Hair Loss Stages Woman: The Ludwig Scale

Quick Summary: Stages of Female Pattern Hair Loss (FPHL)

• The Ludwig Scale: A system to classify the stages of female pattern hair loss (androgenic alopecia). Ranges from stage 1 (widening of the hair part) to stage 3 (advanced hair loss with significant thinning across the scalp).
• Professional advice: In the first instance, hair loss should be discussed with your GP and/or a dermatologist, just to make sure any underlying causes are addressed. If needed, a hair specialist can recommend treatments based on your Ludwig stage and desired outcome, such as medication like Minoxidil, hair loss prevention strategies, or hair transplantation.
• Practical Advice for Managing Hair Loss: Maintain a healthy lifestyle, manage stress, and use gentle hair care practices.

Hair loss is a common concern for many people, but it can be particularly distressing for women. Female pattern hair loss, also known as female androgenetic alopecia¹, affects millions of women worldwide. While it often differs from the receding hairline typically seen in men, female pattern hair loss can still be a significant source of worry. Here at Treatment Rooms London, we understand the emotional impact hair loss can have, and we’re dedicated to helping women regain confidence through personalised hair restoration solutions.

One of the tools used to assess hair loss in women is the Ludwig Scale. Developed in 1977, this scale provides a framework for classifying the stages and patterns of hair loss in women.

The Ludwig Scale

Similar to the Norwood Scale for men, the Ludwig Scale has become a widely accepted method for classifying female pattern baldness in the study of the scalp and hair. It was developed by Dr Erich Ludwig in 1977 to categorise female hair loss into three main stages, each with subcategories reflecting the progression of thinning ^2,3. It’s important to remember that this is a general guide, and individual experiences may vary.

Here’s a breakdown of the stages:

• Stage 1 (Early Hair Thinning): This stage is characterised by a widening of the hair part along the central scalp. You might notice slightly less hair volume overall, but the hairline remains unaffected. (Sub-stages 1.1 and 1.2 can be referred to as natural hair parting, while 1.3 onwards might require treatment).
• Stage 2 (Progressive Thinning): During this stage, hair loss becomes more noticeable. The part widens further, and thinning progresses towards the crown of the head. The hair might feel thinner to the touch. It might not hold styles as well as it used to, and women might notice more hair shedding out when they brush or shower.
• Stage 3 (Advanced Hair Loss): This stage represents the most severe level of hair loss. Significant thinning occurs across the scalp, with a noticeable reduction in overall hair density. In some cases, complete baldness can occur in the frontal scalp area.

Uses of the Ludwig Scale

The Ludwig Scale serves several important purposes. It helps:

• Diagnose Female Pattern Hair Loss: By identifying the stage based on the pattern of hair loss, doctors can distinguish between female pattern hair loss (androgenetic alopecia) and other potential causes of hair thinning.
• Communication: It establishes a common language for both patients and specialists. 
• Guide Treatment Options: Understanding the stage of hair loss allows doctors to recommend the most appropriate treatment course, whether it’s medication, hair loss prevention strategies, or hair transplantation.
• Track Progress: The Ludwig Scale can be used to monitor the effectiveness of treatment plans and assess overall progress.

Causes of Hair Loss in Women

We can categorise the possible causes as below⁴:

• Genetic predisposition: Female Pattern Hair Loss can be passed down through genes.
• Hormonal changes: Women are especially prone to hormonal fluctuations throughout their lives. The changes experienced during puberty, pregnancy, after childbirth, and menopause can all play a role in hair loss.
• Underlying medical conditions: Hair loss can indicate underlying health conditions, particularly genetic, hormonal or autoimmune disorders. Conditions such as Polycystic Ovary Syndrome (PCOS), alopecia areata, lupus, anaemia, and thyroid issues are more prevalent in women than in men, and can contribute to hair loss.
• Medications: Side effects from medications, including blood thinners, beta blockers (for heart conditions), certain antidepressants, and chemotherapy, may cause hair loss.

When to Seek Professional Help?

Early diagnosis and intervention are key to managing hair loss effectively. If you’re experiencing any degree of hair thinning or are concerned about hair loss, it’s wise to schedule a consultation initially with your GP or dermatologist, who may then refer you to a hair loss specialist.

So, when does a hair transplant become an option? Our team always advises patients to first rule out possible underlying causes of hair loss, such as hormonal imbalance, nutritional deficiencies, or autoimmune-driven conditions like alopecia areata. This process can be initiated through your GP or dermatologist, who can arrange the appropriate blood tests and examinations, and advise when you may be a suitable candidate for hair transplant surgery.

Once other potential causes have been ruled out, and your hair loss has stabilised (meaning you’re not actively losing hair), our experienced surgeons can carry out a comprehensive hair loss assessment. This may include a Ludwig Scale assessment to understand the pattern and severity of hair loss, and to discuss the most appropriate treatment options from a surgical perspective.

In some cases, it may be a cosmetic concern (such as lowering a congenitally high hairline) rather than hair loss. In these situations, you may still be a candidate for hair transplant surgery, provided you are not experiencing active or progressive hair loss.

