Norwood Class A
The Norwood Class A pattern is characterized by a front to back progression of hair loss. In Norwood Class A’s, there is one continuous area of balding. When the hair loss extends into the crown, the area of balding is generally more limited than in the regular Norwood classes. The Class A pattern is divided into five stages.

In a Norwood lla, there is recession at the frontal hairline, particularly in the mid-portion. In a Norwood IIIa there is an extension of the hair loss further back with involvement across the entire frontal hairline. In a Class IVa patient the entire frontal area is bald. In a Class Va, the hair loss extends into the crown. At times a Norwood Class 5A will continue to bald and become a regular Class VI. It is very rare for a person with a Class A pattern to eventuate into a regular Norwood VII.

The Norwood Class A patterns are less common than the regular pattern (<10%), but are significant because of the fact that, since the hair loss is most dramatic in the front, the patients look very bald even when the hair loss is minimal. Men with Class A hair loss often seek surgical hair restoration early, as the frontal bald area is less responsive to medication and the dense back and sides contrast and accentuate the baldness on top. Fortunately, Class A patients are excellent candidates for surgical hair restoration.

Diffuse Patterned and Unpatterned Alopecia
Diffuse Patterned Alopecia (DPA) is an androgenetic alopecia manifested as diffuse thinning in the front, top and crown, with a stable permanent zone. In DPA, the entire top of the scalp gradually miniaturizes (thins) without passing through the typical Norwood stages.

In Diffuse Unpatterned Alopecia (DUPA) the back and sides thin as well, so that there is no stable permanent zone. The hair loss in persons with DUPA tends to advance faster than DPA and more often ends up in a horseshoe pattern resembling the Norwood class VII. However, unlike the Norwood VII, the DUPA horseshoe can look almost transparent due to the low density of the back and sides.

The progression of male hair loss in Diffuse Patterned Alopecia (DPA) and Diffuse Unpatterned Alopecia (DUPA). In DUPA, the back and sides thin as well.

Differentiating between DPA and DUPA is a fundamental part of the evaluation of hair loss, since those with DPA are often good candidates for hair transplantation, whereas DUPA patients almost never are, as they eventually have extensive hair loss without a stable zone for harvesting the donor hair.

Patients with DUPA often begin to thin in their teens. The early diagnosis of DUPA can be made with a densitometer by noting increased miniaturization in the donor area. Although these changes can be identified at a relatively early age, they can often be subtle and easily missed by the inexperienced physician. With time, the miniaturization becomes more obvious, so that by the age of 25, the identification of those patients who will eventuate in DUPA is relatively straightforward, even without densitometry. Insuring that the donor area is going to be stable over time, presents a compelling argument for not performing hair transplants on people that are too young.

Classification of Hereditary Hair Loss in Women
The Ludwig Classification uses three stages to describe female pattern genetic hair loss: Type I (mild), Type II (moderate) and Type III (extensive). In all three Ludwig stages, there is hair loss on the front and top of the scalp with relative preservation of the frontal hairline. The back and sides may or may not be involved.

In Ludwig Type I, there is early thinning that can be easily camouflaged with proper grooming. Type I patients have too little hair loss to consider surgical hair restoration. Women with Type II hair loss have significant widening of the midline part and noticeably decreased volume. Hair transplantation may be indicated if the donor area in the back and sides of the scalp is stable.

In Ludwig Type III, there is a thin, see-through look to the top of the scalp. This is often associated with generalized thinning over the entire scalp. Often patients that have progressed to this stage have too little donor hair to make surgical hair restoration worthwhile.

All women experiencing hair loss should have an accurate diagnosis made, preferably by an experienced dermatologist. This is particularly important since the diffuse hair loss that women typically develop, can occasionally be caused by a number of treatable medical conditions. Regardless of the extent or cause of hair loss, only women with stable hair on the back and sides of the scalp are candidates for hair transplantation.

Chapter 5: Psychology of Hair Loss
 

Hair loss affects millions of men and women, both young and old. It can decrease self-esteem and confidence, and limit the ability to enjoy life to the fullest. Persons balding at a young age may feel deprived of an essential element of their youth. This feeling is created and affirmed by cultures all over the world. Images on television, in the movies and on print ads, constantly reinforce the association between a youthful appearance, sexuality, and a full head of hair.

