The Ludwig Scale & Female Pattern Hair Loss: Stages, Assessment & Treatment

Key takeaways:

• What is the Ludwig scale? The Ludwig scale is a visual depiction of the severity of female pattern hair loss shown in three stages.

• What are the stages? Ludwig I involves mild thinning, Ludwig II is moderate hair thinning with a wider hair parting, and Ludwig III is advanced thinning with a clearly visible scalp.

• How does it compare to the Norwood scale? The Ludwig scale is the female equivalent of the Norwood scale of pattern baldness in men.

• How is it determined? A doctor determines your stage on the Ludwig scale by examining the pattern and density of your hair. Your medical history and an examination of your scalp will also be used to help to establish a diagnosis for your hair loss. 

• Does the stage affect treatment? Your stage may impact what treatment you receive. For the most part, medical treatments such as topical minoxidil are the first to be considered. Hair transplantation is an option if you have advanced hair loss and a good, stable supply of healthy hair follicles at the back of your head.

The Ludwig scale aids the description of how advanced your hair loss is. It is not a diagnosis in itself and cannot predict your response to treatment.

What Is the Ludwig Scale?

The Ludwig scale is used as a guide to classify the extent of pattern hair loss in women. It was introduced by dermatologist Erich Ludwig in 1977, and it has three stages according to the amount of hair thinning seen over the top of the scalp.¹

Female pattern hair loss, also known as female androgenetic alopecia, is a progressive non-scarring form of hair loss. The follicles affected undergo a process called miniaturisation, whereby the hairs produced become thinner and shorter over time.²    

The Ludwig scale is useful for women as it better reflects a diffuse loss of hair over the central scalp, with the frontal hairline typically being preserved. If your pattern of hair loss doesn’t fit the Ludwig scale, you may be measured against a different scale that resembles your hair loss pattern more closely. 

The Ludwig Scale Stages

Although it is presented in three stages, naturally hair loss exists as more of a continuum. The amount of scalp you can see changes with wet hair, strong overhead lighting, hair colour, the thickness of individual strands, and styling. For that reason, we suggest you use the descriptions as a guide rather than a definitive way of diagnosing yourself.

Ludwig I (Mild) 

In Ludwig I, your hair coverage remains good. You may notice a slight thinning of hair on the crown of your head, and your central hair parting may also look wider than it used to.

You might detect:

• Less hair volume when tied or styled
  
• A bit more scalp visible under bright overhead light
  
• A parting that looks wider in photos
  
• Shorter, finer hairs mixed with longer strands.

At this stage, changes are often barely noticeable. A great way of measuring the change of your hair is to take consistent photographs over time. This saves you a lot of stress and anxiety compared to constantly checking in different mirrors under changing lighting.

Ludwig II (Moderate) 

In Ludwig II, the thinning is further advanced. The parting is visibly wider, density is reduced, and more scalp can be seen through the hair.

You might find that changing the way your hair parting sits no longer works to cover thinning patches. You may need to use styling products or hair fibres to cover areas you previously managed to hide well without them. The frontal edge of hair often remains, but you will notice the hair immediately behind it has thinned.  

Ludwig III (Advanced)  

In Ludwig III, your scalp is visible over a broad area on the top of your head. The frontal hairline is normally spared. The scalp is easily visible in typical lighting conditions even after your best attempts at styling. A separate assessment will be needed to find out how much hair you have available at the back and sides of your head should you wish to consider hair transplantation. 

How Is Female Pattern Hair Loss Assessed?

The first goal of assessment is to confirm the cause of your hair thinning. The exact pattern and the extent of your hair loss is noted.

You will typically be asked about:

• when the thinning began and whether it was gradual or sudden
  
• increased shedding, recent illness, surgery, childbirth, weight change or significant stress
  
• your menstrual pattern, menopause, acne or increased facial and body hair
  
• medical conditions, medicines, supplements and family history
  
• restrictive diets, heavy periods and symptoms that could suggest iron or thyroid problems
  
• hairdressing practices, chemical treatments and styles that place tension on the hair

The density of your scalp hair will be inspected. This includes a look at the site where hair may be taken for transplantation (donor zone). Checks are made for redness, scaling, bumps, broken hairs, or a shiny scalp. This allows the doctor to rule out any additional causes of hair loss. 

Trichoscopy should be performed. This is where your scalp is examined with a hand held magnifying device. It allows for a closer inspection of variation in hair thickness and length. A small sample of your scalp (biopsy) may be taken to look for inflammation present at a microscopic level.

Blood tests can help when an underlying problem is thought to be responsible for the hair loss. The tests will measure things such as your iron stores and certain hormone levels. Women with pattern hair loss tend to have blood results in the normal range.³

Can Female Pattern Hair Loss Be Reversed?

Your hair loss is unlikely to be completely reversed. It can be slowed with the appropriate care. Try not to judge your progress only by obvious regrowth. If your hair remains stable and you prevent future thinning, you might consider that a successful outcome.

Treatment Options by Stage 

Treatment will be guided by your Ludwig stage, the rate of change of hair loss, your scalp health, your previous medical history, and pregnancy plans (if you are premenopausal).