Hair Loss Treatment Options for Women

Hair transplant specialists offer various treatments to address hair loss at different stages. These can include:

• Topical treatments:
  • Products containing Minoxidil (Regaine) can help stimulate hair growth. Minoxidil potentially widens tiny blood vessels in the scalp, which improves blood flow to hair follicles. This process revives and extends the anagen (growth) phase of the hair cycle, shortens the telogen (resting) phase, stimulates hair follicle activity, increases follicle size, and boosts the production of crucial growth factors for hair development⁵.
• Minimally Invasive Procedures:
  • Procedures like Platelet-Rich Plasma (PRP) Therapy involve extracting a small amount of the patient’s blood, processing it to concentrate the platelets, and injecting the platelet-rich plasma into the scalp. Platelets contain growth factors that can help stimulate hair follicle activity and promote hair regrowth. PRP therapy has shown promising results in treating various types of hair loss, including androgenetic alopecia⁶.
• Hair Transplant:
  • A surgical procedure that involves transplanting healthy hair follicles from a donor area on the scalp to bald or thinning areas. This procedure provides results that are long-lasting, effectively restoring hair growth and improving appearance and self-confidence. Two main techniques are used: Follicular Unit Transplantation (FUT) and Follicular Unit Excision (FUE). Both methods have high success rates and can produce natural-looking results.
  • For women, FUT is often preferred because it doesn’t require shaving the entire head; only a strip of scalp is removed, leaving the rest of the hair intact. FUE, while less invasive and leaving minimal scarring, may involve shaving a small section of the donor area that can be easily concealed by the surrounding hair. This can be done discreetly with an “undercut” approach, but the need to shave even a small area can be a concern for women who are sensitive about changes to their hairstyle. The choice between the two should be made after consulting with a specialist, considering individual needs and aesthetic preferences⁷.
  • For more information, check out our blog post: FUE Vs. FUT

Practical Advice for Managing Hair Loss

While there’s no guaranteed way to prevent hair loss entirely, maintaining a healthy lifestyle with a balanced diet, managing stress, and using gentle hair care practices can all contribute to overall hair health. This may include:

• Diet: Lack of essential nutrients, especially iron (due to anaemia) and vitamins D and B (including B5, B6, and B7 or biotin), can affect hair health. Ensure your diet is rich in essential vitamins and minerals that nourish hair follicles.
• Stress Management: Telogen Effluvium is a condition where a sudden, temporary loss of hair occurs due to situational stress (illness, hormonal changes, physical or mental stress), causing a large number of hair follicles to enter the telogen (resting) phase of the hair growth cycle. This means the follicle is dormant and the hair shaft is not actively growing, resulting in diffuse thinning across the scalp. Techniques like meditation or yoga can help manage stress levels⁸.
• Hair Care: Women are generally more likely than men to frequently style and change their hair, which often involves the increased use of hair products and heat styling tools. Additionally, tight hairstyles such as braids, cornrows, or ponytails can contribute to a condition known as traction alopecia. This occurs when constant tension and pulling on the hair cause damage to the hair follicles, leading to hair loss, particularly in areas under the most strain. As a result, women may need to take extra precautions to protect and care for their hair to prevent long-term damage⁹. For those interested in exploring hair oils, our comprehensive blog on the best oils for hair growth is packed with valuable insights to enrich your hair care journey.

Conclusion

Hair loss can be a daunting experience, but it’s important to remember that you’re not alone. The Ludwig Scale helps us understand the progression of female hair loss, and with the right diagnosis and treatment plan, you can regain confidence and achieve a fuller, healthier head of hair.

If you’re considering a hair transplant or looking for initial advice on hair loss, please don’t hesitate to contact The Treatment Rooms London today, and our friendly team will be able to guide you in the right direction. We’re here to help you explore your options and find the solutions that best suit your needs.

References

1. Female pattern baldness: Medlineplus medical encyclopedia. MedlinePlus. Available at: https://medlineplus.gov/ency/article/001173.htm#:~:text=Female%20pattern%20baldness%20is%20the%20most%20common%20type,Eventually%2C%20the%20follicle%20does%20not%20grow%20new%20hair
2. Ludwig, E. (1977) ‘Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex’, British Journal of Dermatology, 97(3), pp. 247–254. Available at: https://pubmed.ncbi.nlm.nih.gov/921894
3. Gupta, M. and Mysore, V. (2016) ‘Classifications of patterned hair loss: A Review’, Journal of Cutaneous and Aesthetic Surgery, 9(1), p. 3. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4812885/
4. Redler, S., Messenger, A. G., & Betz, R. C. (2017) ‘Genetics and other factors in the aetiology of female pattern hair loss’, Experimental dermatology, 26(6), pp. 510–517. Available at: https://doi.org/10.1111/exd.13373 
5. Suchonwanit, P., Thammarucha, S., and Leerunyakul, K. (2019) ‘Minoxidil and its use in hair disorders: a review’, Drug design, development and therapy, 13, pp.2777–2786. Available at:https://doi.org/10.2147/DDDT.S214907 
6. Paichitrojjana, A. and Paichitrojjana, A. (2022) ‘Platelet-rich plasma and its use in hair regrowth: A review’, Drug Design, Development and Therapy, 16, pp. 635–645. Available at: https://doi.org/10.2147/DDDT.S356858
7. Dunkin, M. and Gardner, S. (2022) Hair Transplants: What to Expect. WebMD. Available at: https://www.webmd.com/skin-problems-and-treatments/hair-loss/hair-transplants
8. Hadshiwer, I., Foitzik, K., Arck, P., et al. (2004) ‘Burden of Hair Loss: Stress and the Underestimated Psychosocial Impact of Telogen Effluvium and Androgenetic Alopecia’, Journal of Investigative Dermatology, 123(3), pp. 455 – 457. Available at: https://www.sciencedirect.com/science/article/pii/S0022202X15309635
9. Billero V, Miteva M. Traction alopecia: the root of the problem. Clin Cosmet Investig Dermatol. 2018 Apr 6;11:149-159. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896661/