Classifications of Patterned Hair Loss: A Review

Abstract

Patterned hair loss is the most common cause of hair loss seen in both the sexes after puberty. Numerous classification systems have been proposed by various researchers for grading purposes. These systems vary from the simpler systems based on recession of the hairline to the more advanced multifactorial systems based on the morphological and dynamic parameters that affect the scalp and the hair itself. Most of these preexisting systems have certain limitations. Currently, the Hamilton-Norwood classification system for males and the Ludwig system for females are most commonly used to describe patterns of hair loss. In this article, we review the various classification systems for patterned hair loss in both the sexes. Relevant articles were identified through searches of MEDLINE and EMBASE. Search terms included but were not limited to androgenic alopecia classification, patterned hair loss classification, male pattern baldness classification, and female pattern hair loss classification. Further publications were identified from the reference lists of the reviewed articles.

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© 2016 Journal of Cutaneous and Aesthetic Surgery | Published by Wolters Kluwer - Medknow 3
INTRODUCTION
Patterned hair loss is the most common cause of hair
loss seen in both the sexes after puberty, typically
presenting with progressive thinning, miniaturization,
and loss of hair at the affected sites. The hair loss
varies in extent and severity and numerous stages exist
between the stages of early frontotemporal recession
to the stage of residual occipital band. Numerous
researchers have proposed different classification
systems for patterned hair loss in both males and
females based on the evolutionary stage of hair
loss ranging from a simple two-stage classication
proposed by Beek in 1950 to the recent advanced basic
and specic (BASP) classication. In this article, we
review the various classication systems for pattern
hair loss described in the literature. Relevant articles
were identied through searches of MEDLINE and
EMBASE. Search terms included but were not limited
to androgenic alopecia classication, patterned hair
loss classication, male pattern baldness classication,
and female pattern hair loss classication. Further
publications were identied from the reference lists
of the reviewed articles.
CLASSIFICATIONS OF MALE PATTERN
HAIR LOSS
Beek (1950)
Beek evaluated 1,000 Caucasian males with patterned
hair loss and classied them into two types — frontal
baldness and frontovertical baldness, based on the
stage of evolution.[1] It was a simple classification,
which described only two stages of hair loss and did
not take into account the various evolutionary stages
but is important as this was the rst attempt to classify
hair loss.
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DOI:
10.4103/0974-2077.178536
Classifications of Patterned Hair Loss: A Review
Mrinal Gupta, Venkataram Mysore1
Sudhaa Skin Centre, Treatwell Clinic, Canal Road, Sidhra, Jammu, 1Venkat Charamalaya — Centre for Advanced Dermatology, Bengaluru,
Karnataka, India
Address for correspondence: Dr. Mrinal Gupta, Sudhaa Skin Centre, Treatwell Clinic, Canal Road, Jammu, India. E-mail: drmrinalgupta@yahoo.com
Patterned hair loss is the most common cause of hair loss seen in both the sexes after puberty. Numerous
classification systems have been proposed by various researchers for grading purposes. These systems vary
from the simpler systems based on recession of the hairline to the more advanced multifactorial systems
based on the morphological and dynamic parameters that affect the scalp and the hair itself. Most of these
preexisting systems have certain limitations. Currently, the Hamilton-Norwood classification system for
males and the Ludwig system for females are most commonly used to describe patterns of hair loss. In this
article, we review the various classification systems for patterned hair loss in both the sexes. Relevant articles
were identified through searches of MEDLINE and EMBASE. Search terms included but were not limited to
androgenic alopecia classification, patterned hair loss classification, male pattern baldness classification,
and female pattern hair loss classification. Further publications were identified from the reference lists of
the reviewed articles.
KEYWORDS: Androgenic alopecia, classification, patterned hair loss
ABSTRACT
rEviEw articlE
How to cite this article: Gupta M, Mysore V. Classications of
patterned hair loss: a review. J Cutan Aesthet Surg 2016;9:3-12.
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Gupta and Mysore: Classications of patterned hair loss
Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2016, Volume 9, Issue 1
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Hamilton (1951)
Hamilton, an anatomist, studied more than 300 males
with hair loss and proposed a detailed classication
system based on frontoparietal and frontal recessions and
frontal thinning, which consisted of eight evolutionary
aspects and three subgroups [Figure 1]. The various
categories of hair loss described by Hamilton include
a) scalps, which are not bald (Types I-III) and b) scalps,
which are bald (Types IV-VIII), which are dened as
follows.
