9/13/26

chemo and cancer

Scalp Cooling and Cold Caps: Does It Work, and What Is It Really Like?

What scalp cooling is, how well it works with different chemotherapy, what women who have done it say it is like, and what it costs. We are not going to talk you into it or out of it.

The decision has to be made before your first infusion, so a lot of women hear about it too late to make it at all.

You may be reading this in the week you were diagnosed, with a dozen other things to decide. This is the one with a date on it, so ask before your first infusion. After that, the choice has been made for you.

This is not a recommendation. Scalp cooling works very well for some women and very badly for others, and the women it fails have often paid thousands of dollars and sat through hours of real pain to find out. You should hear that before you hear the success rates.

We do not sell scalp cooling and nobody who does pays us. What we have is the phone. Women call us who capped and kept their hair, women who capped and lost it anyway, and women who had never heard of the word until somebody said it in week three of treatment. That last group is the reason we wrote this.

the short version

Ask what your own regimen does to the odds.

This is the question that decides it. Taxane-based chemotherapy responds well. Anthracyclines, the ones often nicknamed the red devil, respond poorly enough that many women who capped through them lost most of their hair anyway.

Ask what it will cost you here.

Not just the cap. Ask about per-session facility fees, and about dry ice if you would be using manual caps, and ask your insurer in writing rather than over the phone.

Ask how long your infusion days would become.

Then decide whether you want that, on top of chemotherapy. This is the part women most often say they underestimated.

what scalp cooling is

cold, and nothing cleverer than that

Chemotherapy attacks fast-dividing cells, and hair follicles are among the fastest-dividing cells you have. Cooling the scalp narrows the blood vessels under the skin, so less of the drug reaches the follicles, and it slows the follicles down so that what does reach them does less damage. That is the whole mechanism. It is cold, applied carefully, for a set number of hours around each infusion.

There are two ways to do it, and the difference matters.

Machine scalp cooling systems compared with manual cold caps
	machine systems	manual cold caps
how it works	A cap connected to a small refrigeration unit that circulates coolant and holds the temperature steady on its own.	Gel caps frozen on dry ice, swapped over by hand every twenty to thirty minutes through the whole session.
where you get it	At the infusion center, if that center has one. Systems you may come across in the United States include DigniCap, Paxman and the portable Amma by Cooler Heads. Others have been cleared since, so ask what your own center uses.	Rented directly from the cap company and brought with you. Penguin and Arctic are the names you will hear.
FDA status	Cleared as medical devices, first for breast cancer and since 2017 and 2018 for solid tumors generally.	Not FDA cleared, so centers usually cannot supply or store them for you.
who does the work	Infusion staff fit it and monitor it.	You need a helper, often called a capper: a friend or relative who is trained and comes to every session.
insurance	Now billable, with dedicated codes since January 2026.	Much less likely to be covered, because they are not FDA cleared.

Sources: FDA, American Cancer Society, Living Beyond Breast Cancer, breastcancer.org. Last checked September 2026.

One thing scalp cooling does not do. It works on hair loss caused by chemotherapy. It does not prevent hair loss or thinning caused by immunotherapy or targeted drug therapy, so if that is your treatment, this is not the page you need.

does it work

sometimes very well, and it depends mostly on your drugs

Yes, often, and less than the marketing suggests. Almost everyone who caps sheds something. Very few women keep the hair they have now, untouched.

The percentages below are the share of women who succeeded, not the share of hair they kept. So 59 percent means roughly six women in ten cleared the bar. It does not mean anybody kept 59 percent of her hair.

And look at where the bar is. In many of these studies, success means losing no more than half your hair, or keeping enough not to need a wig. That covers a very wide range. A woman who loses 10 percent and a woman who loses nearly half both land in the success column, and those are not the same experience at all. Someone at the higher end may still be using a root powder, a wider headband, a topper clipped into what she kept, or a hat on the days she cannot face it. Those are the women who call us.

Hair that survives can also be more fragile and take more looking after. Both of the main machine programs tell patients to comb or brush gently and regularly to lift out shed hairs, because leaving them tangled in the hair that remains can lead to matting.