In our experience, mild to moderate cases of hair loss respond best to medical therapies such as minoxidil. If you have advanced hair loss and meet the criteria, transplantation can be a valuable additional option.

Medical treatment (all stages, first-line) 

Medical treatments show benefits regardless of your Ludwig stage. 

Topical minoxidil

Topical minoxidil is the current best medicine available for reducing female pattern hair loss. When applied regularly to the scalp, it can slow the rate of hair loss and may even lead to a slight improvement of hair growth.^4,5 The main side effects are scalp irritation, unwanted facial hair, and a temporary increase in hair shedding when you first start treatment.

Oral minoxidil

Oral minoxidil can be prescribed if you are not showing benefit from topical treatment or you are experiencing local side effects where you apply the foam. It has less evidence behind it than the topical form. It is currently prescribed off-label and requires assessment by a doctor as it has side effects such as dizziness, swelling, and changes in blood pressure. For most women, the oral version of Minoxidil isn’t the best option as it can cause unwanted excessive facial hair growth. 

Spironolactone

Spironolactone is an androgen blocking medication that may be considered when your hair loss is a result of high androgen levels in your circulation. It is used off-label for female pattern hair loss. The evidence is mixed for its use, with studies showing benefit for some women. Response to this medication varies; therefore, it is not used ahead of topical minoxidil.⁶

Finasteride, dutasteride 

Finasteride and dutasteride both reduce the formation of dihydrotestosterone, an androgen that is known to cause pattern hair loss in men. The role of DHT in female pattern baldness is not as clear. The evidence for finasteride and dutasteride is also weak relative to other medications out there.^7,8

Spironolactone, finasteride and dutasteride are not licensed in the UK specifically for female pattern hair loss. Finasteride and dutasteride can harm the growth of a male foetus. As a result,  they cannot be used during pregnancy or if a patient plans on becoming pregnant soon.

You need to be on reliable contraception if there is a chance you may become pregnant and are using these medications. Discuss with your doctor if you are pregnant, breastfeeding, or planning a pregnancy before starting any hair loss medicines.^8,9,10

“Working with our Dermatologist colleagues, we often see our female patients taking a combination of treatments to treat their hair loss. It is uncommon for them to only use Minoxidil to help manage any stage of hair loss in the Ludwig scale.” 

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

• Early-stage focus (Ludwig I–II) 

Starting treatment during Ludwig I and Ludwig II provides the best chance at keeping your hair dense, as at this stage, you have more follicles that are active and productive. The aim is to keep your existing hair as well as seeking hair thickening.²

Underlying factors that cause hair loss should be dealt with. Iron deficiency, thyroid disease, significant calorie or protein restriction, and hormone disorders can cause additional shedding and slow recovery. Supplementation should only be taken when a deficiency has been demonstrated.^3,11

• Advanced-stage considerations (Ludwig III) 

Medical treatment still has a role in Ludwig III as it can protect the remaining hair. Medical treatments alone, however, will not afford you a large visible increase in hair. Stabilising the hair loss and adding some thickening is a reasonable expectation.

A hair transplant can be carried out on women where the diagnosis is secured, the hair loss is either stable or being medically managed, and the site where we take hair for transplanting at the back of the head has enough density and thickness to allow extraction, without leaving it looking visibly depleted.^12,13

• Realistic expectations 

There is as yet no cure for female pattern hair loss. Treatments discussed here may be able to maintain your current density, reduce shedding and perhaps offer partial thickening of your hair. It is unrealistic to expect your hair to return to its previous full density. 

Results can take many months to materialise. Inspecting your hair every day can cause you unnecessary added stress and anxiety. Instead, it is best to measure your progress through consistent photographs, which are much more reliable.

Benefits that you may see from treatments are generally lost over time if you stop taking medical treatments, after which your hair loss will resume its natural course.^2,14

Treatment may still be worthwhile if it prevents hair you would have otherwise lost from falling out, even if you don’t manage to see increased hair density, 

Can You Have a Hair Transplant for Female Pattern Hair Loss?

Yes, hair transplantation may present a great option for some women. Your suitability will be judged by a careful diagnosis of your hair loss and assessments made of the donor region of your scalp.

A suitable candidate will typically have:

• Confirmed non-scarring diagnosis
  
• Sufficient, stable donor hair at the back or sides of the scalp
  
• Minimal donor-area miniaturisation
  
• Stable or controlled hair loss
  
• Enough spacing to place grafts safely
  
• Realistic expectations about coverage
  
• No medical or scalp conditions that make surgery unsafe

The surgeon carrying out the transplant will examine your scalp under magnification to estimate the density, thickness, and presence of miniaturisation in both the region from which hair is being taken from and that which it is being transplanted to. 

A transplant redistributes existing hair follicles; it does not create new ones or stop female pattern hair loss. Surgery is often in conjunction with medical treatments such as minoxidil to continue to counteract hair thinning.^12,13,15

When to Seek Help

Seek help if you have a persistently widening hair parting, reduced crown density or a clear change in your normal hair volume.

