What Is Hair Loss?
Hair loss (also called alopecia) is a condition that has an impact on your hair follicles either on your scalp or the entire body. Hair loss can be temporary or permanent but usually, individuals start to notice hair thinning in some or all parts of the hair. Sometimes, it can be a bald spot rather than hair thinning.
This may cause discomfort for some people as they tend to think it affects one’s self-esteem. It is important to remember that stress and overthinking about hair loss or thinning may add to the ongoing problem further.
There are different potential causes of alopecia and types of hair loss will be explained in detail in the later parts of the article. However, generally speaking, hair loss or thinning happens due to genetic factors of individuals as well as the lifestyle or some other diseases.
It is an important step to determine why you are experiencing hair loss before making any decisions to attempt stopping it and possibly starting to look for options to regrow hair. Taking precautions that wouldn’t work in your case could lead to stress and loss of effort and money. Even worse, in some cases, you may further increase hair loss and damage your scalp or hair. Therefore before taking any step, it could be helpful to understand why we lose hair.
Let’s dig into this.
Hair 101
To understand hair loss, it is vital to learn the basics of the hair structure. Hair is a protein filament that grows through the skin (epidermis) from deep within the skin (dermis). Individuals may have hair in the different areas of the body such as the scalp, face, ear, nose, eyebrows, armpits, front and back of the torso, legs, and genitals.
There are three parts of the hair that is mostly related to hair loss and regrowth:
- The bulb, where the hair follicle is attached to the bloodstream and receives all the nutrients to grow.
- The root, which is the hair below the skin and after the bulb.
- The shaft, which is the hair above the skin.
- Papilla also needs to be noticed as it is the connection between the hair follicle and the bloodstream. It also plays an important role in the hair growth cycle and to simply put, when hair falls, it is because papilla is detached from the blood veins and can’t transmit nutrients to the hair for its maintenance and growth.
The hair on the scalp grows at a rate of 0.4 mm every day. The growth can vary in individuals due to psychological, behavioral, or illness-related issues.
Some quick facts about hair:
- Hair grows 1-1.5 cm every month.
- The fundamental of the hair is the protein called keratin.
- Among all types of hair in the body, facial hair grows the fastest.
- Losing 50 to 100 hair follicles every day is standard.
- Warm weather may result in hair to grow faster.
- The way hair is cut doesn’t impact the growth rate.
- Individuals usually have 100,000 to 150,000 hair follicles on the scalp.
- The hair shaft is not living tissue.
For more detailed information about the structure of hair, Bilgen Erdogan’s Anatomy and Physiology of Hair book is an excellent resource.
Hair Growth Cycle
According to American Academy of Dermatology, it is considered to be normal to shed 50-100 hair follicles a day. Due to different reasons such as genetics, blood nutrient level, or physical stress, hair may fall. When hair falls more than 100 follicles a day consistently, it may mean hair loss.
American Academy of Dermatology website contains great information about hair shedding and hair loss as well as how to distinguish the two.
It is crucial to understand the hair growth cycle to determine the hair loss type and find the right solution for each case.
The hair growth cycle consists of 3 stages, Anagen, Catagen, and Telogen Phases. Each plays an important role in hair loss and growth. Let’s go into details of each phase.
Anagen Phase
The anagen phase is basically when the hair is healthy and is perfectly positioned in the scalp. From 2 to 6 years, hair constantly grows. The papilla is still attached to the blood supply and is able to transmit nutrients.
Every time hair is cut or reshaped, it is the same group of hair follicles that are being worked on. The reason why individuals can have long hair is that most of their hair follicles are in the anagen phase. As hair follicles remain without falling, they have a better chance of getting longer. This could potentially hint that an individual’s hair and scalp are healthy. However, there could be a receding hairline despite having long hair.
It is important to note that when hair starts to fall, it tends to follow a pattern. Norwood scale is one of the ways to identify the hair loss level and understand how hair loss could proceed in the coming years. However, if the reason for hair loss isn’t genetic, hair loss could happen in unique ways. This will be explained in the later chapters of this article.
Catagen Phase
The catagen phase is when the hair follicle is detached from the blood supply. This period is short, lasting only 1-2 weeks on average. When the hair follicle enters this stage, it means all the essential nutrients a follicle need can’t reach the root. Without nutrients, the hair follicle can survive for some time but eventually, it falls.
Healthy individuals lose somewhere between 50-100 follicles every day. Hair that falls is a result of the catagen phase. When more than 100 follicles enter the catagen phase, it could mean that hair thinning could start forming on an area of the scalp. Hair loss would be the deficit of hair in this stage.
Telogen Phase
The telogen phase is the stage where the hair starts to rest after shedding. The papilla completely separates from hair follicles and the root can’t receive the nutrients it needs to regrow follicles. It could take up to 15 weeks until the hair follicle starts to grow again.
After the telogen phase is over the hair follicle enters the anagen phase where it remains in the scalp healthy for 2-6 years. This is what usually happens most of the time. Hair loss occurs even at the back of the head where the follicles are the strongest. The reason why most of the time hair loss won’t affect the back of the head is the hair cycle continues flawlessly and there aren’t more than 100 follicles lost every day on average.
When the catagen phase is over and a follicle falls, there is a chance that the root may never enter the telogen phase. If the papilla doesn’t reattach to the root, this means that blood supply can’t reach the root. Without the nutrients from the blood, a hair follicle can’t be produced. This unfortunately means that until the papilla is attached to the root, there won’t be hair production from this particular root.
If more follicles are falling than regenerating or they completely stop entering the telogen phase, hair loss symptoms such as hair thinning, receding hairline or balding may occur.
Types of Hair Loss
With the hair growth cycle interrupted, individuals may start observing thinning hair or their hairline becoming asymmetric.
When this happens, the first step should be to determine the cause of hair loss. Dermatologists as well as some hair restoration clinics can help patients with identifying hair loss cause by looking at the symptoms or requesting tests such as blood or genetic tests.
By determining the cause of hair loss, one can understand what potential solution there may be for their individual case.
These are the types of hair loss:
- Genetic
- Hair Growth Cycle Related
- Immune System Related
- Fungus Related
- Inflammation Related
- Psychological and Behavioral
Hair loss can occur due to genetic factors as well as medical and behavioral conditions. In some cases, there are multiple causes of hair loss and it could be to the benefit of the patient to make sure all possible reasons are looked into carefully. By focusing on one area and relying on remedies for that could discourage individuals when they don’t see the expected results. It could also be costly.
