Male Pattern Baldness (Androgenic Alopecia)

Introduction

Male pattern baldness, also known as androgenic alopecia in medical terminology, is the most common type of hair loss in men.

The vast majority of men will experience some degree of hair loss across their lifespan, and nearly a third of men will be affected by this condition starting as early as their 20s and 30s.

This condition is ubiquitous. It is so common, that it is considered to be one of the hallmarks of ageing across cultures. In spite of this fact, male pattern baldness remains very poorly understood by the general public.

The widespread availability of misinformation and inaccurate scientific data presented as fact, is causing a lot of confusion, uncertainty, irrational fear, or a false sense of hope amongst men suffering from male pattern hair loss—a population that is already experiencing significant amounts of emotional distress as a result of their condition.

This article is a complete guide on male pattern baldness. It is meant to dispel all the confusion, debunk all the myths surrounding hair loss, and equip you with all the knowledge you need in your fight against this preventable and reversible condition.

We will cover all the important topics related to male pattern hair loss, including the cause and mechanism of action, ways to combat it using clinically-proven treatment modalities, as well as other important information that needs to be known by every man that is suffering from this type of hair loss.

Note: Androgenic alopecia, male pattern baldness, and male pattern hair loss are synonyms and refer to the same condition. This article will use these terms interchangeably.

📝 Table of contents

What does male pattern baldness look like?

As its name implies, male pattern baldness can be easily recognized by its characteristic pattern: the progressive receding of the hairline starting from the temples, followed by a bald spot on the vertex, and subsequent thinning on the top of the head (crown).

As androgenic alopecia progresses over the years, the pattern of hair loss evolves in a highly predictable manner:

1. In the beginning stages of male pattern baldness, only the temporal regions are affected—usually uniformly on both sides. This causes the hairline to form a “V” shape.

2. If left untreated, the hair loss will start affecting the crown region as well, resulting in a small bald spot near the vertex. The frontal recession continues, making the hairline into a “U” shape.

3. As the condition progresses, the bald spot on the vertex becomes increasingly larger as the hairline recedes further backward, even more aggressively. The hair on the top of the head may start to shed diffusely and we see a general drop in the quality of the hair.

4. Eventually, the receding hairline on both sides will connect with the bald spot on the vertex, leaving the top of the head almost completely devoid of hair, with only a small “island” of sparse hair left in the middle.

5. And finally, in the last stage of androgenic alopecia, the top of the head is completely bald, and the only remaining hair is a small strip on the back and sides of the head. This area—known as the donor zone—is the most resilient to the effects of male pattern baldness. This is where hair grafts are extracted from when performing a hair transplant.

The norwood scale

The pattern hair loss seen in men suffering from this condition is highly predictable and reproducible, which has led to the development of several tools and classification systems for assessing the severity of hair loss in men suffering from this condition.

One of the most popular and reliable models is the Norwood scale—a classification system that consists of 7 different stages of baldness. This model is routinely used by hair loss clinicians when diagnosing their patients.

Although male pattern baldness can be treated at any stage regardless of the severity of hair loss, early initiation of treatment is strongly associated with better outcomes. Being proactive and taking action sooner—rather than later—is the winning strategy in the fight against hair loss.

The reason for this is very simple: one of the hallmarks of the pathophisiology of male pattern baldness is the decrease in stem cell activity at the level of the hair follicle—this is thorougly explained in the article on the biology of hair.

How common is male pattern hair loss?

Male pattern baldness is ubiquitous among men all over the world.

The vast majority of men are going to experience some degree of androgen-induced hair loss over the course of their lives. However, not all cases are going to be the same, as there is a lot of individual variability.

There are 3 primary factors that are going to ultimately determine how male pattern baldness is going to affect your hair:

The age of onset
Aggressiveness
Stabilization

Due to these factors, the actual incidence and severity of hair loss—which is merely the result of androgenic alopecia—is going to vary from one individual to another.

1. Onset—How early it starts in life

In some men, the balding can start as soon as their early 20s, or even late teens, while the luckier ones can see the first signs of hair loss when they are well into their 30s and 40s.

The early onset of male pattern hair loss is usually—but not always—correlated with the rapid progression of baldness, which might influence the treatment, requiring a different approach.

As a general observation, the prevalence of hair loss increases by 10% with every decade of life, starting with people in their 20s:

20% of men start losing hair in their 20s
30% of men start losing hair in their 30s
40% of men start losing hair in their 40s
etc.

2. Aggressiveness—How quickly it progresses

The second factor that is going to determine the outcome of male pattern baldness is its aggressiveness, i.e. how quickly are you losing ground since you’ve first seen hair loss.

Just like with the age of onset, the rate of hair loss is also highly variable from one person to another: while most men slowly lose their hair over a 10–30-year period, others experience massive shedding and go bald in a few short years—sometimes in their 20s.

