A Guide to the Norwood Hamilton Scale: Understanding Hair Loss Stages

The Norwood scale (or Hamilton-Norwood scale) is the leading classification system used to measure the extent of male pattern baldness, also known as patterned hair loss. Hair loss, or alopecia, simply means losing hair where it previously grew. Alopecia can affect your entire body or just your scalp

The Hamilton-Norwood scale was first introduced in the 1950s by James Hamilton and then later revised in the 1970s by O’Tar Norwood. This is why the scale is sometimes referred to as the Norwood-Hamilton scale.

The Hamilton-Norwood scale provides easy-to-reference images that indicate different stages of balding, and assess the progression of patterned hair loss in men. It is used worldwide by hair specialists to assess the progression of male pattern baldness.

The scale consists of seven distinct stages, each representing a different degree of hair loss progression from Stage 1 which indicates no significant hair loss, to extensive balding at the crown and front (Stages 5 to 7). The scale helps medical practitioners determine the stage of hair loss and recommend treatment options. 

Understanding Male Pattern Baldness

Male pattern baldness, also known as androgenetic alopecia, is the most common type of hair loss in men the process can start in adolescent years. Male hair loss affects around 80% of men over their lifetime and about 50% of men over the age of 50. 

Male pattern baldness hair affects mainly the temples and the crown of your head, forming an ‘M’ shape, but not the back and sides this is well shown by the Norwood scale. 

Male pattern baldness is caused by DHT (Dihydrotestosterone), which is a common type of hormone called androgen and it is derived from testosterone.

Dihydrotestosterone(DHT), stimulates male characteristics like body hair and is also understood to contribute to hair loss. It binds to receptors in your hair follicles, causing them to shrink, which leads to thin hair over time and also causes you to lose your hair more quickly.

Male pattern baldness can be treated in various ways, but treatment is most successful when started in its early stages.

Understanding the severity and progression of hair loss shown by the Norwood scale is crucial for effective treatment.

Importance of Norwood scale

• Accurate Diagnosis: The Norwood Scale helps in accurately diagnosing the stage of hair loss by the pattern in which it occurs.

• Treatment Planning: Understanding the stage of hair loss enables professionals to recommend appropriate treatments, whether it’s medication, hair transplant surgery, or other therapies. The scale is widely used by dermatologists, trichologists, and other healthcare professionals

•  Progress Monitoring: It helps to assess the progression of hair loss in men and the effectiveness of treatments over time to evaluate hair loss patterns and track changes over time

•  Source of reference: It is used as a source of reference to know the stage of hair loss  since it is a visual presentation of the stages of hair loss

•  Documentation: It helps in documenting what a patient’s hair loss was like when they started treatment, and then at later points during the treatment plan. 

The Norwood-Hamilton Scale Stages

Stage 1: Juvenile Hairline( No Significant Hair Loss)

Stage 1 on the Norwood Scale represents a normal head of hair with minimal to no visible hair loss.  shows no recession of the hairline and has full corners. It’s typically low on the forehead and runs straight across.

Your temples and corners still have thick hair. The Hairline appears symmetric and evenly distributed with no significant areas of the scalp being visible or bald patches. 

It is the age-appropriate hairline and normal maturation of hair typically occurring from adolescence to adulthood. The shedding is generally not excessive and may be attributed to the normal hair growth cycle.

In some severe cases, boys as young as 15 can start to see signs of male-patterned hair loss. however, this isn’t regularly seen. Most juvenile hairlines are kept through your 20s.

Stage 2: Maturing hairline (slight Baldness of the Frontal Area)

In this stage, the hairline isn’t straight across. The corners typically rise along the temples, and hair isn’t as thick along the top of the forehead.

The hairline has likely moved back a centimetre with a slight recession. Stage 2 of the Norwood Scale shows a slight recession of the hairline around the temples.

It marks the beginning of a receding hairline and the appearance of a triangular “widow’s peak” on the forehead. The temple recession is often seen with thinning or miniaturisation of the hair follicles in the affected areas.

While the overall density of the hair might appear normal, the subtle change in the hairline becomes more visible.

This leads to a less dense, and more sparse appearance of the hair. These changes are subtle in comparison to more advanced stages of male pattern baldness but can still have a noticeable impact on appearance, mental state and health.