The book Hair Loss: An Overview by Fabiane Mulinari-Brenner and Wilma F Bergfeld goes into details of hair loss types and how each type of hair loss is diagnosed and treated. If you are having difficulty with finding more information about a certain type of hair loss, it could be a valuable resource.
Genetic Hair Loss
Hereditary Pattern Baldness (Androgenic Alopecia)
Androgenetic alopecia is the most common cause of hair loss. It is essential to acknowledge that this type of hair loss is not a disease. Hereditary hair loss is a combination of genetics, hormone levels, and age of the individual. Although some people don’t notice hair loss even when they are aging, most will experience some level of hair loss or thinning. According to the research (Harvard Health), up to 40% of people, men or women will have a more obvious form of hereditary hair loss. The most common age for individuals to start experiencing hereditary hair loss is after the 20s with some exceptions.
The testosterone hormone plays an important role in hair loss. You can find more information about the effect of testosterone on hair loss later in the guide.
The levels of testosterone in the blood may be affecting the hair growth cycle. Because of imbalances with this hormone, hair follicle roots are blocked and the nutrients in the blood can’t reach the root. As mentioned before in the previous section, when the papilla isn’t attached to the root, it becomes impossible for the follicle to survive.
It is still unclear at this point if the genes are transferred from a specific side of the family. The hair loss could be due to genes transferred from the mother’s or father’s side, contrary to a common misconception that the genes come from the mother’s side. Therefore, when examining hair loss in the family, all the individuals must be included in the process to maximize the chance of diagnosing the situation correctly.
Getting less blood from papilla may cause hair thinning in the early stages. A hair follicle needs a certain amount of nutrients to grow healthy. If it is getting a lesser amount than required, the hair, although it is in the anagen phase, may grow thin and weak. This is the first sign that the hair is not provided with enough resources to continue to grow healthy. In time, this may cause follicles to enter the catagen phase earlier than they were supposed to. That means, there is less hair in the anagen phase and more hair in the catagen phase. Adding the possibility of some of these follicles never entering the telogen phase to grow again, the chances of receding hairline or balding are increased.
Androgenic alopecia causes men to start losing hair at the crown and temples. As hair loss proceeds, the hairline recedes in a way that when looked, it looks like an M shape. Depending on genes and some other conditions, hair loss may happen asymmetrically meaning that instead of an M shape, one side of the temple may have more hair loss compared to the other.
In women, androgenic alopecia affects a wider area rather than when compared to men. Hair loss usually starts from the top of the head and some call this pattern a Christmas tree pattern. It is unusual to see an M shape pattern in women or receding hairline. If a woman experiences M shaped hair loss, it may hint to a different cause such as alopecia areata ( A disorder with the immune system which may cause bald patched), fungus or bacteria, and dermatologic problems.
Diagnosis
The first step would be examining the hair loss pattern in the family, parents, and grandparents. Most of the time, this gives the doctor and patient a good perspective if the patient’s hair loss pattern follows one of the family members. However, as mentioned before, it could be to an individual’s benefit to have more tests to see if there are any other contributors that might be shadowed by hereditary hair loss.
Hypotrichosis
Hypotrichosis is a term that dermatologists use to describe the condition when an individual doesn’t have any hair growth. The difference between androgenic alopecia and hypotrichosis is, hypotrichosis condition causes a person to never have hair growth observed where with androgenic alopecia, the individual starts losing hair after there was hair growth. Hypotrichosis affects individuals starting from birth until the very end.
According to researches, a large number of hypotrichoses happen during embryonic development during pregnancy. The causes is linked to genetic aberrations or defects that happen during pregnancy. It is not uncommon to see these individuals have other physical and mental problems as well as hypotrichosis. Graham-Little syndrome, Ofuji syndrome, cartilage-hair hypoplasia, Jeanselme and Rime hypotrichosis, Marie Unna hypotrichosis, and metaphyseal chondrodysplasia and some other disorders may be involved with the symptom of hypotrichosis.
With continuous investments in research to understand human genome better as well as why and to what extent genetic defects may be causing hair loss, it is expected to find solutions to genetic problems in the future. These efforts are contributing to improving the overall understanding of conditions like hypotrichosis however, finding a suitable treatment is a very challenging task and there is no known treatment for hypotrichosis at the moment.
Congenital Aplasia
Aplasia cutis congenita, or congenital aplasia happens during pregnancy for a reason unknown reason. This condition causes the skin not to fully form as the embryo develops. When the baby is born, a patch of skin like an open wound or ulcer may be observed. Usually, congenital aplasia can be seen at the back of the scalp, at the center of the hair growth on the head. In cases where the scar is small, the skin may have a scab but the scar will remain.
When the condition triggers when the baby is in the womb since the same process happened before it was born, there can only a patch of the scalp without hair follicles be observed.
Hair Cycle Related Hair Loss
Telogen Effluvium
As mentioned before, a follicle stays healthy during the anagen phase for 2-6 years. After the follicle enters the catagen phase, papilla separates from the root, and eventually, the hair follicle falls. Then, it enters the telogen phase where the root rests in a detached position and is incapable of producing a new follicle.
With Telogen Effluvium, around 30% of the hair follicles enter the telogen phase at the same time compared to the normal percentages of 5-10% (Harvard Health). This means, there are fewer follicles entering the anagen phase where the hair grows back. Hair loss due to telogen effluvium could be permanent or temporary depending on the cause and other factors.
Symptoms of Telogen Effluvium
Individuals may start to observe more shedding and eventually, thinning hair or receding hairline at the crown and temples. Because the 20% difference equals a decent amount of hair, it can be more easily noticed.
Causes of Telogen Effluvium
Since this condition occurs when there is a disturbance in the regular hair cycle, there can be many different causes. Here is the list of some possible causes for Telogen Effluvium:
- Extreme Stress: Stress can cause many different problems in the human body. It may affect the brain, organs, and blood pressure. Related to stress, it isn’t unusual to see sleep deprivation and the tendency to be depressed. These and other factors are known to be having an effect on hair and may lead to hair loss. As a result, telogen effluvium can be triggered. It is also important to note that stress-related hair loss tends to happen after 3 months of a stressful event.