Type I: There is an absence of bilateral recessions along
the anterior border of the hairline in the frontoparietal
regions. In this, there is a variant form in which the entire
anterior border of the hairline lies high on the forehead,
which is referred to as Type IA.
Type II: The anterior border of the hairline in the
frontoparietal regions has triangular areas of recession,
which tend to be symmetrica1 and extend no farther
posteriorly than a point 3 cm anterior to a line drawn in
a coronal plane between the external auditory meatuses.
Hair is also lost, or sparse, along the midfrontal border
of the scalp but the depth of the affected area is much
less than in the frontoparietal regions.
Type III: Borderline cases were listed separately as Type
III, which also included scalps in which classication is
rendered inaccurate due to scars, lateral asymmetry in
denudation, unusual types of sparseness and thinning
of the hair, and other factors.
Type IV: It represents the minimal hair loss considered
sufficient to represent baldness. There are deep
frontotemporal recessions, usually symmetrical, and
are either bare or very sparsely covered by hair. These
recessions extend farther posteriorly than a point, which
lies 3 cm anterior to a coronal line drawn between the
external auditory meatuses. If hair is sparse or lacking
as a broad band along the entire anterior border of the
hairline, it is classied as Type IVA.
Type V: It includes extensive frontoparietal and frontal
recessions with a sparseness or absence of hair on the crown.
Type VI: In this type, the tonsural region of alopecia
remains separated from more anteriorly located areas of
denudation by a laterally-directed bar of scalp in which
the hair is only slightly sparse. An island of hair lies in the
midline anterior to this laterally-directed hairy bridge.
In the variant pattern, Type VIA, the peninsula or island
of mid-frontal hair is sparse or lost.
Type VII and VIII: In these types, the horseshoe-shaped
area of sparse hair or of denudation is unbroken by any
well-haired, laterally-directed bridge of scalp. These are
a result of the spread and conuence of the tonsural and
the anteriorly located regions of alopecia.[2]
Hamilton classification set a benchmark for future
classifications of male patterned hair loss as it had
elaborately described the various evolutionary stages of
hair loss and had based the classication on them but it
did not describe a few rare patterns of hair loss, which
were later on added by Norwood to give the commonly
used Hamilton-Norwood classication.
Ogata (1953)
Ogata distinguished 15 different subtypes of patterned
hair loss and classied them into six different subtypes
based on the study of Japanese men. The rst column
shows a normal hairline for Japanese men according to
Ogata. The second, third, and fourth columns represent
early, intermediate, and late stages of patterned baldness,
respectively [Figure 2]. The classification system is
somewhat different from the classification systems
produced based on Caucasian men, suggesting that the
development of patterned baldness in Japanese men may
be distinct from Caucasians.[3]
Setty (1970)
Hamilton classication was based on the study of mostly
white males with hair loss. Setty studied 300 white and
300 black males and gave a different classication in
which he simplied Hamilton’s classication into three
different subtypes keeping into account the patterns
of hair loss in Blacks as well. The classication system
proposed by Setty is as follows:
Figure 1: Hamilton classication of male pattern hair loss.
Type III has not been included in this gure as a large variety
of conditions were included in this type[2]
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Gupta and Mysore: Classications of patterned hair loss
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a. Totopilosis (corresponding to Hamilton Type I):
The entire scalp is covered with hair. Temporal and
frontal indentations are approximately equal at the
greatest length from the anterior end to posterior
end and the anterior hair margin of the scalp forms
a serpentine or zigzag line that extends obliquely
forward across the side of the head.
b. Indentato-pilosis (Hamilton Types II-IV): Frontal
indentation is longer than temporal indentation
at the greatest length from the anterior end to the
posterior end. Hairs in midline of the scalp begin at
a point as far anteriorly or not as far anteriorly as
that in totopilose pattern.
c. Indentato-circulo-pilosis (Hamilton Types VI-
VII) — Almost same as the indentato-pilose pattern
with a circular arrangement of hair around the
vertex of the head. Area void of hair on the vertex
is at least approximately 2.54 cm in diameter. Hair
in the midline of the head begins at a point not
as far anteriorly as that in the totopilose pattern.
There are two varieties of indentato-circulo-pilose
pattern:
a. “confluent” characterized by the frontal
indentation of baldness being separated from
the apical area of baldness by a strip of hair that
connects the medial hair and lateral hair
b. “nonconuent” characterized by a bare strip of
at least 2.54 cm width connecting the frontal bald
area and the apical area.
