Women and men may share certain patterns of hair loss, but there are differences that reflect the importance of hormonal influences. Female hair loss is really a misnomer; there are, in fact, at least two distinctly stress hair loss female patterns. There are perhaps more, but only the type of hair loss with its loss of frontal hair seen in some women involves an entirely different set of influences. It is likely that the frontal hair loss, termed frontal fibrosing alopecia by Kossard, and the frontal hair loss seen in some women with androgenetic alopecia, have a similar pathogenesis. These women differ from other women in that they have a type 1 5-alpha-reductase. The enzyme functions to convert testosterone into dihydrotestosterone, which is the active hormone that causes the hair follicle to miniaturize.
Hair loss for a woman can generate significant emotional and psychological trauma. Unlike men, women have few options available if they are unwilling to wear a wig. Fortunately, many are eligible for hair transplantation, and others would benefit from seeking the advice of a physician. The prevalence of hair loss in women is surprising when compared to reports on men. Incidence estimations range from 80% among post-menopausal women to 42% in adult women aged 20-49. Some physicians feel that these figures may represent significant underestimates; only some of those with clinical hair loss choose to see a physician. Hormonal cycles, particularly those of the menstrual period or pregnancy, are the most common occasions for a transient increased shedding of anagen hairs, a condition termed telogen effluvium.
The classificatory scale described in this paper was deliberately designed to allow accurate estimation of the extent and degree of baldness affecting the midline of the scalp in women. Because of the relatively sparse covering of hair, this region is usually also the one producing the greatest visual balding effect. There would, however, appear to be no sound reason why the currently defined female hair loss androgenetic alopecia should not be extended to embrace more widely the considerable loss of hair affecting the lateral regions of the scalp. Such a broadened concept of the disorder presents no striking new idea. In 1934, for example, Fager described three kinds of baldness and explained that “A striking result of widespread (hair) thinning in women is that it appears like a caput medusae. Small thinning areas may, in this manner, have considerable influence on the cosmetic deformity.” Balbirsingh et al. similarly reiterate that “with advancing age, the entire scalp may show thinning of the hair,” while Benson and Cahill suggest that “since the majority of women demonstrating thinning scalp hair encourage hair growth over the entire scalp, the ‘androgenetic’ aspect of the condition probably requires some reevaluation…”
In order to describe the natural history of androgenetic alopecia in women, a scale for classifying the various degrees of this process seems necessary. Additionally, it is essential that such a scale focuses attention on the thinning process in the midline of the scalp. To qualify for inclusion, a measurement scale must have several characteristics. Three were considered essential: “It (scale) should be simple to use; it should be standardized either by objectivity or thoroughness of description, but preferably by both; and it should be sufficiently sensitive to allow small, but still clinically significant, changes to be recorded.”
The third type is identified by the total baldness that covers the top of the scalp. There is a common forelock of hair in the frontal midpoint of the scalp, but the perimeter of the bald area becomes continuous with the frontal temple and crown of the head, as the syndrome progresses. The solid composition of the forelock appears to cover this frontal thinning from view. It is the principal determinant by which female hair loss treatment differ from males at any stage of androgenetic alopecia. The Ludwig scale classification of alopecia in females has been widely copied.
The Ludwig scale has three grades of female pattern hair loss. Duchatelle adapted this classification for the male pattern type of hair loss, needing only to limit the grading to the area overlying the frontal scalp. In the grade I type, the scalp has a diffuse thinning of the hair. One can see the scalp on either side of the midline through the diminishing density of hair. The thinning field is broadest at Worman’s frontal temporal recessions and widest at the frontal scalp. Grade II gives a U-shaped area of baldness that leaves a central bridge of solid hair connecting the areas on either side of the rim of the U.
Several different aspects of the scale are examined and discussed. Both regard the features of its design and what these features imply in terms of its utility. Due to the scale’s simplicity and its subjective nature, and requirements for follow-up photographs, the data obtained from any one particular physician’s grading of a group of women must be carefully scrutinized in terms of the lack of skin sensitivity to the potential responses of other individuals. If the number of women within any given category of the scale is not sufficient to support any rigorous statistical analysis, then the clinical utility of the scale is only of a very limited nature, and it should be appropriately utilized. The limitations of the scale are presented in some detail, emphasizing both the need to understand its inherent limitations, and the need to modify it and/or combine its features with other grading techniques, so that the true significance of any scale category in terms of ensuing treatment can be specifically addressed. Finally, the manner in which experienced hair transplant professionals and those not very familiar with the aesthetic treatment of the balding scalp respond to the scale is reviewed. In-depth knowledge of the validity of the scale can then be obtained, along with specific ways in which it might be used within these environments.
The decision to operate on a patient with common baldness, that is, a female hair loss treatment with thinning hair occurring in the “patterned” manner, is one that is made with considerable thought on the surgeon’s part. The causes, that is, genetic or acquired events, which have “set up” the baldness and which brought the patient to the surgeon’s office, do not go away after surgical treatment and attempts to arrest or reverse these causes is mandatory before a surgical procedure is considered. It is the task of the surgeon to exploit these concerns as a means to establish eligibility for restoration surgery and this may be done by using the simple classification scheme.
As described earlier in this report, most dermatologists do not recognize stress hair loss female pattern baldness as the early diffuse hair loss seen in premenopausal patients with normal hormone levels. Thus, the majority of women with irrelevant information are classified as having telogen effluvium, a self-limited problem that often necessitates psychological reassurance but no action. Yet, the earlier a sliding scale is diagnosed, the more opportunities there are to prevent further hair loss. Such prevention should in no way harm a premenopausal woman’s future childbearing plans, desires for femininity, desires to minimize emotional distress, and physical health. Taking progestogens is a common method of management but should be cautiously employed, especially when the patient already has a normal blood test finding. Only a minority of women must undergo the more intel-hair restoration methods offered to premenopausal women. The Ludwig Scale has probably helped in educating physicians and their patients to the concept of diffuse and androgenetic hair loss occurring in women with generally normal endocrine function. Yet, women on the scale show pathology and adult balding similar to that of those with hyperandrogenism. How the scale might be refined is addressed in the following paragraphs.