- Dietary Inconsistencies: Hair follicles need key nutrients including protein, iron, B-vitamins, and zinc to grow and maintain. Due to inconsistency in receiving these nutrients in the right amounts, telogen effluvium could be triggered. It is essential for individuals to have a balanced and healthy diet to prevent hair loss.
- Losing Weight Abruptly: When an individual loses a significant amount of weight in a short period of time, it could adversely affect the body. If hair loss occurs due to calorie restrictions, combined with inadequate nutrients, the body may respond by triggering telogen effluvium. Losing weight systematically with regular exercise is advisable to all individuals from all age groups and genders.
- Pregnancy and Childbirth: Pregnancy is known to disturb the hormones of the female body and cause changes in different ways. One of the observed changes is losing hair during pregnancy. While this is usually temporary (until a couple of months after birth), in some cases it could take longer for hair to grow back. In some cases, some or all of hair loss is permanent. If the pregnancy triggers telogen effluvium, which is called post-partum telogen effluvium, women may experience some temporary and permanent hair loss as a result.
- Menopause: When the female body enters menopause, the body goes through some changes as a result of differences in the hormone levels. One of the ways menopause can affect the body is triggering the telogen effluvium.
- Drugs and Smoking: Some medical or recreational drugs may promote hair loss as they cause damage to the body. Depending on the drug, the effect could be on hormone levels, brain, organs, or blood cells.
Similarly, smoking has been associated with many harmful effects on the body.
One of the ways drug usage or/and smoking can affect the body is causing it to suffer from telogen effluvium.
- Other Health Conditions: Going through surgery and other health conditions may have an impact on hair. Telogen effluvium could be one of the ways hair loss occurs.
Treatment
As always, it could be the best approach to start from determining if the patient has telogen effluvium or there are some other conditions triggering hair loss. The cause could be telogen effluvium alone or another cause might be also involved. It is always advised to see a dermatologist or hair clinic before starting treatment.
If the patient is certain that cause of hair loss is telogen effluvium, the first step would be to find out the cause. When the cause or causes are found, possible treatments can be discussed and followed.
Some treatment options are:
- Examining the diet of the individual and making changes to ensure the body receives all the necessary nutrients.
- Hair replacement (without hair surgery)
- Quitting drugs and smoking,
- Hormone replacement therapy for women in menopause.
- Starting counseling support for psychological assistance.
- Losing weight gradually and exercising regularly.
- Changing lifestyle.
Since the hair follicles are already weak, applying heat for shaping hair as well as products may further damage follicles. It is recommended to allow hair to be in its natural state as much as possible.
Dietary Recommendations:
- Hair follicles need protein to produce, grow and maintain a healthy state. the building blocks for hair to grow. There are many different nutrients known to be preventing hair loss and promoting hair regrowth. By identifying sources for nutrients, individuals can include them in their diet.
- Iron deficiency is linked to telogen effluvium and increasing iron intake could help with stopping hair loss.
Regrowth
Once the cause or causes are identified and treatment begins, usually it takes at least 3 months for the hair to enter the anagen phase and start growing back. Individuals may notice a decrease in shedding but at some level, it could still continue. In most cases, hair loss won’t be more than 50%.
Anagen Effluvium
Another type of hair loss due to the interruption of hair growth cycle is the manager effluvium. This type of hair loss occurs as a result of medical treatment, such as chemotherapy. Medical treatments that involve harmful effects on both benign and harmful cells may cause hair follicles to stop working properly. Usually, when this happens, the anagen phase is interrupted and since there aren’t new hair follicles growing, patients may experience hair loss.
With the end of the treatment, individuals could see hair regrowing after a couple of months.
Immune System-Related Hair Loss
Alopecia Areata
Alopecia areata is a condition that affects the immune system. Patients who have this condition experience hair loss as well as some other negative symptoms as a result of individual’s immune system attacking healthy cells. Geneticists call this type of condition “complex polygenic disease” which means there is an interaction between multiple genes as opposed to a mutation in a single gene. There are more than 17 genes that have been linked to alopecia areata and scientists are expecting to find some more in the future.
Adults and children are prone to experience this condition. This type of hair loss may begin suddenly and there are no early signs. Unlike hereditary hair loss, alopecia areata is observed with small patches of hair falling from the scalp. Eyebrows and eyelashes could also fall as a result of alopecia areata. Over time, this condition may turn into alopecia totalis where the individual loses all hair.
Dermatologists usually recommend treating alopecia areata with medication to promote hair regrowth.
More information about alopecia areata can be found in the article from Healthline.
Discoid Lupus Erythematosus
Discoid lupus erythematosus is an autoimmune disease that affects the skin. The inflammation of the disease causes sores and wounds on the ears, face, and scalp.
With the loss of skin, hair follicles lose their positions to grow. This results in hair loss on the scalp. Once this condition is observed, individuals can’t grow hair back even when the skin heals and therefore this type of hair loss is permanent.
Fungus-Related Hair Loss
Tinea Capitis
Tinea capitis (scalp ringworm) a condition that impacts hair loss in children. It is one of the most common hair loss types for children and it is a fungal infection. Similar to alopecia areata, loss of small hair patches are observed with this condition. As a result, there can be some bald spots observed that may get bigger in time.
The scalp might be itch and the areas tinea capitis affects usually look red or scaly. The immune system responds to fight the infection and this may cause fever or swollen glands in the back of the neck.
It is crucial to diagnose tinea capitis in the early stages and start treatment as soon as possible to ensure maximum level of hair regrowth following the disease.
More information can be found on the Healthline’s article about tinea capitis.
Inflammation-Related Hair Loss
Cicatricial Alopecia
Cicatricial alopecia (scarring alopecia) is an uncommon type of hair loss. This condition is caused by the inflammation that destroys hair follicles and scar tissue takes place on the scalp. This makes growing hair in this area impossible.
Hair loss of this type may progress gradually and conceal the symptoms or in some cases, it may happen suddenly and hair starts to fall at once. Some other symptoms are as the following: itching, swelling, and red/white lesions on the scalp that is often mistaken for rash. There is no common age group or gender who experience this condition and the chances of this type of hair loss happening appear to be equally possible for everyone.
More information about cicatricial alopecia can be found in this Webmd article.
