Receding Hairlines

Receding hairline is usually the first indication of pattern baldness in men. In androgenetic alopecia, the recession typically is noticed first in the temporal areas.

As the hair loss progresses, thinning of hair towards the vertex takes place and the Norwood scale can be used to grade the extent of baldness.

In women, a receding hairline is usually the result of conditions other than androgenetic alopecia, like frontal fibrosing alopecia and traction alopecia.

Treatment in the early stages includes medications and non-surgical hair restoration techniques like platelet-rich plasma. Advanced cases often require hair transplant surgery. In this article, we will discuss the causes, stages, and treatment options for receding hairlines in detail.

What is a receding hairline?

Receding hairlines is a common type of hair loss, especially in men. Hair thinning and loss starts at the frontotemporal regions and gradually extend backward to involve the crown of the head.

A related condition that needs to be distinguished is the maturing hairline. Here, the hairline changes after puberty, attaining a higher position and exposing more of the forehead and temples. This is a physiologic process and almost universal in men. Receding hairline, on the other hand, is a classic feature of androgenetic alopecia in men. It can affect both men and women but the underlying causes are different between the two.

In men

There is no single type of hairline that is considered the natural hairline for men. Some have a low-lying while others will have a middle or high hairline and all are normal. Broadly speaking, however, many adult men have a more or less M-shaped frontal hairline.

In androgenetic alopecia, as they age, the hair at the temples starts receding followed by hair thinning at the vertex and recession at the front leading to a higher hairline, which may eventually progress to complete baldness.

The age at which hairline recession occurs varies between men but most of them will have a noticeable change in their hairline by their mid-thirties. Over the age of 50 years, more than 80% of men have some evidence of hairline recession. Apart from male-pattern baldness, traumatic hairstyles can lead to a receding hairline which is reversible, at least early in the disease.

In Women

Receding hairline is not a common feature of pattern baldness in women. Instead, there is thinning of the hair over the scalp, with widening of the part.

Hair loss conditions that do lead to a receding hairline in women include frontal fibrosing alopecia, traction alopecia, telogen effluvium, and trichotillomania. Traction alopecia is associated with certain hair care practices and is particularly common in African women. Telogen effluvium is the shedding of a large number of hairs due to stressful conditions like acute illness. Trichotillomania is a psychiatric condition in which hair loss occurs due to impulsive pulling. 

When does receding hairlines occur?

Hairline recession is common in men as they age. Early signs may be noticed as early as the late twenties or even before that. Teenagers, at 18 or 19, have been reported having a hairline recession. By the time they reach 80 years majority of men have significant hair loss.

In women, the hairline recession may not be noticeable till late in cases of androgenetic alopecia, as generalized hair thinning is the main pattern of hair loss. Frontal fibrosing alopecia results in a receding hairline and mainly affects post-menopausal women. In children, hairline recession can occur due to traction alopecia, caused by tight braids or other traumatic hairlines which damage the hair mechanically.

Symptoms

To begin with, not everyone has the same hairline and this can affect how the appearance of the hairline changes as hair loss progresses.

Various levels for men’s hairlines are the middle hairline, low hairline, or less commonly, the high hairline. A naturally occurring high hairline may be confused with a receding hairline when in fact there is no hair loss in the former. Variations on the common patterns include a cowlick hairline, where a swirl of hair grows in a direction different than the surrounding hair, and an uneven hairline.

Early signs of a receding hairline: Hair loss is often noted first at the temples. This creates the triangular bald areas characteristic of male pattern baldness, on either side at the front. Hair in the affected areas is miniaturized and hair density is significantly decreased. Initially, the thick, mature hair that is lost is replaced by fine villous hair, which, too, is shed later on. Itching or scalp skin changes are not present in androgenetic alopecia and point towards inflammatory causes or infection of the scalp.  In some cases, frontal receding hairline is more prominent than temporal hair loss.

Late signs of hairline recession: Further recession of the hairline is usually accompanied by hair thinning at the vertex in the cases of androgenetic alopecia. A rim of hair around the vertex remains on the scalp in the later stages of patterned baldness. In cases with frontal-fibrosing alopecia, the hairline recession starts at the front with scarring of the scalp and progresses backward creating a high hairline.

Complete baldness: In many but not all patients, androgenetic alopecia eventually progresses to complete baldness where only a horseshoe-shaped patch of hair remains on the back of the head. This extent of hair loss is classified as Norwood 7 (the Norwood scale is described below).

Stages

Receding hairline due to patterned hair loss is a gradual process. The extent of hair loss is graded according to the Norwood scale.