Stage 3: (Stage 3 Vertex)

It represents a further advancement of male pattern baldness. There will be an increased widening of the temple recession and noticeable thinning of the hair in the crown. As hair loss advances from stage 2 to stage 3, there will be a more pronounced recession at the temples.

Patients will notice a receding hairline which continues to move back, creating a deeper “M” shape. Hair thinning will also become more evident in the crown, resulting in a patchy appearance.

While the overall hair density might remain unchanged, the temple and crown regions will become more noticeable.

The increased temple recession is one of the defining features of stage 3. As the hairline continues to move back, it may extend beyond the midpoint of the scalp. This recession can result in a noticeable change in appearance as the forehead may appear larger.

Hair loss at Class 3 is considered balding per the Norwood Scale.

Stage 4: Significant hair loss

Stage 4 on the Norwood Scale marks a significant progression in male pattern baldness. The temple recession continues to progress, with the hairline moving further back, towards the crown. This creates an even deeper and more prominent “M” shape.

Thinning and balding patches can become more evident at the crown. Typically, these two hair loss areas are separated by one patch of hair connecting the bare areas. This results in a more diffuse and widespread pattern of hair loss across the scalp.

Stage 5: Very Advanced Baldness

Stage 5 hair loss is a significant progression of male pattern baldness, with hair loss advancing in the balding areas. There is typically extensive hair loss across the frontal region and the crown.

This results in large areas of the scalp being visible with minimal remaining hair coverage. The temple region has continued to progress back, and the crown thinning has become more pronounced and widespread.

Stage 6: The Monk’s Baldness

Stage 6 on the Norwood Scale is an advanced stage of male pattern baldness and is near total baldness of the crown area. There is typically extensive hair loss across the entire top of the scalp, with only a narrow band of hair remaining along the sides and back.

The temple recession has progressed and has merged with the crown baldness, creating a large horseshoe-shaped pattern of hair loss.

Stage 7: The Most Advanced Androgenetic Alopecia (Full Hair Loss)

Stage 7 on the Norwood Scale is the most advanced stage of male pattern baldness and is the complete loss of hair on the scalp. At this stage, there is extensive and irreversible hair loss across the entire top of the scalp.

The only remaining hair is a narrow band along the sides and back. The crown hair loss can deepen further backwards in stage 7 of the Norwood scale.

Treatment Options for Male Pattern Hair Loss

The different hair loss stages will determine the type of treatment a patient has. Below we have summarised the different levels of hair loss in the Norwood scale and the appropriate treatment regimens patients can explore.

Treatment for Stage 1

Prevention strategies at stage 1 can include the use of topical treatments (minoxidil) or medications (finasteride) to stop hair loss and promote regrowth. It can also include lifestyle modifications, such as maintaining a healthy diet and effectively managing stress levels. Additionally, adopting a proactive approach to hair care, including regular scalp massages, can help maintain a healthy scalp. 

Treatment for Stage 2

Treatment options for stage 2 aim to slow down or halt the progression of hair loss and promote hair regrowth.

A common treatment is the use of topicals, such as minoxidil. Minoxidil is FDA-approved for male pattern baldness and works by stimulating hair follicles and increasing blood flow to the scalp. This promotes healthy hair growth and prevents further loss.

Oral medications, like finasteride, may also be prescribed and can be used in addition to minoxidil. Finasteride blocks the production of dihydrotestosterone (DHT), which is a hormone linked to hair loss. These treatments can help maintain hair density and slow down the progression of male pattern baldness.

Other options for stage 2 may include lifestyle changes, such as dietary changes and effective stress management. These can help support overall hair health and minimise the impacts of hair loss. Introducing proper treatment and management strategies at stage 2 can help preserve hair density and overall hair health.

Treatment for Stage 3

Treatment options for stage 3 focus on addressing both the temple recession and crown thinning to maintain density and minimise further hair loss. Topical treatments, like minoxidil, are one of the most common treatment options. It can help stimulate hair follicles and promote regrowth in the affected areas.

In addition to minoxidil, finasteride can be prescribed as an oral medication to inhibit the production of DHT. By blocking DHT, this prevents further miniaturisation of hair follicles and slows down the progression of hair loss.

If the thinning and recession are extensive in Norwood 3 individuals, hair transplant surgery, both FUE or FUT, can be performed to restore hair where it has been lost. The procedure can be performed with the unshaven hair transplant technique to reduce the recovery time.