If the hair loss is extreme—something which can only be assessed by a professional health care provider—stronger treatment may be required to stop the progression of androgenic alopecia.

When it comes to any type of hair loss prevention, time is of the essence. But for the cases of aggressive hair loss that progress very quickly, this becomes especially important. As mentioned previously, early initiation of treatment is strongly associated with better outcomes.

3. Stabilization—At which point does it stop

The third factor, although it may not be applicable to most men, is the stabilization of hair loss.

What this means, is that in some cases, after an initial period of hair loss, the shedding starts to slow down and the hair count stabilizes to some extent.

This often happens in a man’s early 20s when the hair goes from stage 1 (juvenile hairline) to stage 2 (mature hairline) on the Norwood scale of baldness. This is considered to be normal, and not necessarily an indicator that the balding will continue past this point.

However, there is no guarantee that this is going to happen, and the balding process may continue on to more advanced stages (3, 4, 5, and beyond).

The hair loss may or may not stabilize at one of the later stages, and for this reason, it’s important to not rely on wishful thinking as a hair loss prevention strategy, but instead take proactive action and discuss with a health care professional to get an accurate assessment of your hair.

For those that do not achieve the stabilization of the condition naturally, medication such as finasteride can be used to artificially induce stabilization, thus halting the progression of male pattern baldness.

What causes male pattern baldness?

Male pattern baldness is sometimes referred to as androgenetic alopecia, which gives us some insight into the cause and pathophysiology of this condition:

“Genetic”

The second word, “genetic”, is self-explanatory. There is a very strong genetic component that comes into play in the development of male pattern baldness.

It has been speculated that the gene for hair loss is passed down from the mother’s side of the family, which means that if your mother’s father went bald, you are at a higher risk of developing male pattern baldness yourself. If you haven’t experienced any hair loss yet, but balding does run in your family, it’s very important to stay vigilant and be on the lookout for potential signs of hair loss—early action equates to better results.

Men suffering from androgenic alopecia have both a higher 5α-R expression in the scalp (which leads to increased levels of DHT), as well as higher amounts of androgen receptors at the level of the follicles—with the most vulnerable areas being the temples and crown, where male pattern baldness begins. Both of these characteristics are genetically determined.

“Andro-“

This prefix is derived from the Greek word for “man”, and refers to the fact that:

While there are some cases of women developing this condition, androgenic alopecia primarily affects men—and it does so in very large numbers.
The androgenic hormones in the scalp play a mechanistic role in the progression of male pattern baldness, through a process called follicle miniaturization.

Miniaturization refers to the progressive shrinking of the hair follicles under the negative effects of DHT and other factors. As the follicles become smaller in size, they gradually lose the ability to grow thick and healthy hair. As androgenic alopecia progresses over the years, the follicles get to a point where the hair becomes too weak to penetrate the scalp, and thus stops growing altogether—this results in baldness in that area.

This is a very slow (but steady) process that occurs over the course of many years. But, fortunately, unlike the genetic predisposition to baldness, the process of follicle miniaturization can be slowed down, completely stopped, or even reversed in some cases, by using a number of medical therapies.

The psychological effects of hair loss

Experiencing hair loss can be devastating, especially if it’s progressing rapidly or starts at a younger age.

Due to the massive scare campaign that is currently taking place on the internet, many people have started to fear the side effects of hair loss medication.

This excessive fear can become paralyzing and causes a lot of men to forgo a treatment modality that could have otherwise saved their hair.

Although this fear is not entirely irrational and can be justified—since medication side effects do exist and some people experience them—people who are overly concerned with this seem to overlook one simple fact:

Hair loss itself comes with a number of side effects as well.

Men undergoing the painful process of losing their hair can react in all sorts of ways. Some can even go through one or more of the 5 stages of grief—an emotional rollercoaster that cycles through states such as denial, anger, and hopelessness.

Hair loss can induce (or worsen) symptoms of anxiety, depression, and low self-esteem among other things. Some men view losing their hair as the equivalent of losing their youth and vibrancy, fearing that it might impact their dating life and ability to attract a mate.

All those emotions are perfectly reasonable reactions in the face of a challenge that we did not ask for but was rather chosen for us by the luck of the draw at the genetic lottery.

However, winning the battle against hair loss requires a clear, rational mind, and a stoic approach. Having the right mindset and mastering the psychology of hair loss is the first step towards conquering this challenge.

The treatment of male pattern baldness

Currently, there is no known treatment that can cure male pattern baldness—at least not permanently.

There are, however, a number of treatment options that can be used to stop the progression of hair loss, and even achieve some level of regrowth.

It’s important to note that when it comes to combatting hair loss, an ounce of prevention is worth a pound of cure. It’s always better to be proactive and take action sooner, rather than later.

