Managing Alopecia – Guide for Fighting Receding Hairline

According to the American Hair Loss Association, two-thirds of American men will experience some degree of hair loss (also known as alopecia) by age 35. By age fifty, 85% of men will have significantly thinning hair. Women are equally affected and make up as much as 40% of American hair loss sufferers.

Hair loss can cause psychological problems such as anxiety and depression leading people to try countless therapies and remedies in hopes of a solution.  ABC News reports men in the United States spend over $1 billion each year to fight hair loss yet many give up or settle for mediocre results.

Before trying the latest miracle cure, consider these 8 steps to better understand the science behind alopecia, how to identify it, and how best to treat and prevent it.

Step 1: Understanding the science of hair follicles

Hair growth happens in three distinct phases: anagen (growth), catagen (transition), and telogen (rest).  Anagen is the longest phase lasting between 2 and 3 years; catagen, 2-3 weeks; and telogen, around 3 months. After the telogen phase is complete, the hair sheds and new hair begins the regrowth process

Of the 150,000 hairs on your head, approximately 90% are in the anagen phase, 2% are in catagen phase, and 8% are in the telogen phase.

Step 2: Identifying different types of hair loss

Hair growth slows as we age. Hair becomes shorter and thinner and a higher percentage of follicles transition into the telogen phase. This process is natural and known as involutional alopecia. However, other types of hair loss have various forms and origins. Recognizing the signs and patterns of hair loss helps identify the root causes and increases the effectiveness of treatments. The most common forms include telogen effluvium, alopecia areata, and androgenic or androgenetic alopecia.

Telogen Effluvium or temporary hair loss

Telogen effluvium is a temporary hair thinning across the entire scalp brought on by a stressor.  The trigger usually occurs between 2 and 4 months before the onset of hair loss and causes up to 50% of hairs to transition into the telogen or resting phase.  Factors showed to cause telogen effluvium include childbirth, hypo- or hyperthyroidism, medications, nutrition, and stress.

Telogen effluvium can be classified as acute or chronic depending on the length of symptoms. Acute telogen effluvium lasts less than six months in most cases showing new hair grow to return in three to four months. Chronic telogen effluvium is most common in women between the ages of 30 and 60.

Alopecia Areata or spot baldness

Alopecia areata is classified as an autoimmune disorder in which T-lymphocytes mistake hair follicles as foreign and attack during the anagen phase of hair growth.

Both men and women are affected equally with a lifetime prevalence of around 2%. Symptoms usually occur before the age of 30 and are characterized by at least one or two smooth round patches of hair loss. Most patients (80-90%) experience spontaneous hair regrowth within one year of onset. However, alopecia areata can progress to complete balding of the scalp (alopecia totalis) or hair loss over the entire body (alopecia universalis).

Androgenic Alopecia or pattern hair loss

Androgenic alopecia is the most common type of hair loss. This type of hair loss is also referred to as the androgenetic alopecia. While it’s most recognized name is “male pattern baldness”, androgenetic alopecia affects both men and women. Approximately 40% of women are affected by age 70 compared to half of all men over the age of 50.

Pattern hair loss in men is characterized by a gradual receding in the frontal hairline and crown. Women experience a more general thinning across the entire scalp with most happening at the crown. Men can progress to complete baldness with hair only remaining the areas around the ears and at the back of the head. Complete hair loss in women is rare.

Cicatricial Alopecia or scarring hair loss

Cicatricial alopecia is a rare disorder in which patient’s hair follicles are destroyed and replaced with scar tissue. It often starts with very slow hair loss accompanied by itching or burning of the scalp.

Cause of scarring hair loss is not well understood. It can occur to men and women of all ages around the globe. A scalp biopsy is often required to properly diagnose cicatricial alopecia.

Alopecia totalis

Alopecia totalis is a scalp skin condition that leads to complete hair loss on the scalp. In a more advanced case when facial hairs are affected as well, it is termed as alopecia universalis. It can be caused by several reasons including an autoimmune condition, radiation, or fungal infection.

Step 3: Hamilton – Norwood Scale for measuring hair loss

Alopecia hair loss

Developed by Dr. James Hamilton and Dr. O’Tar Norwood, the Hamilton-Norwood scale is a 7 stage system considered to be the gold-standard for classifying male baldness.

