Introduction
“What gets measured gets improved.”
A wise quote that often gets attributed to Peter Drucker—one of the founders of modern management theory.
He may, or may have not actually said these words, but the principle still applies:
Regardless if you’re in charge of running a company, you’re managing your personal finances, or you’re keeping track of your progress in the gym, measurement is absolutely critical.
This becomes especially true when we’re dealing with a highly subjective—and emotionally charged—matter, such as your painful divorce with your hair.
When trying to keep track of your progress in the battle against hair loss, the mirror becomes completely unreliable.
Like a mirage in the dessert, the mirror will begin to have a mind of its own, and will tell you a different story each and every day you gaze into it, seeking answers for your hair-gaining quest.
Some days you’ll be thinking that your hair loss is not that bad, and perhaps you’ve even made some progress!
Other days will be characterized by anxiety, fear, and the feeling of impending doom, thinking that B day (baldness) may come sooner than expected during this war.
Our personal self-image will vary greatly, depending on a myriad of variables, such as our mood, how well we’ve slept that night, how is life going in general, and so on.
If we want to have any amount of clarity and understanding of the severity of the problem, we need to bring statistics into our hair loss prevention journey.
We need a clear, objective, repeatable tool that we can use to determine whether we’re losing or reclaiming ground—and how quickly is happening.
Armed with this objective knowledge, we can then modify our approach or pivot our strategy as necessary, to get closer to the goal of regaining and maintaining the best hair that we can have.
📝Table of Contents
- The Norwood Scale
- Real life balding examples
- How to use the Norwood scale
- Fine tools of measurement
- Conclusion
The Norwood Scale
Created during the 1950s by James Hamilton, and revised in the 1970s by O’Tar Norwood, the Hamilton-Norwood scale (or simply the Norwood scale) has been the gold standard classification system used by clinicians worldwide to diagnose their balding patients.
This scale describes a simple 7-stage balding model, based on the severity of the hair loss.
The first stage, Norwood 1, is the control group, which has a full head of hair and no signs of baldness. At the other end of the spectrum, we have Norwood 7, which describes a man that has lost all his hair—except for a tiny strip on the back of the head.
Male pattern baldness, as its name implies, evolves in a highly predictable and reproducible pattern: starting with the hairline receding at both temples, followed by a bald spot on the vertex, and ultimately resulting in the balding of the entire head on the top.
Not all cases of baldness are due to androgenic alopecia, and not all cases of androgenic alopecia will follow this pattern down to a T, but most of them will.
By understanding your current level of hair loss as described on the Norwood scale, you will gain insight on what the future may hold, what are your options when it comes to hair loss prevention, and you will be able to make an educated decision moving forward with your treatment plan.
✅ Norwood 1
Completely unaffected by hair loss.
The hair is thick and dense, and there are no visible signs of recession. The hairline is low, and forms a straight, or almost-straight line, giving the hairline a square appearance.
This is the hair most of us had during our high school days—a ship that, in all likelihood, has sailed a long time ago. Being typical for teenagers that are completely unaffected by male pattern baldness, NW 1 is sometimes called the “juvenile hairline”.
The vast majority of men, with very few exceptions, will not keep this much hair past their adolescence.
✅ Norwood 2
The very first signs of slight temporal recession on both sides appear. The overall hair density remains unaffected.
Reaching this stage is perfectly normal, and even expected, and it is not considered to be baldness.
The vast majority of men will reach Norwood 2 by their early 20s, which is why this stage is commonly referred to as the “mature” or “adult” hairline.
At this point, not immediate action is required.
However, if you are concerned about the future of your hair, and baldness does run in your family, now it would be the perfect time to start educating yourself by doing research on the topic of hair loss, and consulting with a professional healthcare provider.
⚠ Norwood 3
The first, clear signs of early baldness.
The hairline is receding visibly at both temples, taking the shape of a V. The overall density of the hair might gradually start to be affected as well.
In the more severe cases, a tiny bald spot may also appear on the vertex. This would be classified under NW 3 – V (vertex),
Unlike the previous two stages, Norwood 3 is considered to be the first, real stage of early baldness.
The good news, however, is that Norwood 3 is highly treatable and responds very well to medication, especially if therapy is started early.
