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A cold cap worn before, during and after a chemotherapy drip can help some people keep much of their hair, especially with taxanes such as paclitaxel and docetaxel. It is not suitable for blood cancers or for people very sensitive to cold. For taxanes, trials show 20 minutes afterwards works as well as longer. It does not always work, and results depend on the chemotherapy.
Machine scalp cooling (DigniCap, Paxman) is FDA-authorised to reduce the likelihood of chemotherapy-induced alopecia in women with breast cancer (the 2015 De Novo and 2017 510(k) decisions read); later extensions were not read. In the SCALP randomised trial (Paxman, 142 evaluable), 50.5 per cent of cooled women kept their hair against 0 per cent of controls. Contraindications in the DigniCap instructions are cold sensitivity, cold agglutinin disease, cryoglobulinaemia and cryofibrinogenaemia, and haematological malignancy treated with curative intent. A 2025 meta-analysis of 67 studies found scalp metastasis in 0.15 per cent; common effects were chills (42 per cent), cap heaviness (35 per cent) and headache (30 per cent), and 18 per cent stopped cooling.
There is no guideline-defined schedule. Pre-cooling of 30 minutes is the accepted standard. Post-infusion cooling time depends on the regimen: randomised trials found 20 minutes as effective as 45 minutes after docetaxel and after weekly paclitaxel (the 2022 authors call 20 minutes the new standard of care), while with FEC extending from 90 to 150 minutes did not significantly reduce head-cover use; the Dutch registry (4680 patients) found under 85 minutes as effective as longer for the taxane and anthracycline regimens studied. Wetting hair before cooling lowers scalp temperature but, in the Dutch registry of 1825 patients, added little and slightly raised discontinuation for intolerance. Results are poorer with anthracyclines and with taxane plus anthracycline regimens.
Why: In blood cancers, cancer cells may circulate in the scalp, and cooling could shelter them from the drugs; cold-sensitive conditions make cooling unsafe.
““Contraindications are cold sensitivity, cold agglutinin disease, cryoglobulinemia and cryofibrinogenemia.””
US Food and Drug Administration 2015 · FDA De Novo decision summary (device instructions)
Why: Success varies with the drugs, dose and infusion time; knowing this helps people decide whether the time and discomfort are worth it.
““Attention: Clinical studies have produced variable success rates in patient reduction of chemotherapy induced alopecia with scalp cooling since the outcome is dependent on several factors including chemotherapy regimen, dose, duration of drug infusion, chemotherapy drug metabolism, and concomitant comorbidities.””
US Food and Drug Administration 2015 · FDA De Novo decision summary (device instructions)
Why: People worry that cooling could protect cancer cells in the scalp; in pooled studies this happened in about 1 or 2 people in 1000.
“Secondary analysis of scalp metastases yielded an incidence of 0.15% (95% CI 0.05-0.47%).”
Breast Cancer Research and Treatment 2025 · systematic review and meta-analysis of 67 studies
Why: The cap must touch the scalp evenly to cool it enough.
“If you have Afro hair, you will need to remove any weaves or braids before trying scalp cooling.”
Macmillan Cancer Support 2026 · patient information, ungraded
Why: Damp hair conducts cold better, but in a large registry it made little difference to hair kept, and a few more people stopped because they could not tolerate it.
“In a large patient group with mainly a European hair type and a high hair mass, no convincing evidence was found whether wetting hair prior to scalp cooling contributes to better prevention of CIA.”
Supportive Care in Cancer 2023 · observational registry study, n = 1825
Why: The scalp must already be cold, with its blood vessels narrowed, when the drug levels in the blood are highest.
“Scalp cooling will begin a minimum of 30 minutes pre-infusion administration of chemotherapy.”
US Food and Drug Administration 2017 · FDA 510(k) summary (SCALP trial procedure)
Why: Two randomised trials found 20 minutes kept hair as well as 45 or 90 minutes, which spares the person cold and chair time.
“A 20 min PICT is as effective as 45 and 90 min to prevent weekly paclitaxel-induced alopecia and should be the new standard of care.”
Supportive Care in Cancer 2022 · randomised multi-centre trial (n = 74 analysed for the primary outcome)
Why: Anthracyclines are harder on the hair; trials used 90 minutes, and going longer did not clearly help.
“Extending the duration of 90-min post-infusion scalp cooling to 150 min in patients treated with adjuvant FEC chemotherapy was well-tolerated but did not significantly diminish the need for head covering.”
Supportive Care in Cancer 2019 · randomised multi-centre trial, n = 102
Why: These are the commonest effects and the main reasons people stop; most are worst in the first part of the first session.
“The most common AEs were generalized chills (42%, 95% confidence interval (CI) 26-58%), cap heaviness (35%, 95% CI 18-52%), and headache (30%, 95% CI 21-39%).”