The study definition matters, because every percentage below has to be read against it.

The biggest factor in whether you clear it is which chemotherapy you are on. Taxane-based regimens do well. Anthracyclines do much less well. Combinations sit in between.

Keep this in mind as you read the table. In many studies, a woman can lose up to half her hair and still be counted as a success.

Reported hair preservation rates with scalp cooling by chemotherapy type
regimen	share of women who kept enough hair not to need a wig
taxane based	Roughly 6 to 8 in 10. The randomized SCALP trial put it at about 59 percent of women; a large Dutch registry at 78 percent. Groups on taxanes with no anthracycline have reported higher still.
anthracycline based	Roughly 2 to 4 in 10. The same SCALP trial reported about 16 percent; the Dutch registry about 40 percent. Still a real benefit for some women, but go in expecting less.
both, in sequence	Roughly 4 to 6 in 10. Commonly reported between 45 and 60 percent. Starting the course with the anthracycline appears to make the whole thing harder on the hair.

Sources: SCALP randomized trial, Dutch Scalp Cooling Registry, DigniCap pivotal trial, published reviews in Pathology and Oncology Research and PMC. Figures vary between studies because "success" is defined slightly differently in each: usually hair loss under 50 percent, sometimes "did not need a head covering", and some studies had patients judge it while others used photographs scored by assessors. Last checked September 2026. These are study and registry averages rather than a prediction for any one woman on any one system, and manufacturer guidance differs by regimen and device.

Worth knowing who paid for some of the evidence: the major US pivotal studies for both Paxman and DigniCap involved manufacturer funding or sponsorship. That does not invalidate the results, and independent studies and registries broadly support that scalp cooling works. It is useful context when you are reading a device company's own materials.

Fit matters too. Scalp cooling works better when the cap sits tight against the whole scalp, so the crown, where a cap fits worst, is where hair most often thins.

What partial success usually looks like. The cold has to be in contact with the scalp to do anything, and a cap contacts the sides and the back far better than it contacts the top of the head. So the common result is hair kept around the ears and the nape and a bald patch on the crown. Some women tell us that is harder to live with than a bare head, because a bare head looks like a decision and a crown patch does not, and they shave at that point having already paid for the capping. Others are perfectly happy with it.

If you are on AC, ask twice. Anthracycline regimens, the ones often nicknamed the red devil, have the worst numbers here by a distance, and the regret we hear most often is from women who capped through AC, suffered every session, spent thousands and lost most of it regardless. Some still say they would do it again for the regrowth. Many say they would not.

what a capping day is like

the part the brochures leave out

Cooling starts about thirty minutes before the drugs go in, so the scalp is already down to temperature. It runs through the whole infusion. Then it keeps running afterwards. Ninety minutes is typical with a machine, and it can be three or four hours depending on the regimen. With manual caps, worn on and changed by hand, you may be capping for several hours after the infusion, often around four in some protocols, and travelling home in the cap with a cooler in the back of the car.

So a treatment day gets considerably longer. Women who have done it commonly describe seven to ten hour infusion days, sitting in the chair long after the pumps are off and the other patients have gone home. If someone drives you, they are waiting all of that too, and if you are using manual caps that person is not waiting, they are working: standing for hours, handling dry ice, swapping a cap every twenty minutes on the clock. Women tell us their partners burn out on this, and that they feel guilty about asking.

how it feels

The marketing language is "mild discomfort for the first ten minutes". The manufacturers' own trials report that most women tolerate it well, and those trials are run by the companies selling the caps. A 2025 review that pooled 67 studies found side effects rather more common than the brochures suggest: chills in about four women in ten, a heavy cap in about a third, headache in about three in ten.

