Retrograde Alopecia: Causes, Symptoms, and Treatment Options

Key Takeaways:

• What is retrograde alopecia? Retrograde alopecia (RA) is when hair begins to thin at the back of the neck. It is sometimes called vertical alopecia, as the hair loss moves upwards towards the centre of the back of the head.
  
• Why is it different from normal hair loss? Retrograde alopecia is atypical in that it begins at the back of the head. The most common types of hair loss usually progress from the frontal hairline or crown. It can impact the reserve of hair that is normally used to supply follicles for hair transplantation. This is a significant feature of RA, considering this hair is usually considered to be the most resistant to hair loss.
  
• What causes it? As it is mainly a description of the location of hair loss, it can have many different causes, whether that is due to autoimmunity, an imbalance of hormones, genetic predisposition, or mechanical causes such as extended traction on that part of the scalp.
  
• How do I know if I have it?  A telltale sign is a rising neck hairline accompanied with a loss of hair density over the ears. The hairs themselves can be affected similarly to hair loss that starts at the temples, in that they will often gradually get thinner and shorter.
  
• Does it affect having a hair transplant? Retrograde alopecia would need careful planning in the event of hair transplantation. This is because it affects the part of the head where most donor grafts are traditionally taken from to carry out the procedure. This makes planning a hair transplantation and mapping the available donor hair important when you have retrograde alopecia.
  

Retrograde alopecia has always been recognised as a phenomenon where the hair loss starts at the nape of the neck. It is increasingly being used as a standalone term. It has a strong association with androgenetic alopecia, in which case it is referred to as retrograde androgenetic alopecia.

Overall, retrograde alopecia refers to the pattern of distribution of hair loss rather than a specific disease mechanism. 

What Is Retrograde Alopecia?

Retrograde alopecia (RA) is hair loss which impacts the back of the neck and just above the ears. This is an interesting departure from the usual pattern of hair loss, which largely affects the front of the head. The areas of hair loss in RA are usually described as resistant to pattern hair loss, which is what makes it a somewhat rare occurrence.

When the cause is specifically a subtype of androgenetic alopecia (called retrograde androgenetic alopecia), the follicles undergo a similar process of producing hairs that are thinner and smaller, much the same as seen in ordinary pattern hair loss. 

This pattern of hair loss is noteworthy because it involves losing hair in often stable areas which hair transplant surgeons usually deem as a ‘safe donor zone’.^2,3

How Is It Different From Normal Pattern Hair Loss?

Retrograde alopecia is not always a form of pattern hair loss, although most cases described in the medical literature have a connection with pattern hair loss (androgenetic alopecia). 

Its location is what primarily distinguishes it from ordinary pattern hair loss. Pattern hair loss in men typically affects the temples and the frontal hairline. In women, pattern hair loss most commonly impacts the crown.⁴

Retrograde alopecia occurs mainly at the back of the head, at the nape of the neck, and works its way upwards. 

What Causes Retrograde Alopecia?

Retrograde alopecia refers to the pattern of development of the hair loss, starting from the neckline and progressing upwards.¹ It is not driven by one cause, but rather can have many different causes that can produce a similar outward appearance.

Retrograde androgenetic alopecia

This appears to be the most commonly reported cause of retrograde alopecia. It is much the same as pattern hair loss in that the follicles respond to potent androgens such as Dihydrotestosterone (DHT), which causes them to produce ever thinner and shorter hairs.

This is a rarer subtype of androgenetic alopecia which occurs at the back of the head alongside a normal pattern of androgenetic alopecia that causes hair loss in the crown and hairline.  

Autoimmune

Sometimes, your hair follicles can be attacked by your own immune system, as seen in alopecia areata. This causes patchy hair loss. In a certain ophiasis type of alopecia areata, you may get a band-like loss of hair around the sides and back of the scalp.⁵

Genetic factors

In some cases, the fact that your hair loss affects the neckline may be a hair loss pattern that runs in your family. Genetics play a significant role in many causes of hair loss.

Mechanical causes

Sometimes when you lose hair from the back of your head, this is because of hairstyles or headwear that places a pulling force on the hairs that eventually causes them to fall out (traction alopecia).⁶

“Patients who present in our clinic looking to have a hair transplant will always have their donor area assessed to review its health. One aspect of the donor area we will appraise is whether it is suffering from retrograde alopecia, as this will affect the total amount of donor hair available for us to use for the patient. If there are signs of retrograde alopecia present, we may need to revise our plans for surgery or delay it until the signs and symptoms of the condition have stabilised.”

Dr Roshan Vara, Co-Founder and Hair Transplant Surgeon at The Treatment Rooms London

Signs of Retrograde Alopecia

Retrograde alopecia often develops gradually, and as it affects the back of the head first, it can be easy to miss.

Some common signs are:

• Reduced density at the nape of the neck
  
• The neck hairline appears to be moving upwards
  
• Thinning above or behind the ears
  
• A mixture of thick hairs and finer, shorter hairs

If the scalp itself shows signs of problems such as redness, scaling, tenderness, or shiny skin, or there are distinct smooth patches of hair loss, this raises the possibility of causes other than retrograde androgenetic alopecia, including damage from traction or an autoimmune disease process.