Lichen Planopilaris
Lichen planopilaris, occurs after a skin condition called lichen planus affects the scalp. The common symptoms are dry, flaky rash to appear on the skin. This causes an unfriendly habitat for the hair follicles to grow and they may start falling in clumps. Similar to cicatricial alopecia, the scalp may be red, irritated, and covered in small white or red itchy, painful or burning bumps.
This is not a common condition and could easily be mistaken for any other condition since it has very similar symptoms with other skin related problems. It is highly recommended to see a dermatologist for determining what type of skin problem the individual has and start treatment accordingly.
More information about lichen planopilaris can be found in this article from Mayoclinic.
Frontal Fibrosing Alopecia
Frontal fibrosing alopecia (FFA) is a form of lichen planopilaris. Typically, this condition is seen primarily with alopecia and causes scarring on the scalp close to temples. Some individuals experience hair loss on the eyebrows, eyelashes, and other parts of the body. There may be a few different reasons why this type of hair loss occurs but hormonal changes and autoimmune response are considered to be the main triggers although it is not proven yet.
At the moment, there isn’t a cure for this type of hair loss however doctors try different medications and regimens to slow or stop hair loss.
Folliculitis Decalvans
Folliculitis decalvans is an inflammatory disorder that causes hair follicles to be destroyed by the inflammation. Similar to other types of inflammatory-related hair loss, redness, swelling, and lesions, or pustules may be observed. Once this condition is triggered, it is not possible to regrow hair however with medications, hair loss may be slowed or stopped.
More information about folliculitis decalvans can be found in this article from Healthline.
Dissecting Cellulitis of the Scalp
Dissecting cellulitis of the scalp is another type of hair loss that is caused by inflammation. Although it is really uncommon to have this condition, when pustules or lumps are observed on the scalp, it may be due to dissecting cellulitis of the scalp. Once on the scalp, this condition may cause scar tissue to form that could destroy the hair follicles. Medications might help control hair loss.
Behavioral or Psychological-Related Hair Loss
Central Centrifugal Cicatricial Alopecia
Central centrifugal cicatricial alopecia may occur due to hair products or hairstyling techniques that damage hair follicles and the scalp.
Hair relaxers, blow dryers, perms, curling irons, and hair extensions might cause this type of hair loss. Moreover, consistently applying oils, gels, and other products to style hair could trigger the condition. Once the individual stops using hair products or styling techniques, there is a chance for hair loss to stop and hair to regrow.
More information about this disease can be found here.
Hair Shaft Abnormalities
Hair shaft abnormalities are the types of hair loss that are caused by damaging or weakening the hair follicles. The hair shaft is the part of the hair that is visible on the scalp. When there is damage to the follicle and it doesn’t cause it to separate from the root, the area looks thin. Another way to spot these follicles is to observe the scalp to see if there are any small follicles.
By changing the way hair is styled or stopping to use hair products, hair shaft abnormalities could be prevented.
Webmd has an extensive page about hair shaft abnormalities, you can visit for more information.
Here are the types of hair shaft abnormalities:
Loose Anagen Syndrome
Loose anagen syndrome is observed in children when hair is not strong enough to hold it’s position on the scalp. This may cause hair to be pulled out easily and there is a maximum length that the hair shaft can get to before falling. Due to this condition, the child’s hair growth is limited and cannot grow beyond a point. This condition tends to affect girls with blond or brown hair.
In people, when this condition is seen hair can fall out easily compared to other individuals even when it grows. Simple friction like drying the hair with a towel or wearing caps or bandanas may cause hair loss. The cause of loose androgen syndrome is unknown although hair loss pattern resembles hair loss due to hair growth cycle-related conditions. There are a number of treatments to stop hair loss and promote hair regrowth.
Trichotillomania
Trichotillomania is a psychological condition that causes hair loss. Some individuals feel the urge to pull their hair and they can’t stop doing so. Over time, this behavior causes hair loss as hair cannot frow back at the speed of destruction. Continuous hair ripping may cause permanent damage as hair follicles may not go into the anagen phase after a point.
The best treatment for this condition would be psychotherapy to help the patient stop the behavior.
Traction Alopecia
When there is too much force on the follicles, it may cause them to get weak over time and eventually start falling. Some hairstyles like ponytails and braids, there is a constant pull force on the follicle. In some cases where the hat is too tight or the individual wears a small helmet, it may cause hair to fall. To prevent hair from falling, it is advised to either change the hairstyle or equipment to ensure hair is in a relaxed position.
Norwood Scale
The Norwood scale (Hamilton-Norwood scale) is the classification system used by dermatologists or hair surgeons to determine the extent of hair loss in men. In some cases, when hair loss is not only due to androgenic alopecia, hair loss may not occur as shown in Norwood Scale. If the individual has hereditary hair loss, it usually follows a pattern.
Norwood scale makes it very easy for anyone who has androgenic alopecia to find out at what stage they are at the moment. Hair transplants use this information to determine if the hair transplant surgery would be ideal for the individual and if so, how many grafts they would need.
Norwood Level 1
Hair loss typically starts with receding hairline in men. Hair starts to fall in the forehead, near the temples. However, at this stage, hair loss doesn’t happen on the sides as can bee seen in the first image. The natural hairline slightly disappears however it is not very noticeable.
It is very unlikely for the individual to go through a hair transplant surgery at this stage as the operation wouldn’t be cost and time effective. Most of the time, hair loss proceeds over time, and gaps in between the transplanted and natural hair may start showing. Therefore, most surgeons would either recommend using regimens to stop hair loss and potentially promote hair growth.
It would be advisable to monitor the progress of hair loss and the effects of the medications if used. This would provide valuable information to plan the next steps.
Norwood Level 2
At this stage, individuals start to observe some more impactful changes in the hairline and sides. A “V” shape starts to take shape on the sides as can be seen in the first image (the image from the side). Moreover, the V shape also begins to form in the middle on the forehead.
At this stage, it is not uncommon to see individuals preferring a hair transplant procedure to immediately reinstate the initial look of the hair. It is important to note that this level of hair loss is still in the early stages and the number of grafts used for a procedure would be small. Therefore, it is important to carefully calculate the costs and time spent to determine if this is the right time to get surgery.
It is usually advised to continue to monitor the progress of hair loss and start looking for options. Hair loss is a lengthy process in most cases and by planning for the future starting from the early stages, a better outcome can be achieved in the coming years.