The indentato-pilose pattern had the highest
incidence in both White males and Negro males, and
the totopilose was over four times more common in
the Negroes than in the Whites.[4]
Setty’s classification was an improvement over
Hamilton’s classication as it incorporated the patterns
of hair loss in Black males also but it lacked the detailed
staging of the evolution of hair loss, so it failed to nd
much favor with the clinicians.
Norwood (1975)
Dr. O’Tar Norwood, a dermatologist and hair
transplant surgeon, revised Hamilton’s classication
in 1975 after studying patterned hair loss in 1,000
males. The Norwood classication is the most widely
used classication for hair loss in men and it denes
two major patterns and several less common types.
Norwood observed that thinning starts in the temples
as well as the crown/vertex and slowly progresses to
encompass the entire top of the scalp, and so he based
his classication on this pattern [Figure 3]. The various
grades of hair loss described by Norwood include the
following.
Type I: There is minimal or no recession of the hairline.
Type II: There are triangular, usually symmetrical, areas
of recession at the frontotemporal hairline.
Figure 2: Ogata classication of patterned hair loss[3]
Figure 3: Norwood’s classication of patterned hair loss in
males[5]
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Type III: This represents the minimal extent of hair
loss sufcient to be considered as baldness according
to Norwood. There are deep symmetrical recession at
the temples that are bare or only sparsely covered by
hair. In Type III vertex, the hair loss is primarily from
the vertex with limited recession of the frontotemporal
hairline that does not exceed the degree of recession
seen in Type III.
Type IV: The frontotemporal recession is more severe
than in Type III and there is sparse hair or no hair on
the vertex. The two areas of hair loss are separated by a
band of moderately dense hair that extends across the
top. This band connects with the fully haired fringe on
the sides of the scalp.
Type V: The vertex hair loss region is still separated
from the frontotemporal region but it is less distinct.
The band of hair across the crown is narrower and
sparser and the vertex and frontotemporal regions of
hair loss are bigger.
Type VI: The bridge of hair that crosses the crown is gone
with only sparse hair remaining. The frontotemporal
and vertex regions are joined together and the extent of
hair loss is greater.
Type VII: The most severe form of hair loss and only a
narrow band of hair in a horseshoe shape remains on
the sides and back of the scalp. This hair is usually not
dense and may be quite ne.
Norwood also defined a Type A variant from his
standard classication system, which is distinguished
by two major features and two minor features.
The major features are: 1) the anterior border of the
hairline progresses to the rear without leaving an island
of hair in the mid-frontal region and 2) there is no
simultaneous development of a bald area on the vertex.
Instead, the frontal hairline recession keeps progressing
to the rear of the scalp.
The minor features are: 1) there is a persistent sparse hair
scattering in the area of hair loss and 2) the horseshoe-
shaped fringe areas of hair that remain on the side and
back of the scalp tend to be wider and reach higher on
the head compared to Norwood’s standard. The various
Type A variants described by Norwood are as follows:
Type IIA: The hairline is anterior to the coronal plane 2
cm anterior to the external auditory meatus.
Type IIIA: The hairline has receded back to a point
between the limit of Type IIA and the level of the external
auditory meatus.
Type IVA: The hairline has receded beyond the external
auditory meatus but has not reached the vertex.
Type VA: The area of denudation includes the vertex.
Hair loss more severe than Type VA cannot be
distinguished from Types VI or VII.[5]
Norwood classication is one of the most detailed
classication systems for male patterned hair loss and
is the most widely used classication worldwide but is
too detailed, divided, and complicated to be used for
various surgical operations. Moreover, it also does not
list some peculiar types of baldness (a balding patch
on the vertex or occiput with a preserved anterior
hairline) and is not very helpful in determining the
surgical method. Numerous researchers proposed
newer classication systems keeping the simplicity
of classication and surgical aspects of treatment in
mind.
