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Norwood Type 4 Hair Loss
Norwood Type 4 Hair Loss
Men with Norwood type 4 hair loss usually have good, dense hair in the permanent zone, making them excellent candidates for hair restoration. It is essential to caution these patients that although the patterns of hair loss do not usually progress, there is always the possibility that progression could occur. Predicting whether the pattern of hair loss will progress in any given individual is crucial, as this will influence treatment planning. This paper describes the features of Norwood type 4 hair loss and reviews the literature concerning its etiology and treatment. It also presents the author’s experience with over 500 patients who have had surgical correction of this pattern with hairline lowering.
Androgenetic alopecia is a hereditary hair loss issue that affects both men and women. Men first experience a hairline recession, eventually leading to hair loss on the entire frontotemporal and vertex areas, leaving a characteristic horseshoe pattern. Women usually present with diffuse thinning over the crown. The Norwood-Hamilton classification system is used to classify the progression of alopecia in men, while the Ludwig classification system is used for women, grading hair loss from I to III with further subdivisions. This article will discuss the superficial aspects of these two classification systems due to their focus on a specific type of hair loss.
Extensive epidemiological studies report that up to 70% of Caucasian men and approximately 40% of women older than 70 years suffer from androgenetic alopecia. Scalp hair loss has significant adverse psychosocial effects and decreases quality of life. The only FDA-approved treatments for hair loss include minoxidil, finasteride, and hair transplantation.
Norwood Classification
Norwood type 4 hair loss is a distinct and significant hair loss pattern that affects a large number of men. It is the first stage of advanced or so-called ‘clear-cut’ balding. The Norwood type 4 pattern is defined by the bilateral, deep recession of the frontotemporal hairline at both the front and temporal areas. Although it preserves the forelock, it makes a patient appear markedly older, changing his facial appearance. The Norwood type 4 classification represents a bridge between the initial hair loss and the advanced, more extensive loss in the Norwood levels of 5 to 7.
What causes Norwood type IV hair loss?
Androgenetic alopecia is associated with an initial shortening of the hair growth cycle, the gradual production of finer and shorter hairs with each successive growth cycle, and a lengthening of the resting phase or telogen. These histologic changes are thought to progress in a caudad direction (from the anterior scalp towards the posterior scalp) and are believed to represent a functional alteration in hair cycle activity rather than simply a hair loss. This is why miniaturization is considered a more sensitive indicator of androgenetic alopecia than follicular dropout. Small bald areas can develop in androgenetic alopecia, not because the follicles have disappeared but because the miniaturized vellus hairs are no longer long enough to reach the skin’s surface.
Norwood type IV hair loss represents an advanced stage in the progression of androgenetic alopecia. Men with type IV loss typically have significant hair loss above the temples and in front of the anterior subline. In the Disease Patterns of the Visual Skin Diagnosis: An Interactive Atlas by Jean Bolognia and Scott Schaffer, this is referred to as a “full military frontal” pattern from the time of Napoleon. The hair loss at the front usually advances more profoundly into the forelock area than in the type III pattern. Hair loss at the vertex may be minimal, or a few wisps of miniaturized hair may be mixed in with the more prominent, permanent hairs still present.
Effects Genetic
A plethora of factors contribute to the onset of Type 4 hair loss. Poor genetics are the primary cause, accounting for over 95% of cases. Hormonal disorders and stress can also contribute to hair loss. A poor lifestyle, including an unhealthy diet and lack of crucial nutrients, can exacerbate hair loss, as can damage from ultraviolet (UV) radiation, pollution, and the continual use of harsh hair chemicals and heat on the hair. It is essential to identify risk factors to devise an appropriate treatment plan to reverse Type 4 hair loss.