Norwood Level 2A
Norwood Level 2A is a variation of Norwood Level 2 with minor differences. Individuals may observe a smaller M shape and hairline staying more of a line while receding a bit further back to the top of the head.
Similar to Norwood Level 2, this level is also an important transition stage as the receding hairline starts to be more obvious.
Monitoring the progress and beginning to learn more about hair loss and regrowth is advised.
Norwood Level 3
Norwood Level 3 is the stage where individuals can start observing a more complete “M” shape. Hair recedes from the temples and the shape is known as “Widow’s Peak” forms.
Individuals usually start to take more effective precautions or treatments to stop hair loss and try to regrow some of the hair loss. Depending on the type of hair loss, some medication and treatments may help to slow down or stop hair loss however, hair loss may continue to progress regardless of the effort made.
In many cases, patients begin to look for temporary hair loss remedies such as using Finasteride or getting PRP sessions. It is also very common that individuals start seeking hair restoration surgery to recover hair. Although hair transplants can solve the problem for the moment, if and when hair loss start to progress again, it may leave and the bald area between the planted and natural hair. This would require the patient to go through a second surgery to fill the gap in between. However, Norwood Level 3 could still be considered as an early hair loss stage. If hair loss continues until the last stage, the patient may have to go through 2 or 3 more surgeries (depending on the quality and quantity of donor hair). If the patient doesn’t have enough donor hair left, it could leave the individual with an undesired look.
At this stage, if the patient decides not to take any steps, it is advised to monitor hair loss. If the patient chooses a temporary solution such as drugs or PRP, it is recommended to monitor the progress as in some cases these methods may promote hair growth. In case the patient decides to go with surgery, it is highly advisable to plan ahead and continue to monitor progress after hair transplant surgery.
Norwood Level 3A
Norwood Level 3A is a variation of Norwood Level 3. The difference is, at this stage, the individual loses almost all of hair in the front and on the sides rather than seeing an “M” shape. Also, compared to Norwood Level 3 Vertext, the patient doesn’t lose hair from the crown (vertex).
At this stage, if the patient decides not to take any steps, it is advised to monitor hair loss. If the patient chooses a temporary solution such as drugs or PRP, it is recommended to monitor the progress as in some cases these methods may promote hair growth. In case the patient decides to go with surgery, it is highly advisable to plan ahead and continue to monitor progress after hair transplant surgery.
Norwood Level 3 Vertex
Norwood Level 3 Vertex is a variation of Norwood Level 3. At this stage, the “M” shape is visible same as Norwood Level 3 however, hair loss also starts to affect the crown of the individual. Therefore, this stage could be seen as the last step of the transition from Norwood Level 3 to 4.
At this stage, if the patient decides not to take any steps, it is advised to monitor hair loss. If the patient chooses a temporary solution such as drugs or PRP, it is recommended to monitor the progress as in some cases these methods may promote hair growth. It is also advertised by companies that sell hair loss treatments that their products are highly effective on the crown. Therefore, many individuals prefer to use these products to stop hair loss on the vertex and potentially regrow some or all of the hair back. In case the patient decides to go with surgery, it is highly advisable to plan ahead and continue to monitor progress after hair transplant surgery.
Norwood Level 4
Norwood Level 4 is the stage that is considered to be the beginning of the mid-stage of hair loss. The remaining hair on the frontal lob falls further and the M shape begins to appear as more of a V shape. Hair loss on the vertex also progresses and starts to form a bald spot that gets larger as hair loss progresses.
Similar to Norwood Level 3 patients, individuals begin to look for temporary hair loss remedies such as using Finasteride or getting PRP sessions. Also, a lot of patients at this stage have regimens they use to slow down or stop hair loss. It is also very common that individuals start seeking hair restoration surgery to recover hair. As mentioned earlier for Norwood Level 3 patients, although hair transplants can solve the problem for the moment, if and when hair loss start to progress again, it may leave and the bald area between the planted and natural hair. This would require the patient to go through a second surgery to fill the gap in between. If hair loss continues until the last stage, the patient may have to go through 1 or 2 more surgeries (depending on the quality and quantity of donor hair). If the patient doesn’t have enough donor hair left, it could leave the individual with an undesired look.
Norwood Level 4A
Norwood Level 4A is a variation of Norwood Level 4. The difference between 4 and 4A is that the latter stage patients start to observe less hair on the top of the head as seen in the image above. The V shape starts to fade as there are fewer hair follicles in the area. However, the patient doesn’t lose hair in the vertex area.
Similar to Norwood Level 4 patients, individuals begin to look for temporary hair loss remedies such as using Finasteride or getting PRP sessions. Also, a lot of patients at this stage have regimens they use to slow down or stop hair loss. It is also very common that individuals start seeking hair restoration surgery to recover hair. As mentioned earlier for Norwood Level 4 patients, although hair transplants can solve the problem for the moment, if and when hair loss start to progress again, it may leave and the bald area between the planted and natural hair. This would require the patient to go through a second surgery to fill the gap in between. If hair loss continues until the last stage, the patient may have to go through 1 or 2 more surgeries (depending on the quality and quantity of donor hair). If the patient doesn’t have enough donor hair left, it could leave the individual with an undesired look.
Norwood Level 5
Norwood Level 5 patients observe that the hairline has receded to the top of the head and the balding on the vertex progresses to form a larger spot. There are signs of irregular hair loss on the top of the head there may be bald spots forming.
At this stage, hair regrowth by conventional, traditional ways is out of scope. The main goal of the individual should be to prevent any further hair loss and increasing the health of hair follicles. The remaining hair follicles could be thinner than earlier stages and this might show the hair as less dense. Also, thinner hair might make it very difficult for hair transplant surgery to take place. As mentioned before, hair surgeons need thick, eligible hair follicles to transfer the hair from the back of the head to the bald areas. If the follicles aren’t thick enough, the transplanted hair may not look natural and the patient’s experience could be poor.
At this stage, determining the strategy for hair transplant surgery is important. If the patient decides to wait until later stages, a procedure might not be possible because of the hair donor quality/quantity. Or, the patient can have surgery at this point but may still lose hair in the coming years and need another surgery. If there isn’t enough donor hair for the second surgery, it may look unnatural.