  • Stage 1: Little to no hair loss. Treatment is not necessary. Patients should continue to monitor if there is a family history of alopecia.
  • Stage 2: Receding is noticeable in the forehead area either in a triangular pattern or symmetrical across the entire forehead but remains in front of the ears. Hair begins to be less dense in the center of the head.
  • Stage 3: Hair loss on the forehead has progressed past the ears. If hair has receded from the crown, the patient is classified as Stage 3 Vertex.
  • Stage 4: Hair loss is more extensive than stage 3 with a noticeable loss at the crown. A region of hair remains between the forehead and the crown.
  • Stage 5: The dividing hair between the forehead and the crown still remains; however, the area is more narrow and thinner.
  • Stage 6: The line of hair dividing the 2 areas into previous stages is now gone. This stage is the beginning of the horseshoe shape around the sides and back of the head.
  • Stage 7: Hair on the sides and back of the head has started to recede. Only a narrow horseshoe may remain.

Ludwig scale for female hair loss

The Ludwig scale for women is similar to the Hamilton-Norwood scale in men. Hair loss is measured at the crown of the head. The scale divides patients into three types and subtypes based on the extent of the alopecia (I-1, I-2, I-3, I-4, II-1, II-2, and III). The greater the extent of the loss from the crown, the higher the patient is placed on the scale.

Step 4: Common causes for baldness

Male hormone DHT – Dihydrotestosterone

Dihydrotestosterone (DHT) is a sex hormone and gives men their male characteristics such as a deeper voice and increased muscle mass. DHT is converted from testosterone by 5-alpha-reductase (5-AR) and is much more potent than regular testosterone. This is important when we consider treatment options later on.

Sadly, the same compound that creates manliness also contributes to hair loss by causing the follicle to miniaturize.  This leads to smaller, thinner hair on the head. Men who have higher levels of DHT may notice more arm, pubic, or beard hair as hair in other places on the body requires DHT to grow effectively. DHT blocker shampoos are often effective against alopecia.

Radiation-induced hair fall

Cancer radiation treatment is a common cause of hair loss. While radiation is successful in destroying numerous types of cancer cells, it is not selective and can also target healthy cells in your body. Fast growing cells, like those found in hair follicles, are some of the more at-risk healthy cells.

Radiation therapy typically only causes hair loss in the area of the body being treated. The dose of radiation and the size of the treatment area are a few factors that can determine the extent of hair loss.

Thinning of hair with age

As mentioned before, involutional alopecia is natural hair loss which increases as we age. As we get older, our bodies lose the ability to repair DNA damage in the hair follicle. The body then removes the damaged cells resulting in increased hair loss.  Involutional alopecia is brought on by a variety of factors including genetics, diet, and overall health status.

Infection of the scalp with fungus or mites

Dandruff in hair and scalp can lead to receding hairline. A simple anti-dandruff shampoo will be enough in such cases. Ketoconazole shampoos such as Nizoral or Revita have anti-dandruff properties.

Fungal infections such as tinea capitis can cause single or multiple patches of hair loss. Commonly known as scalp ringworm, the fungus robs the hair of nutrients and causes the infected hairs to become brittle. Scalp ringworm is uncommon in adults and is seen more often in young children.

Demodex folliculorum is a microscopic mite often present on an oily scalp. The mite feeds on sebum produced by the sebaceous glands in the hair follicle. This prevents the hair from getting essential nutrients and increases the risk of thinning.

Other causes of hair loss

As mentioned before, the list of hair loss causes can be lengthy. Basically, anything that results in a hormonal change in the body can result in partial or complete loss of hair on the scalp or other areas. Here are a few other examples:

  • Diabetes
  • Chronic inflammation
  • Pregnancy
  • Thyroid disorders
  • Lupus
  • Medications
  • Trauma (excessive pulling or bending)

Step 5: Treating baldness with medication

Depending on the type and extent of alopecia, medications can reduce or prevent future hair loss and start the hair re-growth process.  Here are the most common:

Finasteride (brands: Proscar, Propecia)

Remember back to the discussion about DHT and the converting enzyme 5-AR. Finasteride inhibits 5-AR and, thereby, reduces DHT levels.

Proscar is the brand name for finasteride 5mg and is primarily used to treat benign prostatic hyperplasia (BPH). DHT also plays a role in prostate problems.

