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Chapter 4: Hereditary Baldness
The first sign of genetic hair loss in men is often a bit of
recession at the temples, or a little thinning in the crown. One
may notice a subtle change in the texture of the hair at the
hairline, or have the perception that one’s hair feels less full
overall. However, the experience of having large amounts of hair
suddenly appear on the comb, brush or pillow, is generally not a
sign of hereditary baldness.
In hereditary baldness (that also goes under the various names
of male pattern hair loss, androgenetic alopecia, androgenic
alopecia, and common baldness) healthy, full-thickness terminal
hair is gradually replaced by finer, shorter hair. As we saw in
a previous chapter, this process, called “miniaturization,” is
caused by the action of DHT on the hair follicle. Besides
causing the hair to miniaturize, DHT also shortens the hair
cycle so that hair that is at the end of its cycle is replaced
by new, finer hair – each time at a slightly faster rate. The
shortened hair cycle may contribute to the perception of
slightly more hair falling out, but there is no significant
shedding associated with common balding.
To say it another way, male pattern baldness is not a condition
where hair falls out in mass, but rather a condition where full
thickness terminal hair is gradually replaced by finer,
miniaturized hair. At some point the DHT-affected hair will
become so fine, that it will have no cosmetic value and the area
will appear bald. Common baldness, therefore, is a process of
hair “thinning” that only at its end stage leads to actual hair
“loss”.
Men who are going to become very bald usually see the first
signs of hair loss in their late teens and early twenties. The
younger the age that a person begins to thin, the more extensive
the hair loss is likely to become. If a man passes though the
twenties with no hair loss, it is unlikely (thought not
impossible) that he will become very bald. Dark-haired men,
particularly those with light skin, will generally notice hair
loss earlier than light-haired men do, but the rate of hair loss
is no different.
At the first signs of balding, some people panic, some become
depressed, and others resort to using potions, shampoos, or
other over-the-counter remedies. Possibly the worst choice would
be to try to get a quick fix through surgery.
So if you think you are losing your hair, what should one do?
Don’t panic! Consider these three simple things:
1. Decide
if the hair loss really bothers you.
This may seem like a silly comment but, in fact, hair loss
doesn’t bother everyone. Some people just accept it and move on.
If it does bother you, that is O.K. too. You should not feel bad
or guilty about it, even if your response seems a bit excessive.
It is common for people to be worried, concerned, and even
depressed, when they think they are losing their hair.
2. Diagnose
the cause.
Before running to the store and buying an armful of hair loss
remedies, have a consultation with a board certified
dermatologist (these are the doctors whose specialty includes
the diagnosis of hair loss) to have an accurate diagnosis made.
If you don’t know any in your area, you may find one through the
American Academy of Dermatology www.AAD.org. As we saw in a
previous chapter, there are numerous causes of hair loss, many
of them treatable, and the diagnosis is not always clear cut. A
thorough medical history and examination of the hair and scalp
by a professional can secure the diagnosis.
3. Consider
medical treatments before surgery.
Particularly when androgenetic hair loss is in its early stages,
medications are the treatment of choice. Not only can
prescription drugs, like finasteride (Propecia), slow or prevent
further hair loss, they can actually grow hair back if started
when the process is just beginning. Other treatments, such as
changing hair styles and cosmetic camouflage, can also be useful
in certain situations.
As a rule, you should always begin drug therapy early and have
surgery late – after non-surgical options have been exhausted.
It is a poor argument “to start surgery early, so that no one
will notice” or to use surgery as prevention for hair loss.
These strategies only serve the hair transplant surgeon, not the
patient. Hair transplant surgery should not be done early if
your intention is to do it only so that no one will notice a
change in your appearance. If the results are too subtle, the
surgery probably wasn’t necessary in the first place.
Modern hair restoration surgery, properly performed, will be
virtually undetectable after a week to ten days, and grows in
slowly over the course of a year. Therefore, doing a hair
transplant early, so that the existing hair will camouflage the
procedure, is also unnecessary and not a good reason to have
surgery. Have the procedure when you are unhappy with the amount
of hair you currently have.
Diagnosing Hereditary
Hair Loss in Men
The diagnosis of androgenetic alopecia in men is made by
observing:
-
a
“patterned” distribution of hair loss (see Norwood
classification below)
-
the presence
of miniaturized hair in the areas of thinning
-
a normal,
non-scarred scalp in the bald area
The diagnosis is supported by:
As we have discussed, miniaturization is the progressive
decrease of the hair shaft’s diameter and length in response to
androgens, specifically DHT. It can best be observed using a
densitometer, a hand-held instrument that magnifies a small area
of the scalp where the hair has been clipped to about 1mm in
length.
