of their subjects who used a Paxman cooling cap during chemo treatments successfully prevented hair loss.
Certain factors can make scalp cooling more or less successful, like the chemotherapy drug or combinations used, their dosages, scalp temperature maintenance, length of cooling therapy, and how well the cap fits.
Different Chemotherapy Types Affect Effectiveness
Some types of chemotherapy (like cyclophosphamide methotrexate fluorouracil) don’t cause as much hair loss, while others like anthracyclines almost always lead to hair shedding.
“The best candidates [for cold cap therapy] are those who will be receiving taxane-based chemotherapy,” said Paula Klein, MD, an associate professor of oncology and hematology at the Icahn School of Medicine at Mount Sinai.
How Long Is Cold Cap Treatment?
The duration of cold cap treatment can also affect hair follicle protection, and research suggests cooling too long (over 150 minutes) after infusion may be less protective.
But other studies found post-infusion cooling must last at least 45 minutes in some chemotherapies, and over 90 minutes in others. Overall, cold cap therapy timing will depend on your chemo and cap type.
How to Use Cold Caps Correctly
It’s also important to use cooling caps correctly, keeping your scalp close to the goal temperature of 22 degrees C (71 degrees F). For manual caps, you have to change them out three to four times per chemo infusion to keep that temperature, whereas automatic caps keep the temp steady throughout your infusion time.
Who Can Benefit From Cold Cap Therapy?
To decide your eligibility for cold cap therapy, your provider will consider your cancer type, chemotherapy plan, age, and any other medical conditions.
Currently, automated cold cap therapy is FDA approved only for people receiving chemotherapy for solid tumor cancers (as opposed to blood cancers like leukemia).
It’s also not recommended for people who have the following cancers:
- Central nervous system cancers
- Blood cancers
- non-Hodgkin lymphoma
- Some lung cancers
- Cancers of the head and neck
- Metastasis (cancer spread) to the scalp
Scalp cooling is also discouraged if you plan to have a bone marrow transplant, as it can affect its success. Cold caps are also not typically used in children under 18 because research hasn’t yet been done on that population.
Regardless of age, if you have chronic diseases that affect your kidneys or liver, you may not be eligible for scalp cooling, because it can lower the effectiveness of your chemo when combined with symptoms of these diseases.
Pros and Cons of Cold Cap Therapy
Cold cap therapy comes with plenty of pros and cons. The pros of cold cap therapy include reduced hair loss and the ability to maintain diagnosis privacy if you wish. It may also offer emotional and psychological benefits during an already difficult time.
Cold cap therapy cons may involve side effects and financial costs. Some people find the headaches and cold sensations that accompany cold cap therapy uncomfortable or intolerable. Others find the financial burden too high, especially if not covered by insurance.
What to Expect During Cold Cap Therapy
As you plan for a chemotherapy infusion with cold cap therapy, preparation should start before your appointment.
Preparing the Hair and Scalp
Be sure to clean your hair before your infusion appointment, and use shampoo without paraben, silicones, and sodium lauryl sulfate. Don’t add any hair products after washing. That morning or the night before, pack a book, music, earbuds, or other items to keep you busy during your infusion, which typically lasts longer when you add cold cap therapy.
If you’re using a Penguin cap, make sure your infusion center knows this before your first session, as they may need extra equipment and time beforehand.
For automated caps, you may receive your cooling kit from the infusion center at your first treatment, and then be asked to bring it with you for future treatments.
Cold Cap Therapy: Step-by-Step
Your cold cap procedure will depend slightly on which cap you use, but you can expect scalp cooling before, during, and after your chemo infusion.
Before Treatment Cooling before infusion protects your follicles as chemotherapy levels rise and peak in your system.
“Caps should be worn for every chemotherapy session and should be put on 30 to 60 minutes before the start of treatment … with timing varying by type of cold cap used,” says Peled.
Typically, automated caps need 30 minutes of pre-cooling, while manual caps need closer to an hour. Be sure to protect any hairless areas (forehead, areas of hair loss) with a small piece of cloth or gauze.
Cap Application With automated caps, your nurse will help you apply it and attach it to the cooling machine. If you have a manual cap, you can bring a friend to assist with changing out the cold packs as needed. Because manual caps have not been cleared by the FDA, doctors and nurses are not allowed to assist with their use, says Dr. Klein.
During Treatment You may not be as mobile during your infusion with cold cap therapy, especially with an automated version. You can still take bathroom breaks or short walks, but your nurses will need to stop the cooling device for those times. It’s best to keep breaks under six minutes to keep your scalp at the right temperature.
Managing Discomfort About 30 to 50 percent of people experience side effects from cold cap therapy, like headaches, nausea, scalp discomfort, dizziness, or feeling too cold.
After Treatment Once your chemo infusion is complete, you will need to hang around a bit longer for continued scalp cooling: two to three hours for automated caps, and up to six hours for manual caps.
Post-Treatment Care
After cold cap therapy, it’s important to care for your scalp and hair. Use a wide-tooth comb or a hairbrush with soft bristles. Avoid hair dryers, straightening irons, or clips that can irritate your scalp or pull out hair.
Wash your hair less often than usual and use a mild shampoo. Instead of using a hair dryer, pat your hair dry with a towel. If parts of your scalp are exposed, apply sunscreen to those areas before you go outside, or wear a hat or comfortable scarf.
The Takeaway
- Hair loss with chemotherapy can feel distressing for anyone going through cancer treatment, but cold cap therapy can help lessen hair loss for those with some kinds of cancers by lowering your scalp temperature and protecting your hair follicles from damage during chemotherapy infusion.
- You can choose between several types of cold caps, and some are even partially covered by health insurance.
- If you need chemotherapy treatments, you can discuss the option of cold cap therapy with your healthcare provider.
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