Bouhanna (1976)
Based on observations in European Caucasians,
Bouhanna designed a much simplied male patterned
baldness classication system in 1976, which included
just three basic hair loss presentation with two variants
as follows [Figure 4]:
Stage 1
• Type a: Symmetric recession of the frontal margin
forming two temporal areas of recession of varying
depth
• Type b: Sparseness at the cranial summit or vertex
Stage 2
• Type a: Uniform recession of the frontal margin as
far as the cranial summit
• Type b: With associated vertex
Stage 3
• The ultimate stage of alopecia, with only a remnant
temporo-occipital crown.[6]
Bouhanna’s classication was a simplied classication
system based on the extent of hair loss and allowed
a precise evaluation of surgical indication of hair
transplantation but was not helpful in deciding the
type of surgical procedure required, which was later
addressed by Bouhanna himself in a multifactorial
classication.
Blanchard and Blanchard (1984)
Blanchard proposed a different classication with six
evolutional stages determined by six measurements:
glabello-frontal, superciliary frontal, interparietal,
fronto-vertical, helicon-vertical, and nucho-vertical
distances [Figure 5].[7] This classication system is not so
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Gupta and Mysore: Classications of patterned hair loss
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commonly used as it was difcult to apply and required
taking multiple measurements in every patient for
classication purpose, which is a tedious task.
Dynamic classification of Dardour and Bouhanna
(1996)
They proposed a classication system, which included
all the parameters, both morphological and dynamic,
that affect the scalp and the hair itself. This classication
includes for each heading a symbol followed by a
number, which indicates its situation. The various
parameters included in this system include the stage of
hair loss, density of hair, laxity of the scalp, aspect of hair,
color and thickness of hair, and rate of hair growth.[8]
This classication was more detailed than the previously
described systems and it took into account various
parameters, which were not considered by Hamilton
such as the covering power of hair, density in each region,
and rate of growth of hair but it was too complicated and
difcult to apply in routine practice as it involved a large
number of measurements and parameters.
Koo (2000)
As the Norwood classication method is too detailed and
complicated to be used for various surgical operations
and also does not list some peculiar types of baldness,
it is not very helpful in determining the surgical
procedures. Koo et al. studied more than 1,700 Korean
males with patterned hair loss and proposed a new
simpler classication method. In this classication, the
male patterned baldness is classied into six subtypes
by the English alphabetical letter shape of the bald area
[Figure 6]. The various subtypes in this classication
include the following
a. Type M: When both sides of the frontotemporal
hairlines look triangular or like the letter M
b. Type C: When the anterior hairline looks like a half-
circle or the letter C. M and C types of male pattern
baldness do not have hair loss on the vertex.
c. Type O: When there is a round or ovoid bald patch
on the vertex or occiput while the anterior hairline
is well-preserved
d. Type U: When the recession of the anterior hairline
progresses over the vertex, which looks like a
horseshoe or the letter U.
e. Types MO and CO: When recession of the
frontotemporal hairline exists, with a bald patch on
the vertex, as combined patterns, these are types MO
and CO, according to the shape of the recession of
the anterior hairline[9]
This classification system has advantages over the
previous classication as it is simpler, easy to apply,
does not require complex measurements, and is useful
in planning surgery.
CLASSIFICATIONS OF FEMALE PATTERN HAIR
LOSS
Ludwig (1977)
Ludwig observed 468 females with hair loss and
proposed a classication based on the stage of evolution
Figure 4: Bouhanna classication of hair loss among European
Caucasians[6] Figure 5: Blanchard’s evolutionary staging of hair loss[7]
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Gupta and Mysore: Classications of patterned hair loss
Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2016, Volume 9, Issue 1
8
[Figure 7]. The classication consisted of three grades of
hair loss, which include:
a. Grade I: Perceptible thinning of the hair on the
crown, limited in the front by a line situated 1-3 cm
behind the frontal hairline
b. Grade II: Pronounced rarefaction of the hair on the
crown within the area seen in Grade I.
c. Grade III: Full baldness (total denudation) within
the area seen in Grades I and II.[10]
Ludwig emphasized preservation of the frontal fringe
despite progressive centrifugal loss over the top of
the scalp but did not incorporate the accentuation of
frontovertical alopecia, which was later on included
by Olsen. Moreover, the females with male patterned
hair loss also could not be classied with this system.
Ebling and Rook (1975)
They developed a five-stage classification system for
female patterned baldness [Figure 8]. The first two
stages are the same as the Ludwig system. Type I shows
perceptible thinning of the hair on the crown. Type II shows
pronounced rarefaction of the hair on the crown within
the area seen in Type I. Type III shows continued diffuse
hair loss in the region dened in Types I and II but also the
initial loss of hair from the frontotemporal hair line. Type IV
shows a continuation of this diffuse loss and frontotemporal
recession and in Type V, there is complete loss of hair on
the top of the scalp resembling a male pattern of baldness.
