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

Key takeaways:

• What is the Norwood-Hamilton scale? The Norwood-Hamilton scale is a system that hair loss specialists use to classify the extent of pattern baldness in men. It has seven stages, ranging from stage one, which is little or no hair loss, through to stage seven, which is extensive hair loss across the scalp.
  
• How can I tell what stage of hair loss I am at? The main thing to look at is the pattern of hair at your hairline, temples, and the top (crown) of your head.  You can take clear photographs of your hair and compare them to the depicted Norwood scale stages, which should help to give you an estimate of what stage you are at.
  
• Does having a receding hairline always mean that I am going bald? Not necessarily. A small amount of hairline recession is expected as we mature from adolescence into adulthood; however, if this hairline retreat is continuous and doesn’t slow, or you also notice your hair thinning at the crown, then you might be showing signs more indicative of male pattern baldness.
  
• Can male pattern baldness be treated? Yes. There are treatments out there for male pattern baldness. Often, the first-line treatments are medicines such as minoxidil and finasteride, which can help slow further hair loss and encourage some regrowth. If your hair loss is more advanced, then you might be suitable for a hair transplant procedure. 
  
• Is it better to treat hair loss early? Generally, the earlier you begin treating your hair loss, the more hair that you can preserve. 

The Norwood scale (also known as the Hamilton-Norwood scale) is the main classification system used to measure the extent of male pattern baldness (androgenetic alopecia). 

The Norwood scale was first introduced in the 1950s by James Hamilton and then later revised by O’Tar Norwood in the 1970s. This is why the scale is sometimes referred to as the Norwood-Hamilton scale, after the man who first devised it and then the most recent person to give it an update into the modern version we see today.

The Norwood-Hamilton scale provides easy-to-reference images that indicate different stages of balding and assess the progression of pattern hair loss in men. It is used by hair specialists all over the world for this purpose. 

There are seven distinct stages on the scale, and each one represents a different degree of hair loss. This ranges from Stage 1, which indicates no significant hair loss, to extensive balding at the crown and front (Stages 5 to 7). The scale is useful for doctors and hair loss specialists to classify your stage of hair loss and adjust their treatment recommendations accordingly.

Understanding Male Pattern Baldness

Male pattern baldness (also known as androgenetic alopecia) is the most common cause of hair loss in men. This process of hair loss can begin as early as the end of puberty, and affects around half of all men by the time they are 50 and 4 in 5 men by the time they are 70 years old. 

Male pattern baldness characteristically affects the temples and the crown of your head first, often forming an ‘M’ shape. The least affected parts of the head are the back and sides, where the hair is often spared. 

Male pattern baldness is caused by the interaction of DHT (Dihydrotestosterone), a potent hormone derived from testosterone, with genetically susceptible hair follicles.

It binds to receptors on these susceptible hair follicles, causing them to shrink, which leads to them making thinner and shorter hairs over time. Eventually, under this influence of DHT, some hair follicles lose the ability to produce any new hairs, resulting in areas with visible thinning or baldness. 

The severity and progression of hair loss, as shown by the Norwood scale, acts as a guide to understand your treatment options.

Importance of the Norwood scale

The Norwood scale is a valuable tool as it allows for:

• Accurate Diagnosis: The Norwood Scale helps provide an accurate diagnosis of hair loss judging by its presenting pattern and distribution across the scalp.
  
• Treatment Planning: By identifying a particular stage of hair loss, the scale can help professionals to recommend appropriate treatment plans specific for your hair loss, whether that is medication, hair transplant surgery, or other therapies.
  
• Progress Monitoring: It is useful when assessing the progression of hair loss in men and tracking the response to treatments over time.
  
• Source of Reference: It gives a great baseline from which any further changes to your hair can be measured against.
  
• Documentation: It is a concise and standardised way to document what a patient’s hair loss was like when they started treatment, and also at different points during the treatment plan. 

The Norwood-Hamilton Scale Stages

There are seven stages of male pattern baldness that have been identified as part of the scale.¹

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 or recession. The hairline remains at or very close to its original position, with no significant areas of the scalp or bald patches being visible.

In some severe cases, boys as young as 15 can start to see signs of male-pattern hair loss. However, this isn’t typical. Most people keep their juvenile hairlines into their 20s.

Stage 2: Maturing Hairline (Slight Baldness of the Frontal Area)

In this stage, the frontal hairline is no longer slightly concave or straight across. The corners typically begin to rise along the temples to form small triangular areas of hair loss. You might notice that your hair isn’t as thick along the top of the forehead as it used to be. 

This is what is often termed a ‘mature’ hairline and is considered as a normal variation as you move from adolescence to adulthood.

Stage 3: Further Evidence of Receding Hairline (Frontal and Crown)

Stage three represents the earliest stage of clinically apparent baldness. There is an increased widening of the temple recession and noticeable thinning of the hair in the crown.  It is classified as stage 3 vertex when there is crown involvement. As hair loss advances from stage 2 to stage 3, there is a more pronounced recession at the temples.

Patients will notice a receding hairline which continues to move back, creating a deeper “M” or “V” 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 noticeably sparse.

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 level of hair loss can be very apparent as the forehead tends to appear much larger. 

Stage 4: Significant hair loss

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

At the same time, the hair thinning further progresses at the crown, transforming it potentially into an area of distinctive baldness. This results in a more diffuse and widespread pattern of hair loss across the scalp, separated by a remaining band of hair between the frontal area and crown.

