What is cold-capping/scalp-cooling?

Cold capping and scalp cooling are the same thing. The term cold capping tends to be used for portable, manually changed frozen caps and scalp cooling is used when talking about machines that are automated to cool your scalp. I will use the term cold capping to mean both methods.

The goal of cold capping is to protect the hair follicles in your scalp from damage by chemotherapy. Chemotherapy blasts cancer cells but it also attacks healthy cells. Hair follicles are particularly vulnerable to chemotherapy as they are rapidly growing, as are nails and mucous membranes.

It's thought that cold capping works by reducing the blood flow to the hair follicles. 20-40% less blood flow gets to the hair follicles and so less chemotherapy drug gets there. If less drug gets there, then it's less likely to cause damage. The cooling reduces the metabolic activity of the usually fast dividing hair follicles and puts them into a near hibernation/dormant state. Less of the chemotherapy drug gets into the hair follicle cells so there is less damage. This leads to less hair loss, faster hair regrowth and elimination of permanent baldness risk (which may be around 10% risk with some taxane chemotherapies e.g. high dose docetaxel).

Cold capping is done during the time that you have your chemotherapy infusion. It's also done for a period before and after your infusion. This is because your scalp needs to be cold before the infusion starts, to reduce the blood flow before the chemotherapy drug enters your system. It's recommended that people keep cold capping after their infusion because the levels of chemotherapy drug in your body stay high for quite a while after your infusion finishes. The time varies depending on the drug/s you’re having and the cold-capping method you use.

The original type of cold capping has been in use for more than 20 years in the UK. It involves changing the cold caps on your head every 20-30 minutes. Cold caps are either kept in a freezer at the hospital, or in a cooler bin filled with dry ice. You keep changing the caps after chemotherapy, including at home.

The newer, automated type of cold capping involves a machine that sends refrigerated fluid into a cap on your head. This means that you don’t have to change the caps, as the cooling is done by a machine keeping your scalp at the right temperature. You need to be at the hospital for your pre and post infusion cooling periods.

There are several different brands of manual and automatic cold capping devices available internationally. In New Zealand, there are research evidence-based manual cold caps available for hire and scalp cooling machines in some hospitals.

Please see the Availability page for details.

Is it safe?

There have been concerns that if cold capping reduces the chemotherapy drug getting to the scalp, then it could cause the cancer to spread to the scalp.

There has been research with solid tumours like breast cancer, which has shown that there is no significant increase in cancer spreading to the scalp with cold capping. The rate of cancer spreading to the scalp with breast cancer is very low, around 0.5% of people whether they cold cap or not. Cold capping cannot be used for blood cancers.

In the United States, the Food and Drug Administration (FDA) has approved two scalp cooling machines (Paxman and DigniCap) as safe and effective treatments. Manual cold caps e.g. Penguin Cold Caps, have been in use in the UK for more than 20 years. Cold capping with manual or machine systems during chemotherapy is “standard care” in the UK.

Most people tolerate cold capping well, with only very small numbers of people stopping the treatment. Reports of significant side effects are very rare. The most common side effects are feeling cold and a temporary headache.

The usual experience is that the cold caps are uncomfortably cold (and can be tight) when they first go on, and then people get used to it quickly. People report pain medications such as paracetamol and prescribed antianxiety medications such as lorazepam help them adjust to the cold cap.

Please see the Research page for more details.

Does cold capping work?

Cold capping aims to do three things:

1. Reduce hair loss during chemotherapy.
2. Increase the speed and quality of hair regrowth after chemotherapy.
3. Eliminate the risk of severe persistent hair loss caused by some chemotherapies.

Cold capping is regarded as a success if you keep more than 50% of your hair. It is very rare to keep 100% of your hair, even with cold capping. Most people have some hair shedding, starting a couple of weeks after their first chemotherapy. Some people also have some shedding after chemotherapy has finished. People normally lose about 100 hairs per day when they are not going through chemotherapy.

It is generally agreed that cold capping works better for some types of chemotherapy than others. The best results are with taxane chemotherapy (eg paclitaxel and docetaxel) given alone, and the lowest success rates are with combinations of anthracyclines and taxanes (eg AC-T and TAC). There is some research showing better outcomes when the taxane is given before an anthracycline (eg T-AC). It is worth noting there is quite a lot of individual difference in results, that cannot be easily explained, even within the same chemotherapy regime.

Cold capping also has longer term benefits. Hair has been shown to grow back faster and thicker with cold capping during chemotherapy. This means that even if cold capping doesn’t work well in terms of retaining hair during treatment, it’s worth continuing to get improved regrowth after chemotherapy.

Cold capping also seems to prevent the risk of permanent baldness that is reported with some taxanes, eg around 10% with high dose docetaxel. This is called permanent chemotherapy induced alopecia pCIA. The research suggests that cold capping offers 100% protection from severe pCIA.

Please see the Research page for details.