When it is uncomfortable, the first fifteen to thirty minutes are usually the hardest. Some women describe a full-skull ice cream headache, aching in the jaw and the top molars, pressure behind the eyes, shivering that is hard to stop, and nausea. Others find it uncomfortable but manageable. Nobody can tell you in advance which you will be.
It does ease. After the first stretch the scalp dulls to it, and most women who get through the first session get through the rest. Tolerance improves across cycles.
Ask about pre-medicating before your first session, not after it. Many women are given something for the pain, and sometimes something for the shivering or the anxiety. Your oncologist can tell you what is available to you.
You will be cold everywhere, not just on your head. Take a blanket, warm socks, sleeves, a hot drink. Women bring heated blankets. Manual caps run colder than machines and people feel them more.
The cap has to be tight to work, because the cold does nothing where it is not touching skin. Tight enough to leave a mark on the forehead is normal. Some women pad the hairline and the tops of the ears to stop the edge biting.

why women stop partway through

Plenty do. Across the pooled studies about one woman in five stops before the end, and the reasons are better known in advance than discovered in the chair. The largest single reason is not the cold: it is watching the hair go anyway.

Heavy shedding anyway after the first or second cycle, at which point the remaining hair does not feel worth the rest of it.
The cold, for the women it does not ease for.
The length of the day, on top of nausea and exhaustion that are already at their limit.
The crown patch appearing and deciding a bare head is preferable.

Across those studies, the pooled estimate for stopping because of progressive hair loss was about 15 percent. The pooled estimates for stopping because of headache, cold intolerance or general discomfort were each about 4 percent. So the cold is real, and it is not usually the thing that ends it.

Stopping is not wasted. The cycles you capped were still capped, and there is some evidence the follicle protection helps regrowth afterwards even when the hair went.

Side effect and discontinuation figures above are from a 2025 systematic review and meta-analysis of 67 studies in Breast Cancer Research and Treatment, which is independent of the device manufacturers. Last checked September 2026.

what the months actually look like

This is the part hardest to picture in advance, because it lasts for months rather than a few bad hours, and it changes how you handle your hair every day.

You will wash it differently. Most programs limit washing to once or twice a week, in lukewarm water, with gentle products and very little rubbing. Heated styling tools are generally out, though a dryer on a cool setting is usually allowed. For a woman who washed and styled her hair every morning before treatment, that is a bigger adjustment than it sounds. Some women find it gets greasy; the programs say the scalp often settles down to it.

You have to take the shed hair out, regularly. This is the one that surprises people. Both of the main machine programs tell patients to comb or brush gently and often, Paxman twice a day, because hairs that have already shed stay caught in the hair you are keeping. Leave enough of them in and they tangle or mat into what is still attached.

Your hair may not behave the way it did. It can be drier, thinner or patchy, and you will have fewer styling options while you are protecting it. Some women reach for a root powder, a headband, a scarf or a hat on the days the thinning bothers them. Others keep enough that they are perfectly happy wearing it as it is.

Plenty of women read all of that and still want to do it. Keeping some of their own hair, and knowing it is still theirs, matters more to them than any of the inconvenience. That is a real answer, and for some women it is the whole answer.

Others get some way in and decide the shedding, the daily hair care, the thinning and the extra hours are no longer worth it to them. They stop capping, or shave, and describe that decision as a relief. That is a real answer too, and it is not giving up.

Nobody else can weigh that for you, and you may not know which one you are until you are in it. Weigh it knowing what the months can involve, alongside the pain, the hours and the money.

who it is and is not for

a question for your oncologist, not for us

Scalp cooling is used for solid tumors: breast, ovarian, uterine, prostate, lung and others. It is generally not advised for children or for anyone having radiation to the head, and there are further contraindications involving certain blood and central nervous system cancers, transplant conditioning, and specific cold sensitivity disorders. Device labeling differs between systems. Your oncology team has to confirm that it is appropriate for your diagnosis and your treatment.

You will also see the question of scalp metastasis raised, the theoretical worry that cooling could shelter cancer cells in the scalp along with the follicles. The 2025 pooled estimate among women who used scalp cooling was about 0.15 percent, roughly one in 670. That does not mean the cooling caused those cases: earlier comparative research found no significant increase in scalp metastases among women who cooled against those who did not. It is a real question, long-term safety data is still thin, and your oncologist is the person to put it to, not a hat company and not a forum.