This classication system was an improvement over the
Ludwig classication as unlike the three-stage Ludwig
classication, Ebling and Rook took into account that
women could have both a diffuse form of alopecia and
also a male pattern with recession of the frontotemporal
hair line, which was not described by Ludwig.
Savin (1992)
Savin came up with nine computer images, which are
now typically referred to as the Savin scale, as a pictorial
classification scale to quantify patterned hair loss
clinically in women which into eight stages of increasing
crown balding, in addition to a special subcategory to
detect frontal anterior recession [Figure 9]. These staged
illustrations provided a ner visual gradient of hair loss
pattern and density than the previous classication scale
for women with pattern baldness. Savin scale is a useful
tool for assessing degrees of hair loss in women, which is
fairly consistent with different investigators using the same
scale, which adds degrees of hair loss that were missing in
the Ludwig grading but this system also did not address
the progressive frontal hair loss (Christmas tree pattern).[11]
Olsen (1994)
Olsen proposed a classication, which was similar to
Ludwig classication but incorporated the accentuation
Figure 8: Ebling and Rook ve-stage classication of female
pattern of hair loss
Figure 7: Ludwig’s classication of hair loss among females[10]
Figure 6: Koo’s classication of male pattern baldness. (a) M
type (b) C type (c) O type (d) U type (e) MO type (f) CO type[9]
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Gupta and Mysore: Classications of patterned hair loss
Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2016, Volume 9, Issue 1 9
of frontovertical alopecia, which has a triangular or
“Christmas tree” pattern. Olsen observed that hair loss
in women may occur in a subtle pattern of loss that is
only apparent when one performs a midline part where
there is often a progressive decrease in hair density from
the vertex to the front of the scalp, which he described
as a “Christmas tree” distribution of loss. This pattern
is visible both in the early as well as advanced stages of
hair loss.[12]
Sinclair (2004)
It is a self-report photographic measure of patients’
perceptions of the severity of their hair loss, which
comprises ve color photographs of women’s scalps
with the hair parted centrally. The rst photograph is of
a normal scalp and the photographs 2-5 are of scalps of
women with increasingly severe hair loss [Figure 10]. The
photographs are numbered from 1 to 5 and respondents
are required to circle the number of the photograph that
they feel most closely resembles the appearance of their
own hair when parted in the center. Women with stages
1 and 2 hair loss tend to present with either episodic or
continuous increased hair shedding with a reduction in
the volume of the hair when held in a ponytail. Women
with stages 3, 4, and 5 hair loss may present with either
loss of volume of hair over the scalp with widening of
the central part, episodic increased hair shedding, or
continuous hair shedding.[13]
Sinclair grading is a simple grading system and can be
used with ease both by the clinicians and patients alike
for dening the extent of hair loss and for assessing the
response to treatment.
CLASSIFICATION IRRESPECTIVE OF SEX
Bouhanna (2000)
Bouhanna proposed a multifactorial classication for
both male and female patterned hair loss, integrating
several parameters, which included extension of bald
and hair-bearing areas, elasticity and density of scalp,
and hair characteristics such as diameter, length,
shape, and color, which contribute to the covering
power of the hair. This classication has proved useful
in assessing the changes in hair parameters during
the course of medical treatment and also in deciding
the indication of hair transplantation for the surgical
management.[14]
Figure 9: Savin’s pictorial grading of female pattern hair
loss[11]
Figure 10: Sinclair’s self-reporting photographic measure of
female pattern of hair loss[13]
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Gupta and Mysore: Classications of patterned hair loss
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10
This classication system is a detailed classication
system taking into consideration different parameters,
which could be quantied and computerized but the
inclusion of numerous parameters and measurements
also makes it time-consuming and difcult to apply in
routine practice.
Basic and specific classification (2007)
The BASP classication is a novel stepwise and universal
classication system for patterned hair loss regardless
of sex, which is based on observed patterns of hair loss
including the shape of the anterior hairline and the
density of hair on the frontal and vertex areas. Lee et al.
evaluated more than 2,200 subjects with patterned this
classication system, which consists of the basic type
and the specic type. The basic (BA) type represents
the shape of the anterior hairline, and the specic type
(SP) represents the density of hair on distinct areas
(frontal and vertex). There are four basic types (L, M,
C, and U) and two specic types (F and V) and each
of the various types is subdivided into 3 or 4 grades
(subtypes) according to its severity [Figure 11]. The nal
type is decided by the combination of the determined
basic and specic types. The various types of hair loss
according to BASP classication include the following:
a. Basic types
Type L: No recession is observed along the anterior
border in the frontotemporal region resembling a linear
line and usually means that there is no hair loss.