It is highly recommended to find a hair surgeon or clinic that you can build your strategy with and plan all the possible outcomes to ensure the minimum level of risk.
Norwood Level 5A
Norwood Level 5A is a variation of Norwood Level 5. Patients usually see that the remaining hair on the top of the head and vertex are very thin and the area doesn’t look dense enough. The bald spot on the vertex merges the spot on the top of the head.
Similar to Norwood Level 5, at this stage, hair regrowth by conventional, traditional ways is out of scope. The main goal of the individual should be to prevent any further hair loss and increasing the health of hair follicles. The remaining hair follicles could be thinner than earlier stages and this might show the hair as less dense. Also, thinner hair might make it very difficult for hair transplant surgery to take place. As mentioned before, hair surgeons need thick, eligible hair follicles to transfer the hair from the back of the head to the bald areas. If the follicles aren’t thick enough, the transplanted hair may not look natural and the patient’s experience could be poor.
At this stage, determining the strategy for hair transplant surgery is important. If the patient decides to wait until later stages, a procedure might not be possible because of the hair donor quality/quantity. Or, the patient can have surgery at this point but may still lose hair in the coming years and need another surgery. If there isn’t enough donor hair for the second surgery, it may look unnatural.
It is highly recommended to find a hair surgeon or clinic that you can build your strategy with and plan all the possible outcomes to ensure the minimum level of risk.
Norwood Level 5 Vertex
Norwood Level 5 Vertex is another variation of Norwood Level 5. The bold spot on the vertex is larger than Norwood Level 5 but the V shape is denser and more visible without any bald spots.
Similar to Norwood Level 5, at this stage, hair regrowth by conventional, traditional ways is out of scope. The main goal of the individual should be to prevent any further hair loss and increasing the health of hair follicles. The remaining hair follicles could be thinner than earlier stages and this might show the hair as less dense. Also, thinner hair might make it very difficult for hair transplant surgery to take place. As mentioned before, hair surgeons need thick, eligible hair follicles to transfer the hair from the back of the head to the bald areas. If the follicles aren’t thick enough, the transplanted hair may not look natural and the patient’s experience could be poor.
At this stage, determining the strategy for hair transplant surgery is important. If the patient decides to wait until later stages, a procedure might not be possible because of the hair donor quality/quantity. Or, the patient can have surgery at this point but may still lose hair in the coming years and need another surgery. If there isn’t enough donor hair for the second surgery, it may look unnatural.
It is highly recommended to find a hair surgeon or clinic that you can build your strategy with and plan all the possible outcomes to ensure the minimum level of risk.
Norwood Level 6
Norwood Level 6 patients observe that there is almost no hair left on the front & top of the head and vertex.
At this stage, hair regrowth by conventional, traditional ways is out of scope. The main goal of the individual should be to prevent any further hair loss and increasing the health of hair follicles. The remaining hair follicles could be thinner than earlier stages and this might show the hair as less dense. Also, thinner hair might make it very difficult for hair transplant surgery to take place. As mentioned before, hair surgeons need thick, eligible hair follicles to transfer the hair from the back of the head to the bald areas. If the follicles aren’t thick enough, the transplanted hair may not look natural and the patient’s experience could be poor.
It is highly recommended to find a hair surgeon or clinic that you can build your strategy with and plan all the possible outcomes to ensure the minimum level of risk.
Norwood Level 7
Norwood Level 7 patients observe that hair loss progressed through the vertex and came to the back of the head, forming a line.
At this stage, hair regrowth by conventional, traditional ways is out of scope. The main goal of the individual should be to prevent any further hair loss and increasing the health & thickness of hair follicles. The remaining hair follicles could be thinner than earlier stages and this might show the hair as less dense. Also, thinner hair might make it very difficult for hair transplant surgery to take place. As mentioned before, hair surgeons need thick, eligible hair follicles to transfer the hair from the back of the head to the bald areas. If the follicles aren’t thick enough, the transplanted hair may not look natural and the patient’s experience could be poor.
It is highly recommended to find a hair surgeon or clinic that you can build your strategy with and plan all the possible outcomes to ensure the minimum level of risk.
Hair Loss Prevention
Hair loss may occur due to many different conditions and factors. There could be a condition triggering hair loss or a couple of different conditions could be in effect at the same time, causing hair loss.
That is why it is essential to first figure out why the hair falls. As mentioned in the earlier parts of this guide, there are different types of hair loss. Some of them are permanent and although their impact can be reduced, they continue to progress.
Most types of hair loss could be slowed down or stopped. However, before taking a step, it is important to understand the reasons behind hair loss further.
Testosterone and DHT (Dihydrotestosterone)
Testosterone is a hormone that can be found in the human body, as well as some other animals. Testicles in men are responsible for producing this hormone while the ovary in women produces testosterone in the body. Men usually have a much higher level of testosterone level than women.
Usually, children who enter puberty have a lot more testosterone production until after age 30.
Testosterone has an impact on sex drive, bone, and muscle mass, and the way fat is stored in the body. Another effect of this hormone is on red blood cell production.
More information about testosterone can be found in this resource from Healthline.
Another way testosterone affects the body is hair health. When the testosterone level of an individual is at the standard or higher level, this usually doesn’t affect the hair in a bad way. However, if the testosterone level is lower than standard, it may cause hair loss.
About 10% of testosterone in all adults is converted to DHT with the help of an enzyme 5-alpha reductase (5-AR). (Genetics Home Reference)
DHT is a hormone that is derived from testosterone. Although DHT has some good effects on the body, when in excess this hormone attaches to hair root and causes them to shrink or/and interrupt the hair growth cycle, and eventually, hair follicles get thinner and fall. (Healthline)Some individuals may be more susceptible to the adverse effects of DHT based on the variations in their androgen receptor gene. Androgen receptors are proteins that control what hormones and nutrients can or can not bind to the hair root.
When these receptors are more prone to allowing DHT to attach them, it may trigger hair loss.
To slow down or stop hair loss, DHT’s impact on hair follicles must be reduced. There are two ways this can be accomplished.
- Blocking DHT: Even if the DHT level was high in the blood, if this hormone can’t bind to the hair root, then its adverse effects will be prevented. With this logic, if treatment involves a way to manipulate the receptors to not attach to DHT, it may stop hair loss or slow down.