At this point, the baldness has just started to take its toll. The hair follicles are being damaged, but they are not beyond repair yet. Many of them can still be fully restored back to a healthy state.
Most men—even those unaffected by androgenic alopecia—will eventually reach Norwood 3 at some point during their life.
If it happens during your 40s and 50s, that wouldn’t be a real cause of concern, since this mild form of balding is associated with the natural process of ageing.
If, however, you reach this stage during your 20s, this may be a very clear indicator that you may indeed be suffering from a more aggressive form of baldness, and that things are, in all likelihood, going to get worse over time—if left to their own devices.
If this is the case, now it would be the perfect time to consult with a healthcare professional and begin medical treatment.
Acting preemptively and addressing the issue earlier, rather than later, is the winning strategy in the battle against hair loss.
❌ Norwood 4
Things really start going downhill.
At the previous stage (NW 3), a tiny bald spot on the vertex may or may have not appeared.
But at Norwood 4, the bald spot on the crown is always there—and it’s not exactly tiny.
The hairline doesn’t fare very well either, with the temporal recession being even more pronounced. Unlike in the previous stage, the hairline is no longer having straight corners that form a V shape, but now, the receding temples form round patches that look like the letter U reversed. The overall hair density is deteriorating rapidly.
Starting treatment at this stage will still yield better results than waiting even longer, but most clinicians would agree that restoring the hair from stage 4 and beyond is no longer possible without having a hair transplant (in addition to using medical therapies).
❌ Norwood 5
Things get from bad to worse.
The hairline recedes even deeper. The bald spot on the vertex increases in size.
A small bridge of sparse hair is still separating the two balding regions (front and vertex).
❌ Norwood 6
The ever-receding hairline now unites with the balding vertex.
But it’s not exactly a happy reunion, since now the entire top of the head is almost completely bald, and is only covered with sparse and thin hair.
The sides of the head remain mostly unaffected.
☠ Norwood 7
The end of the journey.
The top of the head is completely bald.
Even the sides have been affected to some extent, leaving only a narrow strip of hair on the back of the head, forming the well known “horseshoe”.
This particular strip of hair is known as the “donor” or “safe” region, and is the area from which hair follicles would have been extracted during a hair transplant. Being naturally resilient towards the negative effects of DHT, this region remains unaffected for the reminding of the lifespan.
Most experts would agree that a man who reaches the Norwood 7 stage of baldness can no longer recover their hair to a meaningful degree with the current medical treatments and procedures available. Even in the case of a hair transplant, there are simply not enough grafts left to cover the entire scalp.
Norwood A-pattern
Most cases of androgenic alopecia will follow the regular pattern described above, with the bi-temporal recession in the front and balding crown.
There are, however, some rarer instances where the baldness progresses in a linear fashion—there is no bald spot at the vertex, but, instead, the hairline keeps receding from front to back:
Stages 1, 6, and 7 are identical to the regular pattern. The rest of the stages are suffixed by the letter A, which stands for “anterior involvement” (e.g. NW 3A).
This pattern is unusual, and only a small fraction of men suffering from hair loss will experience this, but it has been added to the article for the sake of completeness.
Norwood Scale: Real life examples
That was quite some information to wrap your head around!
In a clinical setting, the 7 stages of the Norwood scale are described using medical words, drawings, and diagrams.
But to gain a solid understanding of what each stage of baldness actually looks like, we are going to take some examples from the real world.
Yes, it’s true that you should only compare yourself to your former self, and not to other people.
But for the sake of science, we are going to make an exception to this rule and compare our own level of baldness with some real life examples of historic or pop-culture figures:
Now you should have a very clear idea of where you are on the Norwood scale. This would be a great conversation starter at parties!
Want to test your knowledge?
How to use the Norwood Scale
The Norwood scale is widely used by hair loss professionals to assess and diagnose their patients.
This scale can be used to determine the severity of the baldness, and might as well have some degree of predictive capacity. For example, if you’re at NW 3 with receding hairline at the temples, you are expected to become NW 4 and start balding at the vertex as well in the following years.
The severity of your hair loss, as determined on the Norwood scale, will be used by a clinician to formulate an appropriate treatment option for your individual needs.
As a general rule, the more advanced forms of baldness will require more aggressive treatments. For example:
- Stages 1 and 2 require no immediate action, in most cases.