Stage 5: 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 only a partial separation between the balding at the front and the top of the scalp. These areas of baldness are beginning to merge together.

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 already merged with the crown baldness, creating a distinctive 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 remaining hair on the sides may even be thin and sparse. At this point, most hair usually exists only in a narrow band from ear to ear across the back of the head. 

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

At stage one, there is usually little concern about hair loss, so most people don’t take any steps towards treatment, as they don’t consider it an issue. You can take preventative measures at stage 1, including the use of topical medications (minoxidil) or oral medications (finasteride) to prevent further hair loss and promote regrowth. The best thing you can do is maintain a healthy diet and effectively manage your stress levels. You could also adopt a proactive approach to hair care, including regular scalp massages, which can help to keep your scalp healthy.

Treatment for Stage 2

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

A common treatment is the use of topicals, such as minoxidil. Minoxidil is approved by the Medicines and Healthcare products Regulatory Agency (MHRA) and the American Food and Drug Administration (FDA) 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 supportive 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,² 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 minimise the production of DHT. By blocking DHT, this prevents hair follicles from shrinking and slows down the progression of hair loss.³

If the thinning and recession are extensive in individuals classified with Norwood 3-stage hair loss, then hair transplant surgery (usually FUE) can be performed to restore hair where it has been lost. The procedure can be performed with an unshaven technique for convenience in order to maintain longer hair while the transplanted hairs grow to fill in the gaps. 

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 moving healthy hair follicles from the donor site, typically the back or sides, and transplanting them to the balding or thinning areas.

They are often combined with medical therapies to help preserve existing native hair and prevent future hair loss around the transplanted follicles. 

Other combination therapies at this stage include low-level laser therapy (LLLT)⁴ or platelet-rich plasma (PRP)⁵, which can help stimulate hair growth, but aren’t as effective as Minoxidil or 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.

The combinations can vary depending on the specific hair loss needs, but may include the use of minoxidil, finasteride, often combined with a more permanent surgical option, such as a hair transplant. Hair transplant at this stage may need to be carried out in stages rather than all in one sitting. 

Scalp micropigmentation can also help create the appearance of density in thinning areas that still have enough existing hairs for it to appear natural. 

Treatment for Stage 6

As the bridge between the frontal and crown hair disappears completely, 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 and forward planning will be needed to determine whether the patient has sufficient hair to transplant into a balding area.

Scalp micropigmentation can be a great option to consider alongside transplantation, especially if there is limited coverage which can be offered by the amount of grafts available for transplantation.

Stronger DHT blocking medications such as dutasteride could also be considered.

Treatment for Stage 7

While there is no cure for baldness, those patients who are completely bald may consider undergoing surgery to restore their hair. Similar to stage 6 of the Norwood scale, any operation will need to be carefully planned to ensure the outcome is worthwhile for your desired goals. 

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.

Keep your expectations realistic, as depending on how much hair you have remaining, there might only be so much that can be done to improve your hair coverage. 

Conclusion

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

In the early stages, hair loss can often be effectively treated with medications and lifestyle modifications. 

Taking care of your body by exercising, eating a balanced diet, and making sure you stay well-hydrated can promote overall bodily health, and the health of your hair follicles. 

Having a proper scalp maintenance routine, including regular cleaning and exfoliation, can help prevent scalp conditions such as itching and dandruff. 

In more advanced stages of balding on the Norwood scale, surgical options become an important mainstay of treatment. 

Are you considering a hair transplant?

Hair loss can be a deeply personal and sensitive issue. For some people, it is a cosmetic concern, but for others, it can really eat away at their confidence every time they look in the mirror. It can make them second guess how they look when taking a photograph or entering a crowded room. Each individual will have their own experience, and that is why we ensure that they each get a unique hairline that suits who they are. 

Explore our extensive gallery of hair transplant results, where you can view a wide range of before and after transformations.

With each case, you can have a glimpse at how we have helped hundreds of people like you achieve their dream hairline, often just from a single day procedure. 

Furthermore, our patient journey is second to none, with hair transplant aftercare factored into our pricing structure.

For more information about costs associated with an FUE hair transplant, take a look at our dedicated hair transplant cost page or try our hair graft calculator to figure out how many grafts you might need.

Get in touch today if you’d like to book a consultation to discover how our team may be able to help you achieve a fuller, natural finish to your hairline. 

References

1. Norwood OT. Male pattern baldness: classification and incidence. Southern Medical Journal. 1975 Nov;68(11):1359-1365. 
   
2. Suchonwanit P, Thammarucha S, Leerunyakul K. Minoxidil and its use in hair disorders: a review. Drug Des Devel Ther. 2019 Aug 9;13:2777-2786. doi: 10.2147/DDDT.S214907. PMC6691938. 
   
3. Gupta AK, Talukder M. Finasteride for hair loss: a review. J Dermatolog Treat. 2022 May;33(3):1938-1946. doi: 10.1080/09546634.2021.1959506. PubMed. 
   
4. Suchonwanit P, Iamsumang W, Leerunyakul K. Low-level laser therapy for androgenetic alopecia: a review of efficacy and mechanism of action. Drug Des Devel Ther. 2020 Apr 16;14:1483-1491. doi: 10.2147/DDDT.S241416. [PMC7174004].