Type 4 hair loss is a primary genetic disorder with a long-term pattern of progressive hair loss. It is traditionally described in men, progressing from the anterior mid-scalp to the vertex and subsequently to the anterior hairline, culminating in horseshoe-pattern hair loss. Type 4 hair loss is primarily a presentation of androgenetic alopecia (male-pattern hair loss) and is caused by the miniaturization of hair follicles in response to androgens, the body’s naturally occurring male sex hormones, namely testosterone. Dihydrotestosterone (DHT) is an androgen and the primary hormone responsible for hair loss. In genetically predisposed men, the effect of DHT on susceptible hair follicles causes gradual hair thinning and a decrased hair growth period, eventually leading to hair loss.
Hormonal Disorders
Research in this field has shown that hormonal balance is linked not only to the loss of hair on the scalp but also to its regrowth. It was found that men with elevated levels of estrogen regain hair more quickly than those with normal estrogen levels. Estrogen is the female hormone that inhibits the development of male characteristics and counteracts the effects of testosterone on the scalp. This is why some women with an imbalance in estrogen levels begin to develop Norwood type 4 hair loss. Treating such patients with estrogen replacement therapy will usually stop the process of hair loss and may even promote regrowth.
Testosterone is the male hormone, as it is responsible for developing male characteristics. When testosterone reaches the hair follicles, it is converted to dihydrotestosterone (DHT) by an enzyme called 5-alpha reductase. DHT is a highly potent hormone that binds to the hair follicles, gradually miniaturizing them and ultimately causing them to fall out. It was previously thought that elevated testosterone levels caused hair loss, and indeed, some men with Norwood type 4 hair loss initially experience raised testosterone levels. However, further research showed that the increased level of DHT in the bloodstream causes hair loss. Men with higher DHT levels are more likely to lose hair on the scalp, while men with lower DHT levels will generally have hair growth in this area. This discovery led to the development of several medications that prevent hair loss by blocking DHT.
Hair loss from any etiology may represent a cosmetic concern with varying degrees of psychological impact on affected patients. Those who present with complaints and symptoms of itch, burning scalp, or painful scalp, especially with associated erythema or scaling, need to be evaluated for other inflammatory conditions. It is essential to differentiate between scarring versus non-scarring alopecia. A more thorough traction response might also be necessary. The patient’s general medical history and use of medications, supplements, or anabolic steroids should also be included during the evaluation of both men and women who present with hair loss.
Norwood type IV presents with varying degrees of frontotemporal and frontal bitemporal recession. Therefore, the proper examination of these patients is critical. In the modern dermatology and cutaneous surgery era, history taking and physical examination of patients complaining only of unsightly hair loss may be brief and hurried. However, we should be aware and reminded of the importance and potential negative impact of an incomplete consultation.
Symptoms represent the patient’s subjective experience, whereas the signs represent the paradoxical change in the physical appearance of the affected patient. The patient’s symptoms usually begin with frequent complaints regarding increased hair shedding while performing his daily hair grooming or washing. This is prompted by worsening hair thinning on the top of the head, as the frontotemporal and frontal hairline remains stable in most patients for some time.
These symptoms can clearly worsen the patient’s quality of life, even going as far as causing depression in patients with more severe symptom expression. Therefore, addressing these symptoms and treating the patient is vital, not just his hair loss. The physical sign of increased hair shedding or decreased hair density on top of the head, as reported and observed, will be the earliest physical sign of Norwood type IV progression. This represents a relatively insensitive sign, as patients typically lose 50% of the hair population on top of the head before noticing or presenting with complaints. Since this is a visual sign, it will be detected only when the patient’s hair is observed by others. Observing the hair in wet or transmitted light will be more sensitive than the patient’s dry hair observation.
How can you get your hair back?
Treating Norwood type 4 hair loss can be an effective way to restore a patient’s natural hairline. Small changes in the positioning of the hairline can affect the appearance of the face and the overall cosmetic result. It is essential to provide patients with subtle and natural-looking results while ensuring they are satisfied with the treatment’s outcome.