Hair
Densitometer
Hand-held
Microscope
The photo, below left, was taken from a normal scalp. The
follicular units (groups) are made of predominately thick,
healthy terminal hair. Note the relatively uniform diameter of
the hair shafts. The photo, below right, shows that many hairs
have decreased in diameter (miniaturized). This is
characteristic of androgenetic alopecia.
The diagnosis of androgenetic alopecia is supported by a family
history of hair loss, although a positive history is not always
identified. There is a slightly greater incidence of having a
positive history on the mother’s side but, as we have mentioned
before, the inheritance of male pattern hair loss can come from
either side of the family.
If the hair loss is diffuse (thin all over the scalp) rather
than following one of the specific Norwood patterns, the
diagnosis can be more difficult. However, the presence of
miniaturization in the areas of thinning usually confirms the
diagnosis of androgenetic alopecia. If the diagnosis is still
unclear, a number of other conditions must be ruled out.
Medical conditions that can produce diffuse hair loss include
thyroid disease and anemia. Certain medications, including some
drugs used for high blood pressure and depression, and the use
of anabolic steroids, can also cause male hair loss.
The following laboratory tests are often useful when a non-androgenetic
cause for diffuse hair loss is suspected: blood chemistries,
complete blood count, serum iron, thyroid functions, and tests
for lupus and syphilis.
When the diagnosis of androgenetic alopecia is still uncertain,
further diagnostic information can be obtained from a hair-pull
test, a scraping and culture for fungus, a microscopic
examination of the hair bulb and shaft, and a scalp biopsy. A
dermatologic consultation is warranted whenever the cause of
hair loss is unclear.
Classification of
Hair Loss
Once a diagnosis of androgenetic hair loss has been confirmed,
you can compare your degree of baldness with the standard charts
that follow. The Norwood classification, published in 1975 by
Dr. O’tar Norwood, is the most widely used classification for
hair loss in men. It defines two major patterns, the regular
pattern and the Norwood Class A pattern. A third, common type of
androgenetic hair loss, that of diffuse pattern and unpatterned
alopecia, has been detailed by this author [Follicular
Transplantation: Patient Evaluation and Surgical Planning.
Dermatologic Surgery 1997]. The most common system used to
describe the pattern of hair loss in women is the three stage
classification proposed by Ludwig.
Regular
Norwood Pattern
In the regular Norwood pattern, hair loss begins in two distinct
areas, the temples and the crown. Over time, these areas enlarge
and gradually coalesce until the entire front, top and crown
(vertex) of the scalp are bald. [The area where the hair forms a
swirl in the back of the scalp, the same area where hair often
begins to thin at an early age, will be referred to as the crown
or vertex. These terms will be used interchangeably throughout
the text.] The regular Norwood pattern of hair loss is divided
into seven stages. Since hair loss is continuous, many patients
will fall into overlapping categories.
Norwood Class I represents a normal adolescent or juvenile
hairline – it does not signify balding. The adolescent hairline
generally rests on the upper brow crease (the highest wrinkle on
the forehead) and has a horizontal or flat appearance. Class II
indicates a progression to the adult or mature hairline. This
position is approximately one finger's breath (1.5cm) above the
upper brow crease in the middle of the forehead, with some
recession towards the temples. This also does not represent
balding. Class III is the earliest stage of male pattern hair
loss. It is characterized by a deepening temporal recession.
When there is also some thinning in the crown, the pattern is
called a Class III Vertex. Early Class III hair loss should be
treated with medication rather than surgery, particularly in a
younger person.
Norwood Class IV is characterized by further frontal hair loss
and enlargement of the vertex, but there is still a solid band
of hair across top of the scalp that separates the front and
vertex. In Class V, the bald areas in the front and crown
continue to enlarge and the bridge of hair separating the two
areas starts to break down. A person is classified as a Class VI
when the bridge of hair disappears forming a single, large bald
area that extends from the front of the scalp into the crown.
The hair on the sides of the scalp remains relatively high. In
Class VII, the most advanced stage, only a wreath of hair
remains in the back and sides of the scalp to produce a
characteristic “horse shoe” pattern.
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