- Stage 3 would be the optimal time to start a low-dose medical therapy.
- From stage 4 and beyond, the treatment may need to be more aggressive, or even require a hair transplant.
Many respectable clinicians would be hesitant to perform a hair transplant on patients that have just entered the first stages of balding—not only would a transplant be inappropriate, but could actually cause more harm in the long run, if the root cause of hair loss is not thoroughly addressed first.
| Ketoconazole | Minoxidil | Finasteride | Hair Transplant | |
|---|---|---|---|---|
| Norwood 1 | ❌ | ❌ | ❌ | ❌ |
| Norwood 2 | ✅ | ❌ | ❌ | ❌ |
| Norwood 3 | ✅ | ✅ | ✅ | ❌ |
| Norwood 4+ | ✅ | ✅ | ✅ | ✅ |
When it comes to non-surgical treatments, combing finasteride and minoxidil might result in regaining enough hair to reverse back to a previous stage on the Norwood scale (e.g. NW 3 becomes NW 2).
Regardless of the current stage of baldness, it’s worth reiterating that preventing hair loss is significantly easier, cheaper, and more effective than trying to regain lost hair. Early initiation of treatment is strongly associated with more favorable results.
Being well educated on the topic of hair loss and acting preemptively is the winning strategy in the battle against hair loss.
Fine tools of measurement
The Norwood scale is an amazing, macrolevel classification system that can give you an overall view of how well your hair is doing and where you are exactly in your battle against hair loss.
But to be able to accurately measure our progress—or lack thereof—we need to use finer, more granular tools that will give us real-time data on the evolution or involution of our baldness.
Measurement is critically important.
Without constantly monitoring our progress, we will be unable to determine the effectiveness of any particular treatment.
We wouldn’t know whether it’s time to increase or decrease the dose. Are we responding well to a certain supplement, or are we merely experiencing the placebo effect? Without clear and systematic measurement we would never know.
Let’s explore some of the most commonly used tools of measurement, starting with the best ones.
1. Trichoscopy
Trichoscopy is the gold standard hair measurement technique that is used by healthcare professionals and scientific researchers alike.
Without getting too deep into the weeds of medical science, trichoscopy is basically dermatoscopy applied to the hair. It uses a small optical device called a dermatoscope to analyze the surface of the scalp and the hair shafts.
The dermatoscope is essentially a hand-held microscope with its own lighting source. The best ones are are equipped with a digital camera, which can further increase the zoom beyond the physical capabilities of the optical lens, and, most importantly, they can record video and take high-resolution pictures of the scalp and hair, which could be later used for comparison.
Trichoscopy can be a very powerful tool for diagnosing baldness—both its type and severity. A dermatoscope will magnify the area of interest on the scalp, revealing finer details that would have otherwise been invisible for the naked eye:
- Hair thickness
- Hair shape
- Hair pigment, or lack thereof
- Variability amongst different hair shafts
- Scalp lesions or abnormalities
- Etc.
All these particularities can be used to determine the exact type of baldness, potentially revealing its cause (or causes), and allowing for an accurate diagnosis of the patient.
But where this medical technique really shines, is when it is performed regularly (every few months) for the purpose of observing the progression of baldness, or, the gradual regrowth of hair.
By doing these periodic examinations while undergoing a hair loss prevention treatment, you and your prescribing clinician will get a crystal-clear insight into the effectiveness of the treatment, which can then be modified and customized for your individual needs.
The only drawback to trichoscopy is that it can get quite expensive, depending on the clinic you are attending. But due to its remarkable accuracy and usefulness in hair loss prevention, a professional trichoscopy session should be performed once per year—at the very least.
2. Photographic assessment
Photographic assessment is the formal way of saying that you are regularly taking pictures of your hair and monitoring its evolution over time.
This cannot and will not be a suitable replacement for trichoscopy, but rather it’s an additional low-cost and easy to implement technique that you can start doing right now, at home, without requiring additional equipment other than your phone.
Although pictures are never going to be as accurate as the medical grade dermatoscope, they are infinitely more reliable than just looking in the mirror and doing the guesswork.
Our memory is subject to change and our perception of ourselves and our hair will vary over time—so taking pictures and having static images will partly remove the issue of subjectivity.