Diagnosis

The path to diagnosis begins by listening to the story of how the hair loss developed, combined with examining the hair itself. You may be asked about family members with hair loss, when the thinning first started, and how it has changed over time. 

An assessment of your entire scalp, including a comparison across different areas, will help to determine if the change is just in one area or is a wider pattern across your entire scalp.

A magnifying device, called a trichoscope, can help detect differences in hair thickness or length, which is consistent with retrograde androgenetic alopecia, or check for the presence of any scarring.⁷

Blood work may be sent off by your doctor when they think you have a more generalised cause of hair loss, not specific to the head, such as a hormonal disturbance or iron deficiency. 

A small sample of the scalp (biopsy) may be taken when the cause still remains unclear after examination. This will be to look for microscopic signs of inflammation.

Treatment Options for Retrograde Alopecia

As earlier outlined, there is not just one singular cause of retrograde alopecia. As a result, there will also not be a single treatment as a result.

For retrograde androgenetic alopecia, as it is a subtype of pattern hair loss, the primary medication recommended is topical minoxidil. This encourages the hair to re-enter an active phase of growth from a resting state.⁸

If the main cause is autoimmune, such as in alopecia areata, which is leading to patches of hair loss at the neckline, then a common treatment is topical or injected corticosteroids.⁵

If the hair loss is as a result of too much pulling of the hair, then lifestyle modifications removing the causes of hair tension should help the hair grow back.

If you find the hair loss is significant and is affecting your functioning, then you may see hair transplantation as a valuable option. This will involve moving hair follicles from other parts of your body to the affected scalp, but will largely depend on whether you have enough hair available to use as a donor. 

Retrograde Alopecia and Hair Transplants 

Just because you have hair loss that begins near the back of your head, it does not rule out the possibility of getting a hair transplant.

That said, it adds a layer of complexity which will need careful consideration and extensive planning. 

Follicles taken for transplantation usually retain the characteristics of the site they were taken from. For example, the back of the head is usually seen as a stable donor area precisely because the hair there largely remains unaffected by pattern hair loss processes.³

If you have thinning near this zone, the surgeon has to take into account the fact that these follicles may also undergo this process in the place they are transplanted to.

Your stable donor zone is diminished when you have hair loss in the traditional donor zone. As a result, you may have less viable hair to be transplanted than someone who doesn’t have retrograde alopecia.

In some patients, a hair transplant may not be a viable option for you if you lack the required amount of donor hair.

When to Seek Advice 

Arrange an assessment if you notice:

• Progressive thinning starting at the back of your head
  
• A neckline that is advancing upwards
  
• Reduced hair density at the back or sides of your head
  
• Sudden onset of smooth hairless patches
  
• Redness, scaling, pain, or tenderness of the scalp
  
• Shiny skin
  
• The hair loss comes after illness, weight loss, or a change in medication

An assessment of your health by a GP to rule out underlying whole body disease is recommended in the first instance. They will be able to guide whether you need further treatment.

Conclusion

Retrograde alopecia presents as thinning around the nape, lower back of the scalp, and above the ears. It can be linked to androgenetic alopecia (pattern hair loss), but other causes include autoimmune and mechanical stress such as traction alopecia.

The hair loss can extend into the ‘safe donor zone ’, which can raise questions as to the suitability of hair transplantation in these patients. Early assessment and correct diagnosis are the most useful first step to take in order to preserve as much hair as possible.

References

1. Abbasi A, Avram M. Retrograde androgenetic alopecia. Dermatol Surg. 2021;47(11):1521–1522. doi:10.1097/DSS.0000000000003201.
   
2. Mohamed AR, Al Khalawany M, Abdalkarim I. Retrograde alopecia: prevalence, patterns, dermoscopic features among Egyptian men: a cross-sectional study. Int J Med Arts. 2023;5(5):3286–3290. doi:10.21608/ijma.2023.212495.1688.
   
3. Khunkhet S, Chanprapaph K, Rutnin S, Suchonwanit P. Histopathological evidence of occipital involvement in male androgenetic alopecia. Front Med. 2021;8:790597. doi:10.3389/fmed.2021.790597.
   
4. Kanti V, Messenger A, Dobos G, et al. Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men—short version. J Eur Acad Dermatol Venereol. 2018;32(1):11–22. doi:10.1111/jdv.14624. 
   
5. Harries MJ, Ahmed A, Ascott A, et al. British Association of Dermatologists living guideline for managing people with alopecia areata 2025. Br J Dermatol. 2026;194(2):e56–e73. doi:10.1093/bjd/ljaf452. 
   
6. Akingbola CO, Vyas J. Traction alopecia: a neglected entity in 2017. Indian J Dermatol Venereol Leprol. 2017;83(6):644–649. doi:10.4103/ijdvl.IJDVL_553_16.
   
7. Issa NT, Tosti A. Trichoscopy for the hair transplant surgeon—assessing for mimickers of androgenetic alopecia and preoperative evaluation of donor site area. Indian J Plast Surg. 2021;54(4):393–398. doi:10.1055/s-0041-1739245.
   
8. Gupta AK, Venkataraman M, Talukder M, Bamimore MA. Relative efficacy of minoxidil and the 5-α reductase inhibitors in androgenetic alopecia treatment of male patients: a network meta-analysis. JAMA Dermatol. 2022;158(3):266–274. doi:10.1001/jamadermatol.2021.5743