Male Pattern Baldness

Androgens, namely DHT, cause hair to grow in certain places.  When it comes to the scalp, the rules change just a little.  All areas of the body that will be covered by body and facial hair in adulthood were originally covered in vellus (fine) hair before puberty.  However, the scalp wasn’t covered in vellus hair – it was covered in thicker, terminal hairs.  During puberty and adulthood, when DHT stimulates scalp hair, it may cause overstimulation of the hair follicle making it grow too rapidly.  This can cause the hair to become finer and finer and eventually fall out or revert to becoming more like thin, fine vellus hair.  In fact, as men get older they may find that some body hair (pubic, armpit, chest, etc.) may start thinning as well.  This is due to over-stimulation by DHT.  In short, over-stimulation of DHT is what causes male-pattern baldness and a receding hairline in men.  So, the very hormone that causes hair growth in areas all over the male body actually leads to loss of hair on the scalp.

 

A lot of men stress out about going bald, but it’s more common than not.  There are three main types of hairlines in adult men:

  • The lucky guys have little to no hair loss.  The hairline in the front is fairly strait across with little to no receding hairline.  In white men, this is the rarest hair pattern – only occurring 1% of the time!  The incidence is considerably higher in black men with 13% “never going bald.”

  • Receding hairline involves the hairline moving back on either side of the front of the hairline near or above the temples.  This is by far the most common “balding” pattern with 83% of white men having this pattern and 75% of black men.  So; if you’re feeling like you’re the only one receding, look again.  More than three-fourths of men will recede.

  • The final hairline involves a thinning and balding on the crown of the head in addition to a receding hairline.  This can spread to where the balding crown and receding hairline meet to create a “bald cap.”  This type of hair pattern occurs in 16% of white men and 12% of black men.[i]

The Hamilton-Norwood Classification[ii] system puts men in different categories of hair loss.  These categories range from Class I, which is little to no hair loss, to Class VII, which is almost complete hair loss except for a small band of hair above the ears and at the base of the scalp.  These classes are then subdivided into men who recede on either side, men who also have a bald spot on the crown of the head, and men who have a uniform hairline that recedes backwards without the crown balding separately. 

 

The majority of men will bald by receding on either side near the temples (first two columns).  This balding then continues backward.  These men also tend to bald near the crown of the head, some earlier (left column) and some later (middle column).  Another way men may go bald is by simply having the entire front hairline recede almost in a line (right column).  In these men, the middle of the hair recedes almost as much as the two sides near the temples.  Also, these men rarely have a balding vertex or crown.   

  • Class I  – Little to no hair loss is seen

  • Class 2 – Hair begins to recede    

  • Class 3 – Hairline recedes near the center of the head

  • Class 4 – Hairline recedes to the center of the head  

  • Class 5 – Hairline recedes behind the center of the head 

  • Class 6 – The  top of the head becomes consistently bald.

  • Class 7 – Hairline lowers leaving a narrow rim of hair above the ears 

Balding Patterns.jpg

Not all men will follow these patterns exactly.  It’s not uncommon (and in fact it’s quite common) for balding men to have a small patch of hair on the front of the head.  This island of hair may be the last to go or may never fall out completely. 

Islands.jpg

TREATMENT OF MALE PATTERN BALDNESS

Obviously, embracing baldness is not only easier on the pocket book, but also easier for most men in the long run.  “Being bald” doesn’t mean “looking old.”  Keeping the hair cut short or even shaving the head can create a younger look in most men.  Visually, men with longer hair look more bald – hence the reason why the “comb over” and the “bald man mullet” never seem to work.  Growing well-trimmed facial hair is also another optical illusion that can balance the head and actually give a younger look.  However, longer facial hair has a tendency to have the same effect as the “comb over,” accentuating the baldness up top.

 

If you insist on fighting (or at least delaying) a receding hairline or a balding crown, there are two medication options.  The first are medications known as 5 alpha-reductase inhibitors like finasteride.  These medications block testosterone from converting into DHT.  The less DHT a man has, the less DHT can “over-stimulate” the scalp hair causing it to fall out.  These medications cannot be given prior to age 18 or the completion of puberty, and should be kept away from young boys and pregnant women as they can disrupt normal fetal and puberty development.  These medications are only available by prescription. 

The other medication is minoxidil.  It is available over the counter and is applied topically to the scalp.  However, this tends to work better on the crown or vortex of the head rather than on the front receding hairline.  Applying it to thinning areas can increase the number of hair follicles.  But be warned, it only works as long as it is used (hair begins falling out again only a few weeks after stopping minoxidil use).  In addition, minoxidil isn’t picky about where it stimulates hair growth.  So, you want to be sure you keep it on the scalp and not let it run down the back or chest in the shower (some men have developed significant neck, back, and chest hair growth that follows the rinse line of shampoo).  Washing and rinsing minoxidil out of the hair by bending over and allowing the water to drain directly off the head into the drain will prevent unwanted hair in other places.   

Other treatments for hair loss can include procedures to transplant terminal hairs from other areas of the body onto the scalp.  These procedures are often expensive and don’t always look natural.  Other options for thinning hair involve the addition of certain fibrous products that make hair appear thicker.  However, most men find that the earlier they embrace going bald, the less hassle and worry they have in the long run.

[i] Setty LR. Hair patterns of the scalp of white and Negro males. Am J Phys Anthropol. 1970;33:49–56.

[ii] Norwood OT, South Med J Male Pattern Baldness: classification and incidence, 1975 Nov; 68(11): 1359-65

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