The one sentence to take to your appointment. "Given my regimen and my diagnosis, is scalp cooling something you would recommend, and does this center support it?" That gets you both answers, before the first infusion, which is when they are still useful.

what it costs, and who pays now

this changed in January 2026

For years scalp cooling was something you paid for yourself, and women commonly report the whole thing landing somewhere between $1,500 and $3,000 over a course of treatment. Medicare has cited roughly $1,900 to $2,400 for fitting and calibrating a machine cap. Manual caps are rented by the month on top of that.

Two costs get left out of the headline figure. Hospitals often charge a separate per-session facility fee for running the machine, which women report in the region of $65 to $150 a session, so it compounds across a course. And dry ice for manual caps is bought fresh for every infusion, commonly $50 to $100 a time, by somebody who has to go and fetch it on the morning of your treatment.

Ask your own center for the total, in writing, including the facility fee. The headline rental price is not the number you will pay.

What has changed is who might pay it. Insurers have historically denied these claims as cosmetic and not medically necessary, and many still do.

where coverage stands, September 2026

Medicare. Permanent billing codes for mechanical scalp cooling took effect on 1 January 2026, so claims can be made for the fitting and for the treatment itself. How those services are paid or bundled varies by care setting, so the code existing does not always mean the whole cost is covered.
State mandates. New York requires coverage under certain large group policies issued or renewed from 1 January 2026. Louisiana's requirement also took effect on 1 January 2026 for new health plans; plans already in force must conform when they renew, no later than 1 January 2027. West Virginia's Jessica Huffman's Law, Maryland's law and Connecticut's Public Act 26-33 take effect for applicable policies beginning in 2027. California's bill has passed the legislature and, as of September 2026, is awaiting action by the governor. What each law covers, and which plans it reaches, differs by state and by the kind of plan you have, so the answer that matters is your own insurer's. Ask them in writing.
Private insurance. Still the weak point. The long-standing pattern is denial on the grounds that scalp cooling is cosmetic rather than medically necessary, and women report the same policy paying in one state and refusing in another. Apply anyway, in writing, and expect to appeal.
Manual cold caps. Much harder to get covered, because they are not FDA cleared devices.
Federal. An Access to Scalp Cooling Therapy Act was introduced in Congress in 2024 and did not become law. There is no national requirement.

Sources: CMS, American Medical Association CPT code set, New York AB 430, Louisiana HB 357, West Virginia HB 4089, Maryland HB 393 and SB 272, Connecticut Public Act 26-33, California AB 1682, HairToStay, Paxman. Coverage is moving quickly, so confirm anything here with your own insurer.

If you cannot afford it. HairToStay is a national nonprofit that subsidizes scalp cooling for patients who would otherwise go without, usually up to around $1,000. Sharsheret runs a program that has covered cold capping costs for qualifying patients as well. The machine manufacturers run patient assistance programs of their own for uninsured and underinsured patients. Some hospitals have local funds through their own foundations. Almost all of this has to be applied for before treatment begins, so ask your oncology social worker in the same week you ask your oncologist.

looking after your hair while you cap

gentler than you think is necessary

There is no single proven routine that makes scalp cooling work better, and anyone who tells you otherwise is guessing. What every program agrees on is being gentle, because hair that is under chemotherapy and being chilled every three weeks breaks easily, and hair lost to breakage is lost just the same.

what the programs usually ask

Protocols differ by system, so follow the instructions from the team and the machine you are actually using. What they have in common:

Wash less often, in lukewarm water. Once or twice a week is the usual advice, with a gentle sulfate-free shampoo, and lukewarm rather than hot. Alra's mild conditioning shampoo is the one we keep for this: it is formulated for sensitive scalps during cancer treatment. Pat dry rather than rubbing.
Brush it, and this is the one that surprises everybody. Women are often frightened to brush at all, and both of the main systems say the opposite: comb or brush gently every day with a wide-tooth comb or a detangling brush, to lift out hair that has already shed. Leaving it in is what causes the matting, and matting is what does the real damage. Brushing does not pull out hair that was not already coming.
Go easy on heat and leave the color alone. No irons, wands or straighteners, and no dye, bleach or perms for the duration. A dryer on a cool setting is usually allowed, with your fingers rather than a brush so there is no tension at the roots.
Nothing that pulls. No tight ponytails, no clips that drag, nothing elasticated tight to the scalp.
Expect to shed anyway. Shedding starts for almost everybody between day 14 and day 21 after the first treatment, and carries on through the middle cycles. It is not proof that capping has failed.