One of the most powerful and widespread hair loss prevention protocols for male pattern baldness is a medication stack that is commonly referred to as the big three, which consists of:

Finasteride
Minoxidil
Ketoconazole shampoo

These three medications have separate mechanisms of action, each one of them playing a different role in the fight against hair loss.

While they can be used independently from one another, stacking them together is going to yield the best results, since they have complementary effects—finasteride cannot do what minoxidil does, and vice-versa.

1. Finasteride—The follicle guard

Finasteride is the first and most important medication of the big three.

It is a 5α-R blocker that can reduce systemic and scalp levels of DHT by nearly 70%. By doing this, the follicles are going to be shielded from the damaging effects of the hormone, and they will begin to thrive.

By using finasteride, the miniaturization process is stopped, and in many cases, the follicles are even able to revert back to a healthier state—restoring their ability to produce strong and healthy hair.

While finasteride can achieve some decent levels of regrowth, its primary role is to stabilize the condition and prevent further hair loss.

2. Minoxidil—The hair growth stimulator

Minoxidil is the most powerful hair growth stimulant in the world.

It is a topical medication that is applied on the scalp daily. Minoxidil is a very strong vasodilator that increases the blood flow of the hair follicle, opens the potassium channels, and may act as a nitric oxide agonist.

This results in the stimulation of hair growth: new hairs start to emerge and the old ones become thicker and stronger. In addition to that, minoxidil also causes the follicles to switch from the resting phase (telogen), into the active growth phase (anagen)—thus increasing the percentage of anagen hairs and the duration of the growth cycle.

However…

Unlike finasteride, minoxidil does not have anti-androgenic properties, and will therefore be unable to stop the progression of male pattern hair loss by itself. For this reason, adding finasteride into the prevention stack before minoxidil is almost always the right strategy: you first stop the damage and then use minoxidil to stimulate new growth.

3. Ketoconazole—The scalp anti-inflammatory

Ketoconazole shampoo reduces the inflammation of the scalp and also acts as a mild local anti-androgen.

Scalp inflammation is directly causative of hair loss—even in men who do not have androgenic alopecia. For those who do suffer from this condition, inflammation will only make things worse.

Here is where ketoconazole comes into play: due to its antifungal and anti-inflammatory properties, this shampoo is going to clear up the scalp’s microflora and reduce inflammation and dandruff. Better scalp health is going to translate into better hair health.

In addition to that, ketoconazole has also been shown to have mild anti-androgenic effects, disrupting the scalp’s DHT metabolism. This effect is not very powerful and is thus unlikely to singlehandedly stop the progression of male pattern baldness, but it definitely helps.

Since finasteride and ketoconazole shampoo have different mechanisms of action in the way they interact with DHT, using them together might work synergistically and confer additional benefits.

The effects of ketoconazole shampoo for hair loss prevention are mild. And in spite of the fact that it is the weakest medication of the big 3 stack, the ketoconazole shampoo is the first item that should be added to any hair loss prevention regimen, due to its benefits—an excellent safety profile with virtually no side effects, ease of use, and convenience (just swap it for your regular shampoo).

Adjuvant therapies

In men suffering from pattern hair loss, the vast majority of hair maintenance and regrowth is going to come from the big 3 stack. Finasteride, in particular, is going to be the most effective treatment in most cases, since it directly targets DHT, which is the main driver of follicle miniaturization.

However, DHT is not the only agent that can damage the hair. Therefore, there are a number of adjuvant strategies that can help improve the health of your hair, through the elimination of other damaging factors. Examples include cessation of smoking, controlling blood sugar levels, and ensuring proper nutrition.

In all likelihood, none of these strategies are going to singlehandedly stop male pattern baldness, but they are definitely going to improve your overall health, and, by extension, the health of your hair follicles.

Other types of hair loss

Genetically-determined male pattern hair loss is by far the most common type of hair loss in men, with nearly half of the population being affected by the time they enter their 40s.

This condition is easily recognizable due to its highly predictable pattern—starting with the receding hairline at the temples, the bald spot near the vertex, followed by the slow degradation of the hair on the top of the head.

However, although it’s the most common, male pattern baldness is not the only type of hair loss affecting men. And just because someone is already suffering from underlying androgenic alopeica, it doesn’t mean that they can’t have another type of hair loss going on at the same time, making the hair loss issue even worse.

For this reason, it’s important to know the difference between the common male pattern baldness and the other types of hair loss, since they differ in causes, sympthoms, and treatment modalities:

	Cause	Pattern	Treatment
Male Pattern Baldness	Genetic	✔	Finasteride / Minoxidil
Telogen Effluvium	Stress	❌	Stress management
Alopecia Areata	Autoimmune	❌	?
Retrograde Alopecia	?	✔	Finasteride / Minoxidil

1. Telogen effluvium

The second most common type of hair loss is telogen effluvium.