Balding affects people in different ways, but certain emotional reactions seem to be shared by many.

The most common concern that people have when they begin to lose their hair is that they will be less attractive to the opposite sex. The interesting thing is that this is often only the view of the person that is balding and not that person’s partner. The spouse or friend of those experiencing hair loss commonly state that the only thing that bothers them is that it makes their partner depressed. The balding does not bother them per se.

It is interesting that women sometimes express that they want their spouses to look good for the wedding pictures, but once married, they become far less concerned about their spouse’s hair. In fact, when a married man suddenly becomes interested in having a hair transplant, we have seen the spouse become suspicious of extra-marital interests and even object to the husband having the procedure.

Hair loss is a universal marker for aging, with one’s mane gradually diminishing over time. Your body slowly changes as well, with more sagging and wrinkles and ones muscle mass decreasing. However, hair loss hair can also occur suddenly at a young age, making you appear much older than you actually are.

A practical concern with looking older is that the person may not be as competitive in the work force. Unfortunately, studies have shown that this is a real phenomenon. When employers are screening job applicants, all other things being equal, those with hair are viewed more favorably than those who are bald.

People experiencing hair loss complain that the way they look does not fit with their own image of themselves. This occurs when someone begins to lose hair early i.e., in their late teens or twenties, but it is as much a problem when someone has had a full-head of hair for years (and is used to receiving compliments about their hair) and then their hair thins unexpectedly in middle age.

Another aspect of balding is that people feel a loss of control. Hair is one of the few body parts that you can actually manipulate yourself. You can grow hair long, cut if off, you can wave it, dye it, or pull it back in a pony-tail. It serves as a form of self-expression. As people start to lose this form of self-expression, they can become depressed and withdrawn. But not everyone responds this way. People react very differently to their hair loss, with some considering it only a minor nuisance and others finding it so debilitating that they won’t be seen in public without their head covered.

One of the things that makes going bald difficult is that, for some reason, people feel that commenting or joking about hair loss is “fair game” when they wouldn’t dare mention that someone had bad skin, or had a limp. I often point out to patients, that just because people chose to comment about thinning hair, doesn’t mean they are judging that person or really care much about it. It just seems to be a socially acceptable thing to mention.

Women seem to believe that female hair loss is less acceptable than hair loss in men. While this may be true, the vast majority of women have hair loss in a pattern that can be easily camouflaged. Women are often reassured when they realize that about 40% of women experience hair loss over their lifetime, but it is to such a small degree that it is rarely recognized by others.

The important things to remember are that hair loss is very common, it is much more acceptable with age, and it is generally less important to other people than the person experiencing hair loss thinks. That said it is not unreasonable to be upset about going bald. Fortunately, for those who are bothered by their hair loss, there are now excellent medications to prevent hair loss and excellent surgical treatments to restore hair once it is gone.

Hair Loss Medications
 

The FDA approval of oral finasteride, in the form of Propecia, has been a major breakthrough in the medical management of male pattern baldness. Before Propecia, the only medically proven treatment was topical minoxidil (Rogaine) and this medication was only minimally effective and, for many, a nuisance to apply. Propecia, on the other hand, is a once-a-day pill that can significantly alter the progression of genetic balding, particularly if started when the hair loss is still in its early stages.

The recent availability of finasteride in a generic, 5mg tablet, has decreased the cost of the drug – for those who don’t mind cutting up pills.

Avodart (dutasteride), a more potent medication that is related to finasteride, has been approved for the treatment of prostate enlargement, but not hair loss. Because of its affect on the balding process we will discuss this medication as well.

Rogaine (Minoxidil)
Rogaine, the brand name for minoxidil, was the first FDA approved medication for the treatment of hair loss. Rogaine is a topical solution that is applied directly to the scalp. Although originally a prescription drug, it can now be purchased over-the-counter in a generic form. It is sold in concentrations of 5% for men and 2% for women.

Rogaine was developed from the oral blood pressure medication minoxidil (Loniten). Minoxidil taken orally has potential serious side effects on the heart and circulatory system and is used only when other blood pressure medications have been unsuccessful. It was observed that patients who were taking minoxidil began growing body hair and it was reasoned that applying minoxidil directly to a bald scalp might cause hair to grow in this area as well – without producing the side effects of the oral medication. Studies showed that this was indeed the case, although the growth was generally modest.