On headwear, advice differs and it is worth asking rather than assuming. DigniCap tells patients that headbands, clips, hats and scarves are fine. Other programs would rather you kept anything tight or gripping off while you are capping. We sell hats for a living and we would still rather you followed your own program than bought from us, so ask your capping team, and if you want something on your head, ask for something loose. If loose is what you are told, two we would reach for: the cotton snood, which pulls on like a hood with nothing to tie and nothing gripping the scalp, and the Trinity cotton turban, which is just as loose and can be worn three ways, so you are not in the same thing every day.

if it only half works, or does not work

Have a plan B. Buying a scarf does not jinx the capping, and having something in the drawer already makes the thin stage easier.

A partial result most often means hair at the sides and the back and a bare patch on the crown, sometimes with long thin original hairs left lying over it. The things that help are the things that help anyone covering a crown: a tinted root powder to take the contrast off the scalp, a wide headband, a hair topper that clips into the hair you kept, or one loose hat. Plenty of women get through the whole of treatment on a headband and a powder.

Shedding carries on for several weeks after your last infusion, so the day chemotherapy ends is not the day your hair stops coming out, and a lot of women think capping has failed at exactly that point. And you can decide to shave at any stage.

If it does not work at all, our guide to chemo and hair loss picks up from there, and help, my hair is falling out covers the practical and emotional side of it.

Some studies have found faster early regrowth among women who used scalp cooling, even where it did not prevent the hair loss, and a number of women say the hair that came back mattered more to them than the hair they kept during treatment. If that is your reason for considering it, say so to your oncologist, because it is a different question from the cosmetic one.

questions we get asked

open only the one you need

do cold caps really work?

Often, and partially. Read the percentages carefully: they are the share of women who succeeded, not the share of hair kept. In most studies success means losing no more than half your hair, or keeping enough not to need a wig, which covers everything from barely noticing to covering a thin crown every morning. Both count in the same column. On that measure, taxane-based regimens report roughly 6 to 8 women in 10, and anthracycline-based regimens far fewer, roughly 2 to 4 in 10. Almost everyone who caps sheds something and very few keep their hair untouched.

is cold capping worth it?

That depends almost entirely on your chemotherapy and on what you are prepared to trade, and nobody can answer it for you. You would be adding several hours to every infusion day, and for some women a stretch of real pain or intense discomfort at the start of each session, washing your hair once or twice a week for months, and paying somewhere in the low thousands that your insurer may refuse. In return, on a taxane regimen, roughly six to eight women in ten keep enough hair not to need a wig. On an anthracycline regimen it is closer to two to four in ten, and a lot of those women describe it as money and suffering spent for very little. The women we hear from who kept their hair are glad they did it. The ones who did not are often angry about it. Both are right about their own experience.

does cold capping work with AC chemo?

Less well than with anything else. Anthracycline-based regimens, often nicknamed the red devil, report the lowest hair preservation rates in every study, and the regret we hear most often from women who have capped is from those who went through AC, paid for the whole course and lost most of their hair anyway. Some still say the faster regrowth made it worth it. Many say they would not do it again. If you are on AC or AC-T, put this question to your oncologist directly and ask what they expect for you, rather than what the brochure says.

why do I have a bald patch on top when the sides kept their hair?

Because cooling only works where the cap is touching the scalp, and caps contact the sides and the nape more reliably than the crown, where head shapes vary most. It is the disappointment women report most often. Fit is what reduces it, so capping teams cinch the cap much tighter than feels comfortable. If you are still capping, ask your nurse or your capper to check the crown contact at the next session.

when do I have to decide?