There are seven stages in the Norwood scale starting from Norwood I which describes mild to minimal hair loss and ends at Norwood VII which defines complete baldness. A quick description of the stages is as follows:

• Norwood type I: At this stage, there is minimal to no recession of the hairline.
• Norwood type II: Mild thinning of the hair is apparent at the frontal-temporal hairline.
• Norwood type III: There is deep recession of the hairline which may or may not be accompanied by hair loss at the vertex.
• Norwood type IV: Recession of hairline deepens but a band of hair separates the bald patches at the front and the vertex.
• Norwood type V: The hairline recedes further, reaching the midline on the scalp. The band of hair between the frontal hairline and the bald patch at the vertex turns into a thin strip.
• Norwood type VI: This is an advanced stage of hair loss. The receding hairline extends enough to join the bald area of the vertex.
• Norwood type VII: This equates to complete baldness. Most of the scalp has lost hair, with only a U-shaped hair-bearing area remaining at the back of the head.

Causes

Many conditions can lead to hair loss manifesting as a receding hairline. Androgenetic alopecia or patterned baldness is the most common one, especially in men, as has been mentioned above. Male-pattern baldness occurs due to the effects of the hormone, DHT (dihydrotestosterone).

Androgenic hormone-related mechanisms are likely involved in female-pattern baldness too but the scientific basis is less clear. Patterned baldness in women can occasionally present with a receding hairline. Other causes include lifestyle measures, medications, scalp infections, and inflammatory diseases.   

Genetics

Androgenetic alopecia in men has a strong hereditary component. Research has shown that in people with noticeable balding, more than 80% had a history of hair loss in their fathers.

Initially, it was thought that patterned hair loss is due to the inheritance of a single gene. Later, it was established that the hereditary pattern is polygenic. Researchers have identified more than sixty genes that play a role in the inheritance of susceptibility to baldness. Many of them are located on the X-chromosome. Genetic factors probably play a role in female pattern hair loss too, but the involved genes appear to be different than the ones implicated in male pattern baldness.

Lifestyle

Haircare practices are an important determinant of the overall health of hairs. Traumatic hairstyles may put more pressure on a specific subset of hair follicles leading to mechanical damage and hair loss. Tight ponytails and braids if worn for long enough can lead to traction alopecia, presenting as a receding hairline. Chemical relaxers may make the hair more susceptible to damage. Similarly, repeated usage of heat (flat irons, blow dryer, etc.) makes the hair dry and brittle. Some hair types are more prone to mechanical damage. For instance, the incidence of traction alopecia is more common in women of African ethnicities partly because of the shape of their hair follicles which makes them more susceptible to the effects of mechanical factors.

Disease and infections

Medical conditions associated with receding hairline include:

• Frontal fibrosing alopecia: It is an inflammatory condition mainly affecting post-menopausal women and predominantly involving the frontal hairline.
• Alopecia areata: An autoimmune condition that leads to the appearance of discrete bald spots on any area on the scalp, including the frontotemporal hairline. It may affect body hair as well, like the eyebrows and beard.
• Infections: Tinea capitis is a fungal infection of the scalp which can lead to hair loss in the affected area.
• Other Conditions: Hair loss may be a feature of lupus (SLE), thyroid abnormalities, and other hormonal disorders. Chemotherapy drugs are known to cause reversible hair loss.

Prevention

Of the factors that may lead to receding hairlines, some are modifiable while others are not. Genetic susceptibility, for instance, is not amenable to corrective measures. Nonetheless, healthy lifestyle measures are important to improve overall hair health.

Some such measures that can help prevent hair loss include:

• Diet: A balanced diet is vital for overall health including that of the hair. There is no substantial scientific evidence to support a specific diet for hair loss prevention. A recent study ¹, however, found that the use of vegetables and fresh herbs (called the Mediterranean diet) may reduce the risk of androgenetic alopecia. Certain nutrients are known to be important for hair growth including proteins, vitamin A, vitamin D, biotin, and the micronutrients zinc and selenium. Adopting a diet providing sufficient quantities of these dietary components is likely to promote hair health. Other studies have found the use of saw palmetto and ginseng beneficial for hair growth. It is advised to consult your doctor before starting supplements.
• Haircare practices: The role of traumatic hairstyles in traction alopecia (TA) has been discussed above. Hairstyles that increase the risk of TA include tight ponytails or braids, cornrows, dreadlocks, use of headbands, and hair extensions. Other harmful practices include the use of chemical relaxers and heat treatment. If you are wearing hair extensions, use them for short periods. Regular washing and the use of coconut or olive oil have been found helpful in some studies. Adopting gentle hairstyles, changing hairstyles frequently, and wearing your hair naturally can help prolong their life.
• Early identification and treatment: Prevention and corrective measures are more likely to be effective when started early. When detected early, a receding hairline may be managed with medications like minoxidil and finasteride. An early consultation is also useful to identify causes other than androgenetic alopecia, which if left untreated for long may result in scarring of the scalp and irreversible hair loss.