Breast Cancer Research and Treatment 2025 · systematic review and meta-analysis of 67 studies
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
No society guideline sets a scalp cooling procedure; the best-supported version comes from the device authorisations and randomised trials of timing. Offer cooling to people with solid tumours on regimens where it works best (taxanes), after excluding haematological cancers treated to cure and cold-sensitivity disorders; pre-cool for 30 minutes; cool throughout; then 20 minutes after docetaxel or weekly paclitaxel (two randomised trials) and about 90 minutes after anthracyclines (trial standard, with no significant gain from 150 minutes). The Dutch registry suggests under 85 minutes suffices across the regimens it studied, but it is observational. Wetting the hair is optional. Manufacturers' instructions and many units use longer post-infusion times than these trials support.
US Food and Drug Administration 2015 · US Food and Drug Administration 2017 · Supportive Care in Cancer 2022 · Supportive Care in Cancer 2016 · Supportive Care in Cancer 2019 · Supportive Care in Cancer 2025 · Supportive Care in Cancer 2023 · Breast Cancer Research and Treatment 2025 · Supportive Care in Cancer 2025 · Oncology Nursing Forum 2022
Where it differs: A cap filled with frozen gel, changed every 20 to 40 minutes by a nurse or carer, instead of a machine-cooled cap.
Evidence: Macmillan describes the method; the 2025 review notes that gel caps must be pre-frozen, often with dry ice, and changed every 25 to 30 minutes by a caregiver. No head-to-head comparison with machine cooling was read.
Macmillan Cancer Support 2026 · Supportive Care in Cancer 2025
Where it differs: Macmillan tells patients both types of cap need to be worn for 30 to 45 minutes before chemotherapy, longer than the 30-minute minimum in the SCALP trial.
Evidence: No trial of pre-cooling time was read; the 2025 review reports pre-cooling of 5 to 30 minutes in studies, with 30 minutes the generally accepted standard.
Macmillan Cancer Support 2026 · Supportive Care in Cancer 2025
Where it differs: The SCALP trial and many units cool for at least 90 minutes after every infusion, whatever the drug.
Evidence: Used in the SCALP trial that supported FDA clearance. For taxanes, two randomised trials found 20 minutes as effective; the 2025 review notes that institutions often follow manufacturer guidance or internal protocols because there is no guideline.
US Food and Drug Administration 2017 · Supportive Care in Cancer 2016 · Supportive Care in Cancer 2022 · Supportive Care in Cancer 2025
Losing hair is one of the most distressing side-effects of chemotherapy and can often be prevented with a cooling cap. Make it routinely available and paid for.
People using a cold cap often stay in the chair, cold, for an hour and a half after their chemotherapy drip ends. Two randomised trials found that after docetaxel or weekly paclitaxel, 20 minutes of cooling afterwards keeps hair as well as 45 or 90 minutes. Shortening it frees chairs and spares discomfort, yet many units still follow longer manufacturer timings.
Scalp cooling keeps patients in the chemotherapy chair for up to two hours longer, which limits how many people a unit can treat. Shorter cooling after the drip and portable coolers could free the chair without losing hair protection.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Paxman cooling preserved hair in 50.5 per cent against 0 per cent of controls (SCALP) “Results show 48 (50.5%) out of 95 in the cooling group and 0 (0%) out of 47 in the control group had hair preservation.” | randomised trial, n = 142 evaluable, p < 0.0001 | US Food and Drug Administration 2017 |
| 20 minutes of post-infusion cooling was as effective as 45 minutes with docetaxel “A 20-min post-infusion cooling time is effective and tolerable for patients treated with scalp cooling to prevent docetaxel-induced alopecia.” | randomised multi-centre trial, n = 134, p = 0.5 | Supportive Care in Cancer 2016 |
| Shorter post-infusion cooling (under 85 minutes) was as effective as longer across taxane and anthracycline regimens “For all anthracycline and taxane-based chemotherapy regimens studied, shorter PICTs delivered comparable results to longer PICTs.” | observational registry study, 4680 patients, 68 hospitals | Supportive Care in Cancer 2025 |
| Guideline recommendations on scalp cooling are lacking “There is a lack of guideline recommendations about the use of scalp cooling for preventing chemotherapy-induced alopecia (CIA).” | overview of 14 systematic reviews (poor quality by AMSTAR 2) | Oncology Nursing Forum 2022 |
Shares Wigs, cranial prostheses and head coverings, Scalp cooling (cold caps: DigniCap, Paxman), Docetaxel, Doxorubicin and the tag supportive-care.
Shares Docetaxel, Paclitaxel / nab-paclitaxel and the tags protocol, supportive-care.
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Shares Scalp cooling (cold caps: DigniCap, Paxman), Docetaxel, Doxorubicin, Paclitaxel / nab-paclitaxel and the tag supportive-care.
Shares Fund scalp cooling and hair-preserving measures for every alopecia-inducing regimen, Scalp cooling (cold caps: DigniCap, Paxman), Docetaxel, Doxorubicin.
Shares the tags protocol, supportive-care.
Shares the tags protocol, supportive-care.
Shares the tags protocol, supportive-care.