Seek advice more promptly if you have: 

• sudden or rapidly accelerating hair loss
  
• smooth patches
  
• scalp pain, burning, marked itch, redness, heavy scale, crusting or pustules
  
• shiny areas where follicular openings are no longer visible
  
• eyebrow loss or hair loss elsewhere on the body
  
• new facial hair, severe acne, irregular periods or other signs of androgen excess
  
• fatigue, weight change, heavy periods or other symptoms that may suggest an underlying health problem
  
• significant distress or anxiety related to the hair loss

A GP can assess your general health and arrange for appropriate blood testing if necessary.

Conclusion

The Ludwig scale is a practical way to describe mild, moderate and advanced pattern hair loss in women. It is not, however, intended to be used for self diagnosis. A proper assessment by your doctor can help you find the underlying cause of your hair loss and help you move towards the right treatment.

Medical treatment gives you the best opportunity to maintain your existing hair. In certain women, hair transplantation can be a good option to improve appearance, but only after certain criteria of diagnosis, stability, donor density, and long term expectations are favourable for transplantation. Regardless of Ludwig stage, your GP should be the first point of contact for a thorough assessment. 

References 

1. Ludwig E. Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex. Br J Dermatol. 1977;97(3):247–254. doi:10.1111/j.1365-2133.1977.tb15179.x. 
   
2. Starace M, Orlando G, Alessandrini A, Piraccini BM. Female androgenetic alopecia: an update on diagnosis and management. Am J Clin Dermatol. 2020;21(1):69–84. doi:10.1007/s40257-019-00479-x. 
   
3. Carmina E, Azziz R, Bergfeld W, Escobar-Morreale HF, Futterweit W, Huddleston H, et al. Female pattern hair loss and androgen excess: a report from the Multidisciplinary Androgen Excess and PCOS Committee. J Clin Endocrinol Metab. 2019;104(7):2875–2891. doi:10.1210/jc.2018-02548.
   
4. van Zuuren EJ, Fedorowicz Z, Schoones J. Interventions for female pattern hair loss. Cochrane Database Syst Rev. 2016;2016(5). doi:10.1002/14651858.CD007628.pub4.
   
5. British Association of Dermatologists. Hair loss: female pattern (androgenetic alopecia) [Internet]. London: British Association of Dermatologists; updated 2024 Oct [cited 2026 Aug 7]. Available from: https://www.bad.org.uk/pils/hair-loss-female-pattern-androgenetic-alopecia.
   
6. Werachattawatchai P, Khunkhet S, Harnchoowong S, Lertphanichkul C. Efficacy and safety of oral spironolactone for female pattern hair loss in premenopausal women: a randomized, double-blind, placebo-controlled, parallel-group pilot study. Int J Womens Dermatol. 2025;11(3). doi:10.1097/JW9.0000000000000227.
   
7. Price VH, Roberts JL, Hordinsky M, Olsen EA, Savin R, Bergfeld W, et al. Lack of efficacy of finasteride in postmenopausal women with androgenetic alopecia. J Am Acad Dermatol. 2000;43(5 Pt 1):768–776. doi:10.1067/mjd.2000.107953.
   
8. Ong MM, Avram M, McMichael A, Tosti A, Lipner SR. Antiandrogen therapy for the treatment of female pattern hair loss: a clinical review of current and emerging therapies. J Am Acad Dermatol. 2025;93(3):749–760. doi:10.1016/j.jaad.2025.04.074.
   
9. Organon Pharma (UK) Limited. Propecia 1 mg film-coated tablets: Summary of Product Characteristics [Internet]. Electronic Medicines Compendium; updated 2026 Jul 14 [cited 2026 Aug 7]. Available from: https://www.medicines.org.uk/emc/product/2194/smpc.
   
10. GlaxoSmithKline UK. Avodart 0.5 mg soft capsules: Summary of Product Characteristics [Internet]. Electronic Medicines Compendium; updated 2024 Oct 7 [cited 2026 Aug 7]. Available from: https://www.medicines.org.uk/emc/product/6758/smpc.
    
11. Müller Ramos P, Melo DF, Radwanski H, de Almeida RFC, Miot HA. Female-pattern hair loss: therapeutic update. An Bras Dermatol. 2023;98(4):506–519. doi:10.1016/j.abd.2022.09.006.
    
12. True RH. Is every patient of hair loss a candidate for hair transplant? Deciding surgical candidacy in pattern hair loss. Indian J Plast Surg. 2021;54(4):435–440. doi:10.1055/s-0041-1739247.
    
13. Brinks AL, Needle CD, Kearney CA, Singh M, Carreño N, Osei-Tutu A, et al. Hair transplant: patient candidacy, medical optimization, and surgical considerations. Int J Dermatol. 2026;65(2):245–256. doi:10.1111/ijd.17961.
    
14. Takwale A, Arthur E, Pearce J, et al. A practical guide to the standardisation of hair loss photography for clinicians. Clin Exp Dermatol. 2025;50(3):564–572. doi:10.1093/ced/llae341.
    
15. Queen D, Avram MR. Hair transplantation in women. J Drugs Dermatol. 2025;24(9):851–855. doi:10.36849/jdd.8988.