Before your first infusion. Scalp cooling is used before, during and after every treatment starting with the first one, and it cannot be picked up later once shedding has begun. If treatment is booked and nobody has mentioned it, raise it at your next appointment rather than waiting to be offered it.

does scalp cooling hurt?

For many women, yes, and more than the marketing suggests. When it is uncomfortable, the first fifteen to thirty minutes are usually the hardest: a full-skull cold headache, aching jaw and top molars, pressure behind the eyes, shivering, sometimes nausea. It does ease after that as the scalp dulls to it, and tolerance improves across cycles. Ask your oncologist about pre-medicating before your first session rather than after it, and take a blanket, warm socks, sleeves and a hot drink.

how long does it add to a chemo day?

About thirty minutes before the infusion, then the whole infusion, then the tail afterwards. With a machine that tail is commonly around ninety minutes and can run to three or four hours depending on the regimen. With manual caps it is longer again, often around four hours, changed by hand every twenty to thirty minutes and frequently continuing at home.

what is the difference between cold caps and a scalp cooling machine?

A machine system is a cap plugged into a small refrigeration unit at the infusion center, which holds the temperature steady and is fitted by staff. Manual cold caps are gel caps you rent, freeze on dry ice, bring with you and swap over by hand every twenty to thirty minutes, which needs a trained helper. The machines are FDA cleared and now have insurance billing codes; the manual caps are neither, so most centers cannot store or supply them.

will insurance pay for scalp cooling?

More often than it used to. Permanent billing codes took effect in January 2026, so Medicare claims can be made. New York and Louisiana require coverage as of January 2026; West Virginia, Maryland and Connecticut have laws starting with policies issued or renewed from January 2027, and California's bill is with the governor. What is covered and which plans are reached differs by state, so ask your own insurer in writing. Private coverage is still patchy and manual cold caps are much harder to get paid for. Apply regardless, ask your oncology social worker about the nonprofit subsidies and manufacturer assistance programs, and do it before treatment starts.

can I use scalp cooling with any cancer?

No. It is used for solid tumors and is generally not advised for children, for anyone having radiation to the head, or for some blood cancers such as leukemia. Certain cold sensitivity conditions rule it out as well, and it does not help with hair loss from immunotherapy or targeted therapy. Your oncologist has to make that call for your diagnosis.

why we wrote this

specialists in hair loss since 1995

In 1990 my mother Carol lost her hair to breast cancer treatment. There was no scalp cooling on offer, and nothing she wanted to buy either. She and I started Headcovers in 1995 because of the second of those.

If cooling had existed then, she would have wanted to know about it, and she would have wanted somebody to tell her the truth rather than sell it to her either way. It is cold, it is a long day, it works well with some drugs and poorly with others, and many of the women who try it end up shaving anyway. It is also one of the few things a woman gets to choose in a year when nothing else is up to her, and that counts for something too.

I am not going to tell you to do it and I am not going to tell you not to. I would just rather you had the choice, and had it early enough to make it properly. That is what my mother did not have.

Whatever happens with the capping. Soft hats, scarves and wigs made for hair loss, since 1995. And a person on the phone if you would rather ask.

hats & scarves → wigs & hair pieces

keep learning

chemo and hair lossWhat happens, and roughly when. hair growth after chemoThe first year, stage by stage. help, my hair is falling outCoping, scalp care and what to wear. should I shave my head before chemoHow to decide, and how to do it kindly. how to choose a cancer hatFabrics, coverage, and what to look for. free wigs for cancer patientsPrograms, insurance and where to ask.

written by Danielle Galland-Yates President of Headcovers. Designing and fitting wigs and headwear for women with hair loss since 1995. page last updated September 2026

This guide is for informational purposes only and is not medical advice. Headcovers does not supply scalp cooling and has no commercial relationship with any scalp cooling company. We sell headwear and wigs, which means we stand to gain if you do not use scalp cooling, and we have tried to write this as if that were not true. Whether scalp cooling is suitable for you depends on your diagnosis, your treatment and your own health, and only your oncologist can answer that. Coverage rules and prices change; confirm anything here with your care team and your insurer.

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