Propecia is finasteride 1mg and is the recommended treatment dose for alopecia.

Finasteride is available by prescription. Results are typically seen in three months; however, if finasteride is stopped, hair loss will resume within twelve months if not sooner.

Dutasteride (brand: Avodart)

Dutasteride is another 5-AR inhibitor like finasteride only more potent. One study showed 2.5mg of dutasteride was superior to finasteride 5mg at increasing hair counts at 12 and 24 weeks.  

The only strength of dutasteride currently available is 0.5mg and is not FDA approved to treat male pattern hair loss.  However, in the same study mentioned above, 0.5mg of dutasteride produced 94.6 hairs compared to 75.6 hairs by finasteride 5mg.

Minoxidil (brand: Rogaine)

Originally studied as a blood pressure medicine, minoxidil is an over-the-counter topical treatment for androgenic alopecia. The medication is applied twice daily on the balding spots on the scalp and works by reversing the shrinking process and stimulating new growth.

Minoxidil is recommended for men and women with early signs of hair loss. Up to 40% of users report thicker hair and slow hair loss in 3 to 6 months. The treatment must be continued indefinitely or hair loss with a return.

Spironolactone (brand: Aldactone)

Spironolactone is another prescription hypertension medication with anti-androgen properties. Spironolactone works by blocking DHT from its receptor in the hair follicle. Like dutasteride, spironolactone is not FDA approved to treat alopecia but some clinicians use it off-label.

Doses of spironolactone start at 25mg with a max daily dose of 200mg per day. Side effects include lower blood pressure, increased potassium levels, dizziness, and increased trips to the restroom.

Women, especially those with polycystic ovarian syndrome (PCOS), have shown benefit with spironolactone.

Flutamide (brand: Eulexin)

Flutaminde is an anti-androgen medication originally designed to treat prostate cancer. Like others mentioned above, flutamide blocks testosterone and DHT from binding to its receptor. The list of side effects for this drug is rather lengthy. So much so, flutamide has taken a back seat to newer medications both in the treatment of prostate cancer and alopecia.

Flutamide, like spironolactone, has shown more benefit in women than in men due to side effects and other precautions.  One study showed improvement in Ludwig scores with doses as low as 62.5mg per day.

Ketoconazole (brand: Nizoral)

Ketoconazole is an anti-fungal medication available over-the-counter or by prescription depending on the concentration. Customers often use ketoconazole shampoos such as Nizoral or Revita. While ketoconazole is more often used in dandruff and dermatitis, it has been shown effective in treating alopecia as well. It works by treating fungal infections, like those mentioned above, to reduce inflammation around the hair follicle. Ketoconazole also as anti-androgen properties and may have benefits similar to minoxidil. Ketoconazole cream can also be used.

Ketoconazole shampoo is used two to three times per week and should be left on the scalp at least 5 minutes before rinsing.  Treatment lasts four to eight weeks and then as needed.

Step 6: Surgical treatments for hair loss

alopecia hair loss

Follicular unit transplantation (FUT)

In Follicular unit transplantation (FUT), a small strip of tissue is removed from the back of the head. This tissue’s hair follicles are then extracted from the strip and individually transplanted to the desired areas. FUT is considered the preferred method because physicians can use more grafts per session and achieve better results.

FUT is an outpatient procedure but is associated with more pain than follicular unit extraction (see below). Patients have reported mild pain and swelling after the surgery and are left with a small scar (approximately 1mm) at the extraction site.

Follicular Unit Extraction (FUE)

The main difference between FUT and follicular unit extraction (FUE) is FUE donor follicles are removed directly from the scalp without a strip of tissue. This results in less pain and better recovery time, but also increases the cost since hairs are harvested individually.

Scalp reduction surgery

Scalp reduction surgery is a method used to move skin to cover balding areas. It is especially useful for hair loss at the crown or top parts of the head where the sides can be pulled upward and stitched together.

Patient who have healthy, elastic scalps are ideal for this procedure. They should have significant hair on the sides and back of the head to ensure enough coverage on the top. Scalp reduction surgery does not work for patchy hair loss or telogen effluvium.

Step 7: Alternative treatments for balding

Biotin or vitamin B7

Biotin, also known as vitamin H, helps to improve the protein infrastructure of hair, skin and nails. It can be purchased separately, as part of a vitamin B complex supplement, or in other formulations marketed for hair, skin and nail health.