- Inhibitors: If the body produced less DHT, then hair loss could be prevented. With this logic, a treatment that involves a way to prevent the body from producing excessive amounts of DHT hormone could stop hair loss or slow it down.
Here is the list of ways to reduce DHT:
- Improving diet with essential nutrients
- Reducing alcohol and tobacco consumption
- Activity levels and sleep pattern
- Using education such as Finasteride
Improving Diet With Essential Nutrients
Hair needs essential nutrients to maintain a healthy growth cycle and continue to grow. When the body lacks some or all of the necessary nutrients, hair loss may occur. It is vital to remember that hair loss might not only happen due to nutrient deficiency and there could be many reasons that a person can or can not control.
With that being said, to minimize hair loss or stop it, it is important to ensure the body has all the nutrients it needs to grow hair. Also, some of the nutrients may work well against DHT and protect the follicles from its impact.
The nutrients can be grouped to make it easier to see what sources provide the resources for hair to stay healthy. Here is the list:
- Vitamins
- Minerals
- Protein
- Omega Acids
Here is a table with the food that contains most of the essential nutrients to prevent hair loss.
Dairy Products | Green Leafy Vegetables | Nuts (Mixed) | Citrus Fruits | Fish | Red Meat |
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*Source Healthline
Vitamins
Vitamins are very small organic molecules that assist an organism’s metabolism to function properly. Usually, the human body needs very small quantities of vitamins and can’t store them. Vitamins are used if they are necessary otherwise, they will be disposed of. That’s why it is crucial to intake vitamins on a daily basis not only for hair but for many other functions they have. (Harvard Health)
It is not advisable to rely only on the vitamins that are listed below as even if there is no direct correlation between a vitamin and its positive effect on hair, there still may be an indirect impact.
Vitamin A
Vitamin A is important as it is involved in vision, growth, cell division, reproduction, and, immunity. Another benefit of Vitamin A is its antioxidant properties. Especially individuals who are exposed to radiation or consume tobacco products may benefit from Vitamin A as it protects the body from the adverse effects of harmful substances.
For more information about Vitamin A, the National Institutes of Health has excellent content.
Since the body needs Vitamin A for growth and immunity, consuming enough Vitamin A could help the body to maintain hair health. Moreover, with the immunity benefit of Vitamin A, the body can protect itself better against microbes, thus this would improve the endurance of hair follicles.
It should be noted that as helpful as Vitamin A can be, taking higher doses than recommended may be harmful. The recommended daily amount of vitamin A is 900 micrograms (mcg) for adult men and 700 mcg for adult women. Furthermore, too much Vitamin A intake is associated with hair loss ( The Role of Vitamins and Minerals in Hair Loss: A Review).
Spinach, dairy products (milk, cheese, yogurt), liver, green leafy vegetables, carrots, and cantaloupe are rich in Vitamin A, and consuming these regularly can ensure having enough amount of Vitamin A in the body.
B Vitamins
The vitamin B complex includes eight water-soluble vitamin substances—thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), vitamin B6, biotin (B7), folate, and vitamin B12—that aid in cell metabolism. The recommended daily allowances of these vitamins can be reached by eating a balanced diet, with the exception of biotin, which is the only B vitamin produced by the body. In healthy individuals, biotin does not need to be supplemented.
More information can be found on the National Institutes of Health’s related page.
Only riboflavin, biotin, folate, and vitamin B12 deficiencies have been associated with hair loss.
Vitamin B2 (Riboflavin) helps cells to produce energy and maintain a healthy structure. This vitamin deficiency may cause hair loss since the hair follicles are made up of cells and these cells need riboflavin to produce energy and eventually grow (The Role of Vitamins and Minerals in Hair Loss: A Review).
Vitamin B7 or Biotin takes place in histone modification, cell signaling, and gene regulation. Although Biotin deficiency is linked to hair loss, there are no large-scale studies to support this thesis. According to a study, when 18 patients with biotin deficiency were supplied with the vitamin, they showed improvement in hair and nail production. ( The Role of Vitamins and Minerals in Hair Loss: A Review).
Vitamin B9 (or Folate) and Vitamin B12 may have an effect on hair follicle production however studies so far are not high in numbers or convincing enough.
B Vitamins can be found in whole grains, meat, fish, seafood, and dark, leafy green vegetables.
For Vitamin B12, the only source is from animals and this could be a problem for vegans or vegetarians. It is advisable for these individuals to start taking supplements to ensure the body has enough Vitamin B12.
Vitamin C
Vitamin C is one of the well-known vitamins in the world. This vitamin helps the body with controlling infections and healing scars. The vitamin itself is a powerful antioxidant and its structure can kill the radicals or harmful organisms in the body.
More information can be found on the National Institutes of Health’s relevant page.
As covered in the earlier chapters, hair loss may occur due to hair follicles getting damaged by the radicals in the bloodstream. If the follicles are damaged or blocked, the hair can’t survive and eventually falls.
Vitamin C can act as a vital protector against the oxidative impact caused by elements in the blood. Moreover, the body needs collagen, an important aspect of hair structure, and collagen production requires Vitamin C. Additionally, Vitamin C helps the body to absorb iron, a mineral essential for hair production.
Vitamin C can be found in good quantities in strawberries, peppers, guavas, and citrus fruits as well as can be taken with a supplement.
More information about Vitamin C can be found here (The Role of Vitamins and Minerals in Hair Loss: A Review).
Vitamin D
Vitamin D is a fat-soluble vitamin that also is present in the human body as a hormone. This vitamin assists the body with absorbing and keeping the phosphorus and calcium. There are many other benefits of the vitamin in the human body such as reducing cancer risk, controlling infections, and promoting bone growth.
Vitamin D deficiency could trigger hair loss, according to the search. Also, consistent levels of Vitamin D in the body might help growing new hair follicles.
This vitamin can only be synthesized with the sunlight, so just having enough amount of Vitamin D in the body is not enough. Direct sunlight is mandatory.
Fatty fish, cod liver oil, some mushrooms, and fortified foods are good sources of Vitamin D as well as supplements.
More information about Vitamin D can be found here (The Role of Vitamins and Minerals in Hair Loss: A Review).
Vitamin E
Vitamin E is an important antioxidant that has many benefits in the human body. In structure, it is fat-soluble.
The common duty of antioxidants is to protect the cells from free radicals and help with the immunity of the body. Vitamin E can help the body to combat sickness and protect the body from getting ill.