Surgical options include hair transplantation. Hair transplantation can be completed using the follicular unit or the follicular unit extraction method. Both methods allow for natural results. Discussing their desires, expectations, and possible outcomes with patients is essential to help them choose the best treatment option.
Norwood type 4 hair loss is often the first stage in which patients seek medical treatment, as it is visually apparent. Many options exist to help treat Norwood type 4 hair loss medically and surgically. Medical treatment often involves minoxidil, finasteride, low-level laser therapy, or hair transplantation. Minoxidil is a topical over-the-counter medication that can promote hair growth. Finasteride is an oral and topical(spray form) prescription medication that can prevent further hair loss. Low-level laser therapy can also prevent further hair loss and promote hair growth.
Possible Medical Treatments
Apart from the two FDA-approved medications, there are many other over-the-counter or prescription options that patients with Norwood 4 hair loss can use. Such options include oral dutasteride, topical finasteride, low-level light therapy, ketoconazole, and others. Recently, there has been an increase in the use of platelet-rich plasma and other regenerative hair treatments for androgenetic alopecia. The technology surrounding hair loss treatment is rapidly evolving, and many patients are willing to experiment with various treatment options to achieve hair regrowth while minimizing side effects. This chapter will discuss current and emerging pharmacological interventions and their supporting evidence for treating Norwood type 4 hair loss in men. Be aware that many treatments discussed in this chapter are off-label unless expressly stated.
The Food and Drug Administration (FDA) has approved two pharmacological options for treating androgenetic alopecia in the United States: topical minoxidil and oral finasteride. Minoxidil is a potassium channel opener (first used to treat high blood pressure) that is thought to prolong the anagen phase of the hair cycle. It is available over-the-counter, and do not have side effects other then irritation or allergic contact dermatitis. Finasteride is a competitive inhibitor of type II 5α-reductase, which inhibits the conversion of testosterone to the more potent dihydrotestosterone. It is approved for use in men only and has documented sexual side effects, which are likely under-reported. The efficacy and safety of finasteride in the treatment of male androgenetic alopecia are currently under scrutiny, and some men are seeking natural alternatives to it.
Hair Transplantation
Because of the low position of the type IV forelock, it is usually possible to excise it and lower the hairline further. This excisional technique is seldom used today because it can produce an unnatural result and does not treat the patient’s bald area; the patient usually wants it treated as the primary focus. The excisional technique became unpopular with the advent of hair transplantation and is rarely performed by hair restoration surgeons. Sometimes, the combination of excising the forelock and advancing the hairline is performed in two separate maneuvers. This combination provides better results because the hairline does not appear to be abruptly terminated.
Understanding and treating Norwood Type 4 hair loss involves four surgical options:
- The simplest surgical option is to extend the hairline combined with hair transplantation into the mid-scalp and crown.
- The forward extension of the hairline and enhancing the mid-scalp density with transplantation are slightly more complicated.
- The hairline advancement flap is a more complex surgical maneuver that advances the hair-bearing skin of the upper forehead without a visible scar.
- Tissue expansion of the upper scalp is a significant procedure that recruits available laxity in the scalp to provide hair-bearing skin to correct large areas of alopecia.
Given the high demand and excellent cosmetic outcomes of modern hair transplantation, the dermatological surgeon needs to understand the evaluation and treatment of Norwood type 4 hair loss. As hair restoration suergeries continues to evolve, a collaborative approach between dermatologists and dermatological surgeons will allow for the best outcomes for the patients we treat. With the increasing interest and demand for hair restoration, dermatological surgeons must understand the full spectrum of medical and surgical treatments for patients with this hair loss pattern.
Norwood type 4 hair loss represents one of the crucial landmarks in established genetic pattern hair loss in men. To effectively address patient concerns, it is essential to have an in-depth understanding of medical and surgical treatments. Patients are interested in medical and surgical options and are motivated to seek effective treatments. Medical management options can offer modest and variable benefits that ultimately do not satisfy the long-term expectations that patients desire and are readily achievable with hair transplantation.