The original studies on Rogaine were performed on the crown, so there is a misconception that it only works in this area. Although minoxidil usually works best in the crown, it also works to a lesser degree in other areas, such as the front of the scalp, as long as there is some fine (miniaturized) hair in the area. It will not work when the area is totally bald. The greatest benefit from the medication is seen from 5 months to 2 years. After this time there is a gradual decrease in effectiveness, so that those using minoxidil will continue to lose hair, but at a somewhat slower rate.

The exact mechanism by which minoxidil works is not known, but the drug is felt to increase the duration of the hair follicle growth cycle (called anagen). This improves the quality of the hair by increasing the diameter and length of fine, miniaturized hair. The simultaneous use of minoxidil and Propecia, which directly inhibits the formation of DHT, may have some synergistic benefit in the treatment of hair loss, although the latter medication is significantly more effective.

Minoxidil is most effective if applied to the scalp twice a day. The medication only works if it is in direct contact with the scalp (not the hair) and only works in areas where it is applied. Therefore, it is important to use the medication in the front part of the scalp if this is an area of thinning.

The 5% formulation is twice as effective as the 2% solution, but contains propylene glycol, a compound that can irritate the scalp and can make the hair feel sticky and difficult to manage. If this is a problem, one should consider using the 5% solution at bedtime and the 2% solution (which is alcohol based and less sticky) in the morning.

When using minoxidil, it may take 6-12 months before any results are seen. The majority of patients who see an effect from minoxidil experience a delay, or decrease, in the rate of hair loss. The drug also serves to thicken already existing hair, but most patients who do have results, grow only short, thin fuzz. It will not grow any new hair on a bald scalp.

Once a day topical use of Rogaine (topical minoxidil 2% and 5%) seems to be almost as effective as using it twice a day. The reason is that although minoxidil has a relatively short half-life of several hours when given orally, when topically applied, it has a half-life of 22 hours in the skin. This suggests that once a day dosing is a reasonable option. It is important to realize, however, that Pfizer, the company that now makes Rogaine, specifically states that it will be less effective if used only once a day.

If minoxidil is discontinued, the effects of the drug wear off within three months and the previous pattern of hair loss resumes. When minoxidil is restarted, one generally does not regain the hair that was lost, so it is best not to stop and start the mediation, but to use it regularly.

Minoxidil has been prescribed (off-label) in conjunction with other medications, such as topical retinoic acid (Retin-A), to enhance its penetration into the skin and thus increase its effectiveness. This combination of medications, however, can greatly increase the absorption of minoxidil into the bloodstream and may increase the risk of potential side effects, including changes in blood pressure and severe scalp irritation that has led to scarring.

Only the 2% concentration of minoxidil has been approved for use in women. Female patients are generally more sensitive to the side effects of minoxidil in decreasing blood pressure (hypotension) and may get light-headed from the medication. Women also have an increased risk of developing allergic skin reactions (contact dermatitis).

An annoying local reaction that women sometimes get from topical minoxidil is the development of facial hair. Although the facial hair slowly resolves when the medication is discontinued, at times the hair may need to be removed. Carefully trying to avoid the medication dripping down onto the temples and forehead seems to reduce, but not totally prevent, this problem. There is a significantly greater incidence of these side effects if the 5% solution is used.

Propecia (Finasteride)
As we have discussed, male pattern baldness or androgenetic alopecia is caused by the effects of the male hormone dihydrotestosterone (DHT) on genetically susceptible hair follicles that are present mainly in the front, top, and crown of the scalp (rather than the back and sides). DHT causes hair loss by shortening the growth (anagen) phase of the hair cycle, causing a decreased size or miniaturization of the follicles. The effected hair becomes progressively shorter and finer until it eventually disappears.

DHT is formed by the action of the enzyme 5-alpha reductase on testosterone.
Finasteride is a drug that works by blocking the enzyme 5-alpha reductase Type II that converts testosterone to dihydrotestosterone (DHT) in the hair follicle. Propecia (finasteride) decreases both scalp and blood levels of DHT and its effect is felt to be related to both of these factors. Finasteride 1-mg/day decreases serum DHT levels by almost 70%. Although many think that finasteride lowers a man’s testosterone, the medication, on average, causes a rise in serum testosterone levels by 9%, although this is still within the range of normal.