Type M: Recession in the frontotemporal hairline is
more prominent than the mid-anterior hairline and the
hairline resembles the letter M. It is further divided into
four subtypes depending on the severity of baldness.
Type M0: The original hairline is preserved and no hair
loss has occurred.
Type M1: Frontotemporal recession extends posteriorly
but not beyond the anterior third of a virtual line
connecting the original hairline and the top of the vertex.
Type M2: Frontotemporal recession extends further
posteriorly but not beyond the middle third of a virtual line
connecting the original hairline and the top of the vertex.
Type M3 - Frontotemporal recession extends beyond the
middle third section into the posterior third of the area
of a virtual line connecting the original hairline and the
top of the vertex.
Type C: Recession in the mid-anterior hairline is more
prominent than the frontotemporal hairline. The entire
anterior hairline regresses posteriorly in the shape of
half-circle, resembling the letter C. It is further divided
into four subtypes depending on the severity.
Type C0: The original anterior hairline is preserved and
no hair loss is visible.
Type C1: The mid-anterior hairline recedes to the anterior
one-third of the virtual line connecting the original
hairline and the top of the vertex.
Type C2: The mid-anterior hairline recedes to the middle
one-third of the virtual line.
Type C3: The mid-anterior hairline recedes to the
posterior one-third of the virtual line.
Type U: The anterior hairline recedes posteriorly beyond
the vertex forming a horseshoe shape resembling the letter
U. It is the most severe type of hair loss. It is further divided
into three subtypes depending on the severity of baldness.
Type U1: The anterior hairline recedes to lie within the
superior one-third of the virtual line connecting vertex
and the posterior occipital protuberance.
Type U2: The anterior hairline recedes to lie within the
middle one-third of the virtual line connecting the vertex
and the posterior occipital protuberance.
Figure 11: Basic and specic (BASP) classication of hair
loss[15]
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Gupta and Mysore: Classications of patterned hair loss
Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2016, Volume 9, Issue 1 11
Type U3: The anterior hairline recedes to lie within the
inferior one-third of the virtual line connecting the vertex
and the posterior occipital protuberance.
b. Specic types
Type F: It represents a general decrease in the density
of hair over the entire top of the scalp regardless of the
anterior hairline and is usually more marked over the
frontal area of the scalp.
Type F1: Thinning of the hair on the crown is perceptible
(mild change).
Type F2: Thinning of the hair on the crown is pronounced
(moderate change).
Type F3: The hair on the crown is very sparse or absent
(severe change).
Type V: The hair around the vertex is notably sparser
and hair loss is seen more distinctly in the vertex than
in the frontal area.
Type V1: Thinning of the hair around the vertex is
perceptible (mild change).
Type V2: Thinning of the hair around the vertex is
pronounced (moderate change).
Type V3: Thinning of the hair around the vertex is very
sparse or absent (severe change).
The nal type is decided by a combination of the basic
and specic type. e.g., basic type (C1) + specic type (V1)
denotes nal type C1V1.[15]
This classication system offers numerous advantages
over the preexisting systems as it is more comprehensive
and systematic and can be used irrespective of the gender.
Moreover, this system is easy to memorize and practice
and has better reproducibility and repeatability than the
previous classications in routine clinical practice.[16]
Practical applications of classification systems:
These classication systems, especially the common ones
such as the Norwood-Hamilton and Ludwig system
have been widely used by patients and practitioners
for determining the stage of hair loss and assessing the
response to therapy. Apart from these, a few classication
systems have been helpful in determining the surgical
procedure for hair loss management. Few authors have
described indications for different surgical techniques
depending on the stage of hair loss. Bouhanna[6] devised
the following operative indications based on his own
classication system.
Stage 1A: For restoration of original frontal line, two
small preauricular aps are used if the laxity of donor
site is adequate or two strip grafts are combined with
minigraft transplantation if the laxity is inadequate.
Stage 1B: If vertex laxity is adequate, scalp reduction
with minigraft transplantation is arranged in a spiral or
transposition of one or two aps with excision of residual
bald zones. If vertex scalp is taut, 300-400 minigrafts are
transplanted.