According to a small study, Vitamin E is linked to hair production. Patients who have taken Vitamin E had 40% hair growth while placebo group had almost none.
Moreover, Vitamin E may increase blood flow. This could bring more nutrients and oxygen to the follicles and help them to grow if they are in the rest phase. Additionally, having the recommended amount of Vitamin E could increase the health and thickness of existing follicles and combat against hair thinning.
Vitamin E can be found in green leafy vegetables as well as some nuts. There are also many dietary supplements that have Vitamin E.
More information about Vitamin E can be found here (The Role of Vitamins and Minerals in Hair Loss: A Review).
Minerals
Iron
The most common nutritional deficiency in the world is iron deficiency.
Iron is one of the most important minerals that provide the body with the energy it needs as well as improving immunity system and regulating body temperature.
The deficiency of iron could lead to hair loss or thinning.
Iron can be found in clams, oysters, eggs, red meat, spinach and lentils. Dietary supplements may also include Iron.
More information about Iron can be found here (The Role of Vitamins and Minerals in Hair Loss: A Review).
Zinc
Zinc takes part in DNA synthesis, immune system, metabolism and growth. Moreover, it could help the body with reducing inflammation .
The recommended daily intake would be 11 mg for men and 8 mg for women. Zinc deficiency could cause hair loss or thinning. However, taking too much of this mineral could cause side-effects and therefore individuals should be careful when taking this mineral.
Hair tissues need Zinc to grow and maintain. Another benefit of Zinc to the hair would be keeping the oil glands in the scalp working properly.
Zinc deficiency may cause alopecia. According to a couple of studies, individuals who had hair loss had lower levels of zinc in their system when compared to the healthy individuals. However, there are some contradicting studies that find no correlation between zinc and hair loss (The Role of Vitamins and Minerals in Hair Loss: A Review).
You can find more information about these studies and results here.
Zinc can be found in oysters, beef, spinach, wheat germ, pumpkin seeds and lentils. In addition, many dietary supplements contain Zinc.
Protein
Protein is one of the most important elements in human body, Protein helps the body to form almost all of the tissues such as muscles, brain and nervous system.
Hair follicles are made of a protein called keratin and if there is protein deficiency, this protein can’t be created. Thus, hair follicles start to enter the telogen or rest phase. Over time, this could cause hair thinning and loss. Having enough protein in one’s diet could even help with hair regrowth.
Meat, poultry, fish and seafood, dairy products and some green leafy vegetables are rich in protein. (Betterhealth.gov)
Omega-3 Acids
Omega-3 is linked to promote hair growth and prevent hair loss although the studies are not strong enough to make a case.
Omega-3 acids could provide essential proteins and nutrients to hair follicles to help them grow and stay healthy. Moreover, omega-3 acids may prevent hair follicle inflammation. This effect could save follicles from falling due to inflammation. Furthermore, omega acids are linked to improving blood circulation in the scalp that may help more blood and thus nutrients supplied to the hair follicles (Healthline).
Reducing Alcohol and Tobacco Consumption
Alcohol consumption may, directly or/and indirectly, cause hair loss and thinning. The essential nutrients for hair production and maintenance were listed in the previous section.
There are two main reasons why drinking may cause hair loss (Healthline):
- Not getting enough nutritions
- The inability to absorb nutrients
With alcohol consumption, individuals may slowly lose their inhibitors and this may cause consuming food that does not contain useful nutrients such as vitamins and minerals. It is usually advised to serve food that contains protein and fat with alcohol to slow the absorption rate of alcohol to avoid being too drunk. This kind of food commonly contains some protein and a lot of fat. Eventually, the body would be left without the nutrients it needs for hair production and maintenance.
Even when individuals consume food that contains all the nutrients the body needs to grow and maintain hair follicles, alcohol may cause these nutrients to be absorbed less or not at all. In this case, the body will not have the sources it needs to promote hair health and this could cause hair loss or thinning (Healthline).
Another reason why alcohol could cause hair loss or thinning is related to the hormone testosterone.
Excessive alcohol consumption may cause testosterone to be suppressed in the body. When the testosterone levels are low in the body, this may cause DHT to increase. As mentioned earlier, in high amounts, DHT could cause hair loss and thinning.
Smoking tobacco is also associated with hair loss. According to research made by Dr. Lin-Hui Su and Tony Hsiu-Hsi Chen from the Far Eastern Memorial Hospital and the National Taiwan University, the number of individuals who experienced hair loss was twice for the group who were current smokers or smoked at some point their lives.
Tobacco contains harmful substances that could damage hair follicles as well as other cells and tissues in the body, Moreover, tobacco consumption causes red blood cells to carry less oxygen and nutrients to the body. Eventually, cells get fewer sources needed to maintain themselves and grow or reproduce. Therefore, tobacco consumption is likely to cause hair loss or speed it up.
Activity Levels and Sleeping Pattern
As mentioned before, DHT may cause hair loss or thinning. One of the ways to lower levels of DHT in the body is to increase testosterone hormone production (Standard Media).
Physical activity such as cardio and weightlifting could help the human body to produce more testosterone. Moreover, consistent physical activity may improve metabolism and help the body to filter the harmful substances. With more space for nutrients and oxygen, hair follicles could receive more resources to successfully grow hair or maintain existing follicles.
Sleeping pattern is also essential for suppressing DHT in the body. Depending on the quality of sleep, duration, and time, sleeping could help the body to produce more testosterone. The human body releases growth hormones while asleep and most of the repairs occur during sleeping. Sleeping early could help the body to produce more testosterone hormone and potentially suppress more DHT. A healthy sleep pattern could improve hair production and maintenance.
Using medication and products to suppress DHT
There are many drugs and products in the market to help individuals combat hair loss and thinning. These methods can be temporary remedies to hair loss and thinning. In some cases, these methods could even lead to hair regrowth. However, it is essential to acknowledge these methods are temporary and not everyone is eligible for them. Also, after some time, the human body grows tolerance and the effectiveness of these solutions is reduced or completely ignored.
Here is the list of DHT blockers:
- Finasteride
- Green Tea
- Nettle
- Saw Palmetto
- Pumpkin Seeds
John Baris
Hair Adviser
John Baris has been assisting patients who experience hair loss since 2018. He has published books and articles about hair loss and restoration.