Biotin deficiency is rare since most people get enough in their daily diets. The recommended daily dose is 2.5mg.  

Cholecalciferol or vitamin D3

Over the last several years, vitamin D has been shown to play a role in a variety of health problems. Several studies have reported vitamin D can help create new hair follicles and wake up dormant ones.

Vitamin D can be found in foods like salmon and milk or produced by the body through sun exposure.

The recommended daily dose for most adults is 600mg but can increase to 1200mg as we get older.

Nioxin hair care products

Nioxin is a three-step hair care system which includes a shampoo, a conditioner, and a hair treatment. The system does not claim to regrow hair, only to promote a healthier scalp, thicken existing hair, and remove residues which prevent hair growth.

The shampoo is gently massaged and rinsed from the hair much like a normal shampoo. The conditioner is then added and left in for 1 to 3 minutes before rinsing. The scalp treatment is added after the shower is complete and left in.

Nioxin has 6 different systems, each containing the same 3 product types, for different types of hair and different degrees of thinning.

Saw Palmetto

Saw Palmetto is an herbal supplement often used to treat an enlarged prostate. Similar to finasteride and dutasteride, saw palmetto blocks 5-AR and prevents testosterone from converting to DHT.


Ginseng may improve alopecia in two ways. First, ginseng can improve blood circulation and boost the immune system thereby improving the hair’s ability to regenerate. Additionally, compounds found in ginseng have been shown to improve hair root strength.

Ginseng is available in a variety of forms and can also be found in some shampoos. Patients who take blood thinners like warfarin should consult with their healthcare provider before starting ginseng as it can increase the risks for bleeding.

Ginkgo biloba or Maidenhair tree

Like ginseng, ginkgo biloba can increase blood flow and nutrients to hair follicles. Ginkgo also has the added benefit of improved memory and brain function.

Ginkgo can, likewise, increase the risk for bleeding in patients on prescription blood thinners.

Laser therapy to regrow hair

Low level laser therapy (LLLT) is thought to encourage hair growth in a variety of ways such as increased blood flood, activating heat shock proteins, tissue regeneration, and 5-AR inhibition.

Several different caps, helmets, combs, and other devices exist to deliver red light at wavelengths between 630 to 670 nanometers. Typical treatments last between 20 and 60 minutes.

Step 8: Ways to disguise thinning hair

Disguising thinning hair is unique to both the individual and the type of hair loss. Wigs and toupees are the classic methods and new technologies have improved the look and durability of hair pieces.

Accessories such as hats and scarves are useful, especially at outdoor events.

Changing hairstyles is another option. Stylists have methods to reduce or cover up thinning hair or bald patches. Others embrace their alopecia and shave off their remaining hair.

Common questions people ask about hair loss

How much hair loss is normal when brushing?

We lose between 50-100 hairs per day to the normal growth cycle. A few hairs caught in your brush are normal. If you notice more, especially if it comes out in clumps, it may be time to see your healthcare provider.

What makes your hair grow faster?

Hair growth is determined by a long list of factors. Some ways to promote hair growth are:

  • Get regular haircuts
  • Reduce the use of styling products
  • Eat healthier and take supplements
  • Rinse hair in cold water

How to get strong and healthy hair?

The same factors that promote hair growth work to make it strong and healthy.  Here are a few more:

  • Don’t wash hair everyday
  • Use shampoo and conditioner designed for weak or damaged hair
  • Don’t blow dry hair.

What vitamins are good for hair growth and thickness?

Most supplement companies offer a product that promotes or is even named healthy skin, hair, and nails. Those combination products are usually more affordable but here is a list of individual supplements useful for hair growth and thickness.

  • Fish Oil
  • Vitamin C
  • Zinc
  • Iron
  • Vitamin B Complex (including biotin)
  • Vitamin D

What is a good diet for healthy hair?

Foods rich in biotin and B vitamins will improve hair health and growth.  Almonds, eggs, milk, salmon, spinach, broccoli, and cauliflower are some examples.

Now that you have a better understanding of alopecia, do your own research and find the best treatment option for you. Consult your primary care provider or pharmacist for more details about prescription medications and over-the-counter supplements. And if all else fails, embrace the baldness; your hair is never your best quality.

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