Patient-Reported Hair Thinning
Woman reports gradual hair thinning; diagnostic evaluation begins here.
- Diffuse thinning: Chief complaint (patient reports overall volume loss)
- Gradual: Onset (months to years, not sudden)
- ~40%: Prevalence (women 50+) (increases steadily with age)
- Frequent: Family history (polygenic inheritance suspected)
Chief complaint intake
Patient notices a wider part and less volume.
Gradual onset favors pattern hair loss over effluvium.
History and exam basics
Ask about onset speed, shedding amount, family history.
Initial visual inspection
Note part width and crown density first.
Diffuse Crown Thinning & Preserved Hairline
Widened central part with crown thinning; frontal hairline stays intact.
- Diffuse: Crown thinning (vertex and crown affected)
- Preserved: Frontal hairline (key distinguishing feature)
- Widened: Part width (central part increases)
- Christmas tree: Pattern shape (triangular thinning zone)
The Christmas-tree sign
Wider anterior part tapering toward the back.
Hairline stays intact
Unlike male pattern loss, the frontal line rarely recedes.
Preserved hairline is the single most useful clue.
Miniaturization on exam
Trichoscopy shows varying hair shaft diameters.
Grading Severity on the Ludwig Scale
A 3-point visual scale grades diffuse crown thinning severity.
- Mild: Ludwig I (barely visible widening)
- Moderate: Ludwig II (noticeable diffuse thinning)
- Severe: Ludwig III (near-total crown involvement)
- 3-point scale: Staging tool (visual severity grading)
Grading severity
Ludwig scale ranks diffuse crown thinning from I to III.
Why staging matters
Guides treatment intensity and follow-up interval.
Photographic staging tracks progression over time.
Limitations of the scale
Does not capture part width or density directly.
Distinguishing FPHL From Look-Alike Causes
Compare pattern shape against effluvium and alopecia areata clues.
- Diffuse, sudden: Telogen effluvium (no localized pattern)
- Patchy, sharp: Alopecia areata (well-demarcated round patches)
- Recommended: Thyroid / iron labs (rule out reversible causes)
- Hairline + shape: Key discriminator (pattern vs diffuse vs patchy)
Ruling out telogen effluvium
Sudden diffuse shedding, no part widening pattern.
Ask about a triggering stressor 3 months prior.
Ruling out alopecia areata
Look for round, sharply bordered bald patches.
Laboratory workup
Check ferritin, TSH, and androgen levels.
Confirmed Diagnosis Guides Treatment
Pattern, staging, and labs align — treatment begins now.
- FPHL confirmed: Diagnosis (pattern and staging consistent)
- Minoxidil: First-line therapy (topical, twice daily)
- Spironolactone: Adjunct therapy (anti-androgen option)
- 6–12 months: Monitoring (photographic follow-up interval)
Confirmed diagnosis
Pattern, staging, and labs align with FPHL.
Treatment initiation
Start minoxidil; consider spironolactone if indicated.
Early treatment preserves more existing follicles.
Long-term follow-up
Reassess severity and adjust therapy over time.