However, don’t be misled by the image above (sorry)—not any random selfies will do! There are a number of variables that are radically going to alter the appearance of the hair, potentially skewing the results:
- Camera angle
- Lighting
- Wet or dry hair
- Applied cosmetic products
- Haircut and hairstyle
Ideally, you would want to keep all these variables constant—take the pictures at the same angle, under the same light, with the hair being perfectly dry, etc.
You can take the pictures monthly—or even weekly, if you want more data points. Store them somewhere safe, and now you can go back in time and check on your progress in the battle against hair loss.
3. Counting lost hair
Another strategy for keeping track of the progress made in the battle against hair loss, is to literarily count the hair that is being shed every day.
This can be done either by combing your hair over a sheet of paper, or placing a hair catcher over the shower drain, then recovering the hair and counting it.
Due to the natural growth cycles of hair, a man is expected to lose anywhere between 50–100 hairs each day. This natural shedding process occurs when the hair follicles transition from the telogen (resting) stage to the exogen (shedding) phase, making room for a brand new hair that is going to replace the old one.
However, the number of hairs being shed will vary from one person to another, from one season of the year to another, and will also be heavily influenced by a variety of other factors (e.g. levels of stress, frequency of washing, etc.). This variability further decreases the usefulness and reliability of this technique.
Since there is no scientific consensus on the exact number of hairs expected to be shed by a healthy scalp, this method only becomes useful if the hair is being counted daily over a long period of time, and the results are compared to see if the shedding is increasing, decreasing, or remaining constant.
Doing this on a daily basis is very tedious and time consuming, and, due to its low reliability, using this technique might not be worth the effort—knowing the fact that we have access to medical-grade tools that are highly accurate, reliable, and easy to use.
Conclusion
In the battle against hair loss, or in any other endeavor in which we strive to win, measurement is an absolute necessity.
Without clear, reliable, and objective measurement, we are unable to determine if we’re making any progress, staying the same, or losing ground. We will not be able to determine the effectiveness of any particular treatment.
And this can lead to under- or over-medicating. Some people may unnecessarily throw the kitchen sink at their scalp, while others would stay true to their herbal supplements, wrongly believing they are on their path to reclaim their hair.
Clear and objective recorded measurement dispels all the uncertainty and guesswork, and puts us in a position of power, from which we can make a confident and educated strategic decision in the battle against hair loss.
The Norwood scale is the gold-standard classification system used by the medical community worldwide in the assessment and the treatment of hair loss. This scale consist of 7 different stages of baldness, ranging from a full head of healthy hair (NW 1), up to the most severe degree of baldness, in which only a narrow strip of hair at the back of the head is all that is left (NW 7).
In addition to the Norwood scale, which can give you a top-level, broad overview of your current stage of hair loss, there are other, finer tools of measurement that can and should be used to assess your progress in your efforts of combatting hair loss.
One such tool, which is considered by many hair restoration experts to be the gold-standard measurement device for hair loss, is trichoscopy—the usage of a dermatoscope to analyze the quality of the hair. This device can be used both for diagnosing, as well as monitoring the progression of hair loss.
🔬Scientific References:
- Gupta M, Mysore V. Classifications of Patterned Hair Loss: A Review. J Cutan Aesthet Surg. 2016;9(1):3-12. doi:10.4103/0974-2077.178536
- Dhurat R, Saraogi P. Hair evaluation methods: merits and demerits. Int J Trichology. 2009;1(2):108-119. doi:10.4103/0974-7753.58553
- Jain N, Doshi B, Khopkar U. Trichoscopy in alopecias: diagnosis simplified. Int J Trichology. 2013;5(4):170-178. doi:10.4103/0974-7753.130385
- Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evaluation of hair and scalp disorders. J Am Acad Dermatol. 2006;55(5):799-806. doi:10.1016/j.jaad.2006.04.058
- Lacarrubba F, Dall’Oglio F, Rita Nasca M, Micali G. Videodermatoscopy enhances diagnostic capability in some forms of hair loss. Am J Clin Dermatol. 2004;5(3):205-208. doi:10.2165/00128071-200405030-00009
⚠ Disclaimer: This article does not constitute medical advice and is intended for general informational purposes only. The information in the article is not a substitute for and should never be relied upon for professional medical advice, diagnosis, or treatment. Always discuss with your doctor if you have any questions. Please read our Medical Disclaimer.