Stage IIA: If laxity is adequate, two preauricular aps
combined with a concave and a straight ap along with
150-200 minigrafts are advised. If laxity is inadequate,
500-800 minigrafts are advised.
Stage IIB and III: If laxity is adequate, the appropriate
treatment is transposition of two, three, or four superior
pedicled, nonautonomized aps, along with excision of
the bald area or transplantation of minigrafts in the bald
areas between the aps. If laxity is inadequate, placement
of two expanders followed by transposition of two aps
is advised.
Koo et al.[9] also devised surgical indications for the
various stages of hair loss according to their classication
system. For type M, hair transplantation or a preauricular
ap can be performed. For types O, MO, and CO, scalp
reduction with or without an expander followed by
hair transplantation can be performed. For type U,
expanded triple advancement transposition or bilateral
advancement transposition or scalp reduction are the
primary options while hair transplantation remains the
secondary option. For type C, scalp advancement after
expansion, scalp ap, or hair transplantation can be
performed according to the patient’s preference.
CONCLUSION
Although a large number of classication systems are
available today, all of them have certain limitations as
they either do not describe the complete evolutionary
stages of hair loss or are too detailed for practical use.
Hence, the clinician should assess all of them and choose
the classication system as per his/her own convenience
and requirement.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
REFERENCES
1. Beek CH. A study on extension and distribution of the human body-hair.
Dermatologica 1950;101:317-31.
[Downloaded free from http://www.jcasonline.com on Saturday, January 13, 2018, IP: 190.100.247.29]

Gupta and Mysore: Classications of patterned hair loss
Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2016, Volume 9, Issue 1
12
2. Hamilton JB. Patterned loss of hair in man: Types and incidence. Ann
N Y Acad Sci 1951;53:708-28.
3. Ogata T. Development of patterned alopecia. Sogo Rinsho 1953;2: 101-6.
4. Setty LR. Hair patterns of the scalp of white and Negro males. Am J
Phys Anthropol 1970;33:49-56.
5. Norwood OT. Male pattern baldness: Classification and incidence.
South Med J 1975;68:1359-65.
6. Bouhanna P, Nataf J. A propos des transplantations de cuir chevelu.
Critiques et propositions. Rev Chir Esthet 1976;7:17-23.
7. Blanchard G, Blanchard B. A topographical approach to hair transplantation
and scalp reduction. Ann Chir Plast Esthet 1984;29: 152-61.
8. Bouhanna P, Dardour JC. Male baldness: Dynamic classification of
Dardour and Bouhanna. In: Bouhanna P, Dardour JC, editors. Hair
Replacement Surgery. Berlin: Springer-Verlag; 1996. p. 33-4.
9. Koo SH, Chung HS, Yoon ES, Park SH. A new classification of male
pattern baldness and a clinical study of the anterior hairline. Aesthetic
Plast Surg 2000;24:46-51.
10. Ludwig E. Classification of the types of androgenetic alopecia (common
baldness) occurring in the female sex. Br J Dermatol 1977;97:247-54.
11. Savin RC. A method for visually describing and quantitating hair loss
in male pattern baldness. J Invest Dermatol 1992;98:604.
12. Olsen EA. Androgenetic alopecia. In: Olsen EA, editor. Disorders of
Hair Growth: Diagnosis and Treatment. New York: McGraw-Hill; 1994.
p. 257-83.
13. Sinclair R, Jolley D, Mallari R, Magee J. The reliability of horizontally
sectioned scalp biopsies in the diagnosis of chronic diffuse telogen
hair loss in women. J Am Acad Dermatol 2004;51:189-99.
14. Bouhanna P. Multifactorial classification of male and female
androgenetic alopecia. Dermatol Surg 2000;26:555-61.
15. L ee WS, Ro BI, Hong SP, Bak H, Sim WY, Kim do W, et al. A new classification
of pattern hair loss that is universal for men and women: Basic and specific
(BASP) classification. J Am Acad Dermatol 2007;57: 37-46.
16. Hong H, Ji JH, Lee Y, Kang H, Choi GS, Lee WS. Reliability of
the pattern hair loss classifications: A comparison of the basic
and specific and Norwood-Hamilton classifications. J Dermatol
2013;40:102-6.
[Downloaded free from http://www.jcasonline.com on Saturday, January 13, 2018, IP: 190.100.247.29]