This type of hair loss is characterized by a massive amount of shedding that occurs uniformly across the scalp—as opposed to androgenic alopecia where the hair loss follows a pattern.

Unlike male pattern baldness, telogen effluvium is not caused by androgens, and therefore finasteride will not be effective as a treatment modality.

The primary cause of telogen effluvium is an excessive amount of stress on the system—either physical or psychological. Examples of such events include excessive training in the gym, a car accident, a sudden change in diet, losing a job, or other stressful events.

Another important distinction between male pattern baldness and telogen effluvium is that the latter is both temporary and fully reversible.

Although seeing massive amounts of shedding can cause some level of panic, the vast majority of telogen effluvium cases resolve on their own after 3–6 months, without requiring any treatment—other than better stress management and cleaning up the diet.

2. Alopecia areata

Another type of hair loss is alopecia areata.

This type of hair loss is perhaps even easier to detect than male pattern baldness. It is characterized by the sudden and complete hair loss in small round patches, roughly the size of a coin. This can happen on the scalp, beard, or body hair. The location appears to be random and does not follow any predictable pattern.

Just like the previously mentioned telogen effluvium, alopecia areata is not caused by androgenic activity and cannot be treated using traditional male pattern baldness medication.

This rare condition is believed to be an auto-immune disease, in which the body’s natural immune system attacks the hair follicles in a specific area.

Minoxidil is sometimes used on the bald patches in an attempt to stimulate hair growth, although this is merely treating the symptoms and not addressing the underlying root issue—which is believed to be autoimmune in nature.

Most cases of alopecia areata are self-limiting, meaning that the symptoms will resolve themselves after a few months, and most of the hair will grow back and cover the previously affected area.

3. Retrograde alopecia

The third type of hair loss you need to be aware of is retrograde alopecia.

Unlike the previous two, retrograde alopecia does have a correlation with male pattern baldness, meaning that those who are already suffering from this condition are more likely to develop retrograde alopecia as well.

Retrograde alopecia is characterized by hair loss that occurs on the sides of the head (above the ears) and on the back of the neck.

While male pattern baldness causes the hair to recede front-to-back, retrograde alopecia goes in the opposite direction, causing the hair on the sides and back of the head to recede upwards. This may end up affecting the donor region (back of the head), thus making a hair transplant more challenging.

The cause of retrograde alopecia is not fully understood. Some have hypothesized that it is caused by thyroid issues, while other experts consider it to be a subset of the standard male pattern baldness, which occurs in the most severe cases.

Nevertheless, it has been observed that follicles affected by this type of hair loss undergo the same miniaturization process as seen in androgenic alopecia. Therefore, this condition is often treated with the same medication: blocker therapy (finasteride) and stimulation therapy (minoxidil).

Conclusion

Male pattern baldness—also known as androgenic alopecia—is the most common type of hair loss affecting men.

Androgenic alopecia is easily distinguishable from other types of hair loss, due to the fact that the progression of baldness follows a specific pattern—hence the name pattern hair loss. It primarily affects the top of the head, starting with the hairline, which often takes the shape of a “V”.

As a result of this condition, the vast majority of men will experience some degree of hair loss throughout their lifespan—although there is a lot of individual variability, which is going to determine the severity of the hair loss, as well as the age at which it happens.

Male pattern baldness is genetic in nature, which means that an individual’s proclivity toward hair loss is determined at birth. Poor lifestyle choices and other environmental factors may exacerbate the condition, but the main determining factor remains the person’s genetics.

The main driver of hair loss in male pattern baldness is an androgenic hormone called DHT, which is a derivate of testosterone. In men affected by this condition, DHT binds to the androgen receptors in the hair follicles, causing them to shrink over time—a process that is referred to as miniaturization.

As the miniaturized follicles become progressively smaller and weaker, the hair also becomes shorter and thinner, until it reaches a point where it can no longer penetrate the scalp, and it stops growing altogether—hence causing baldness in that area.

There is no known treatment that can permanently cure androgenic alopecia, however, there are a number of therapies that can stop this condition in its tracks, achieving near-complete cessation of hair loss, and, in some cases, eliciting some degree of hair regrowth.

The most common treatment for male pattern baldness is a medication stack—commonly referred to as the big three—which consists of finasteride, minoxidil, and ketoconazole shampoo.

Male pattern baldness is a chronic, progressive, life-long condition, which is going to worsen over time if it is left unchecked—with more hair being lost every single year.

Early initiation of treatment is strongly correlated with better outcomes for the hair.

Preventing hair loss is significantly easier than recovering the lost ground, therefore being proactive and addressing the problem at the first signs is the winning strategy in the battle against hair loss.

⚠ 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.