Treatment

The treatment of a receding hairline depends on the underlying cause of hair loss. As the most common one is androgenetic alopecia, we will discuss that in detail.

Early androgenetic alopecia is treated usually with medications. If severe, other options include minimally invasive techniques like PRP. Micropigmentation, an aesthetic solution, is another option. Hair transplant will be required in cases with significant baldness that are unlikely to respond to non-surgical treatment options.

Medical treatments

Medications that are known to prevent hair loss and restore hair include Finasteride and Minoxidil. These two are the most commonly used drugs for less advanced androgenetic alopecia, i.e., Norwood type I to III/IV.

• Finasteride: It blocks the formation of DHT, the hormone responsible for androgenetic alopecia in men. It is a prescription medicine taken orally and approved for use in men with male-pattern baldness. It prevents hair loss and results in the regrowth of scalp hair. The effects of Finasteride, however, last as long as the drug is in use.
• Minoxidil: The drug is available for topical application, sprayed twice daily over the scalp or applied as a foam. 2% and 5% solutions are available. Like Finasteride, it stops further hair loss and leads to hair growth. It is FDA-approved for androgenetic alopecia and female-pattern hair loss. Hair shedding recurs within 3-4 months when the medication is stopped.
• Other medications: Hair loss due to immune-mediated or inflammatory conditions may be treated with corticosteroids, either topical or oral. Fungal infections will require treatment with anti-fungal medications.

It is important to realize that medications may have adverse effects and if you have certain medical conditions, they should be discussed with your treating physician before starting any new medicine.

Hair transplants

Medications are effective in patients with receding hairlines but their effects wear off as soon as they are stopped. Moreover, patients with extensive hair loss may not respond to medical treatment. Hair transplant is a widely used hair restoration procedure for such patients with long-lasting results. Timing is an important consideration for patients with receding hairlines who want to undergo hair transplantation. Doing a hair transplant on a hairline that hasn’t stabilized and continues to recede may result in an unnatural look as the hair behind the transplanted area is shed.

 Commonly used surgical techniques include follicle unit extraction (FUE), follicle unit transplant (FUT), and direct hair implant (DHI).  In FUT, a strip of hair follicles is cut from the donor area, usually the back of the head, and the follicles are then implanted into the bald area. In FUE, individual follicles rather than a whole strip are harvested. It is the most commonly used hair transplant technique currently. DHI is a modification of FUE.

Hair transplant is performed under local anesthesia. The results are good with more than 90% of implanted follicles surviving in many reported studies. The procedure is performed by qualified dermatologists or plastic surgeons. Being minimally invasive it is generally safe. A suitable donor area is required from which enough follicles can be harvested. Hair at the back of the head is a common donor site. The number of grafts required depends on the extent of hair loss. Norwood type II hair loss may require 500-800 grafts while advanced baldness (Norwood VI/VII) can take 5000 or more grafts. Complete hair restoration after a transplant takes 9-10 months.

Home remedies and other treatments

Platelet-rich plasma (PRP): PRP contains various growth factors and cytokines that promote the healing and growth of body tissues including hair follicles. It is an autologous preparation of platelets and is generally safe with occasional allergic reactions. Local injections of PRP are used in many conditions including hair loss, arthritis, and muscle injuries. In patients with receding hairlines, PRP when used in the earlier stages can halt the progression of hair loss and restore hair leading to a fuller head.

Scalp micro-pigmentation: It is a cosmetic procedure and more suitable for patients with hair thinning than obvious baldness. Small dark dots are tattooed over areas of hair thinning on the scalp to give the appearance of a fuller head.

Stem cell treatment: Stem cells retain the ability to transform into many types of specialized body cells given a suitable tissue environment. Stem cell-based therapies have mainly been used in patients with receding hairlines due to patterned hair loss. The cells, collected from adipose tissue, bone marrow, or healthy hair follicles, are transplanted into the areas of hair loss where they transform into hair follicles.

Home remedies and alternative medicine approaches: Various natural remedies and alternative medicine approaches are being used for hair growth, many of them without concrete scientific evidence. Some of the popular ones are amino acids (cysteine and lysine), capsaicin, biotin, garlic gel, rosemary oil, and acupuncture.