Treatment for Stage 4

At this stage, surgical treatments are often considered a viable option for a permanent solution to restoring hair density. Hair transplant surgery involves removing healthy hair follicles from the donor site, typically the back or sides, and transplanting them to the balding or thinning areas.

They are often in combination with medical therapies to help preserve existing hair and prevent future hair loss.

Other combination therapies at this stage include low-level laser therapy (LLLT) or platelet-rich plasma (PRP), which can help prevent hair loss but aren’t as effective as Minoxidil and Finasteride.

 Treatment for Stage 5

Like stage 4, combination therapies are often recommended for stage 5 hair loss to address the visible signs of male pattern baldness.

These treatments can include a combination of topical treatments, oral medications, and procedural interventions. Combined, these treatments will target different aspects of hair loss and maximise treatment efficacy.

The combinations can vary depending on the specific hair loss needs, but may include the use of minoxidil, finasteride, and other treatments such as low-level laser therapy (LLLT) or platelet-rich plasma (PRP). A more permanent surgical option, such as a hair transplant, can also be used to restore hair.

Treatment for Stage 6

Both surgical and non-surgical treatments can be considered for addressing stage 6 hair loss. Surgical options, like hair transplant surgery, can help restore hair in the hairline or crown. Careful consideration will be needed to determine whether the patient has sufficient hair to transplant into a balding area.

Those with little or no hair left in stage 6 may have trouble covering their scalp with hair. The risks associated with both surgical and non-surgical procedures need to be evaluated to ensure the right decision is made for treating hair loss.

Treatment for Stage 7

While there is no cure for baldness, those patients who are completely bald may need to consider undergoing surgery to restore their hair. Similar to stage 6 of the Norwood Hamilton scale, patients will require careful evaluation of their surgical goals and the amount of hair that can be transplanted to achieve a natural result.

At this advanced stage of hair loss, you will need an expert Surgeon who is familiar with donor area management and surgical techniques to achieve a natural-looking outcome.

Other causes of male hair loss

• Genetics: hair loss may run in your family. Male and female pattern baldness (androgenic alopecia) is the most common type of hair loss, and this is a hereditary condition. The AR gene, also known as the ‘baldness gene’, is found on the X chromosome and is strongly associated with baldness

• Medical conditions: many medical conditions can cause hair loss. These include: hair pulling disorders (trichotillomania); autoimmune disorders such as alopecia areata, diabetes and lupus, ringworm, a fungal infection of the scalp, and sexually transmitted infections such as syphilis and HIV

• Medications: there is a range of medications that have potential side effects, including hair loss, such as drugs for high blood pressure, heart problems, cancer and arthritis

• Shock: emotional and physical shock can lead to the thinning of the hair called telogen effluvium, although this is typically temporary

• Hairstyles: ‘Tight’ hairstyles could contribute to hair loss. This is due to traction alopecia, which may have contributed to David Beckham’s hair loss. Be wary of cornrows, braids, buns, ponytails and any other styles that drag back the hair and pull it tightly

• Hair treatments: As mentioned earlier, the hair treatments you use can also contribute to

  hair loss. These include hair dye, hot styling tools (from rollers to straighteners and blow dryers), and chemical texturizers for hair management.

• Radiotherapy: radiotherapy is a cancer treatment that can result in hair loss in the area of the body being treated. This hair loss is typically temporary, although hair may grow back differently.
  

Conclusion

The Norwood Scale for hair loss is beneficial in determining the degree and extent of male pattern baldness. By understanding the severity and progression of hair loss, individuals can make informed decisions about treatment options. 

In the early stages, hair loss can often be effectively treated with medications and lifestyle modifications. Exercise, a balanced diet, and adequate hydration can promote overall health and support the health of hair follicles. Proper scalp maintenance, including regular cleaning and exfoliation, can help prevent scalp conditions such as itching and dandruff.  In the later stages, several surgical options are available.

Get in touch

Take the step toward a fuller hairline: schedule your complimentary consultation with our London FUE hair transplant specialists, or visit our FUE hair transplant clinic in Oxford. Additionally, we also serve Brighton and Bristol.

Our award-winning team, including leading London hair transplant surgeons Dr Fernando and Dr Vara, is here to support you every step of the way.

Learn more about hairline and temple transplants at The Treatment Rooms London. Contact us by calling 020 8706 0076 or using our contact form.