Receding Hairline: An Early Indicator of Hair Loss

A receding hairline is typically an early indicator of hair loss that develops due to androgens (male sex hormones) and genetic predisposition. (1) Male pattern baldness typically progresses slowly. Rapid and sudden hair loss may be indicative of various dermatological conditions underlying it. A genetic predisposition to MAA (Male Androgenetic Alopecia), often showing racial variability in its prevalence, is widely acknowledged, with hereditary factors contributing to roughly 80% of susceptibility.” Histological changes characterized by hair follicle miniaturization signify the essence of androgenetic alopecia. Irreversible hair loss is probable once the arrector pili muscle, encircling the primary follicle, detaches from all secondary follicles, and primary follicles undergo miniaturization and detachment. Hair loss resulting from hair follicle miniaturization typically manifests with the following symptoms in the temporal and vertex regions: thinner appearance compared to occipital hair, changes in color (usually lighter), slow growth, and a sparse appearance.

Psychosocial Impact of Receding Hairline

The adverse effects of receding hairline caused by male pattern hair loss are often overlooked and trivialized by those unaffected. (2) However, hair is perceived as a symbol of strength and healthy appearance in many societies. Numerous studies have presented evidence that hair loss impacts individuals’ social lives. Researches supports the connection between anxiety and depression in young individuals experiencing hair loss. (3) A recent study shows that  bald man looking less attractive more than %90 (2) Considering these circumstances, physicians should not overlook the fact that patients affected by hair loss may be under intense emotional stress. Considering these reasons, it is evident that hair loss creates trauma in an individual’s psychological and social life. Being hairless is universally regarded as a disadvantage in nearly all societies. As numerous studies have shown, it is not abnormal for individuals experiencing receding hairline or general hair loss to lack support from their surroundings, and they need to seek necessary support from experienced physicians in this regard.

Receding Hairline and Associated Diseases

Cotton et al. were among the first to propose the notion that male pattern baldness starting with receding hairline and crown hair loss might serve as a potential risk factor for cardiovascular disease (4). Subsequent studies have lent further credence to this idea (5-6). Notably, a recent investigation revealed that asymptomatic young men exhibiting at least Grade 3 vertex baldness face a significantly elevated risk of arterial stiffness compared to their counterparts with normal hair status (7).

However, it’s worth noting that many of these studies were conducted without dermatological involvement for confirmation of male androgenetic alopecia (MAA) diagnoses. While statistically significant, these associations, identified through epidemiological, cohort, and case-control studies, are often considered weak. Moreover, the onset of severe MAA before the age of 30 may correlate with a heightened risk of ischemic heart disease. For instance, a retrospective analysis involving 22,071 American subjects found a higher incidence of myocardial infarction among men experiencing vertex balding compared to those with receding hairline or frontal alopecia (8).

Additionally, research suggests that frontal male pattern baldness in young men may be linked to elevated serum cholesterol levels and increased blood pressure relative to age-matched peers without hair loss (8). Research has uncovered a positive correlation between male androgenetic alopecia (MAA) and prostate cancer in various studies (9, 10). A significant Australian case-control study on a large scale reported a 50% increase in the risk of prostate cancer associated with vertex balding. Furthermore, longitudinal data spanning 11 years suggests that vertex androgenetic alopecia at the age of 40 might serve as a marker for heightened susceptibility to early-onset prostate cancer.

The vascularization of the scalp is well-developed. Therefore, changes in the body’s vascular structure can affect the transportation of blood, oxygen, and nutrients to the scalp. Hence, hair loss is a problem that needs to be thoroughly examined. Smoking, alcohol consumption, an unhealthy diet, and unhealthy weight gain can lead to atherosclerosis in the blood vessels, which can disrupt microcirculation.

Recent investigations have highlighted a higher prevalence, comorbidity, and mortality rates of COVID-19 in males compared to females. A comprehensive review of 59,254 individuals across 11 countries revealed a greater mortality rate from SARS-CoV-2 infection among males. The potential link between MAA and worse COVID-19 outcomes has spurred multiple studies exploring this association. One such study evaluated the severity of hair loss in 1,941 male symptomatic patients admitted for SARS-CoV-2 testing, comprising 1,605 negative-tested individuals and 336 positives. Hair loss classification, based on the Hamilton–Norwood Scale (HNS), revealed a significant association between severe MAA (HNS 4–7) and a higher rate of positive COVID-19 tests. (11)

After the COVID-19 pandemic, we have observed an increase in cases presenting with hair loss issues at our center. Interestingly, some studies have found a significant correlation between COVID-positive cases and baldness. The reasons behind this phenomenon should be investigated further.

Medical Treatment of Early Receding Hairline 

Minoxidil operates as a hair growth promoter with a non-specific mechanism; however, the gradual miniaturization of hair follicles stimulated by androgens persists despite treatment. This observation is supported by findings from a 120-week double-blind study. The study compared the clipped hair weight among men undergoing treatment with 5% minoxidil, 2% minoxidil, and a placebo, alongside a group receiving no treatment (12).

Administering a daily oral dose of one milligram of finasteride leads to a reduction of scalp dihydrotestosterone (DHT) levels by 64% and serum DHT levels by 68% (13). Initially prescribed at 5mg per day for benign prostatic hyperplasia, finasteride has also been utilized for treating androgenetic alopecia. However, dose-ranging studies have indicated that there is no substantial variance in clinical efficacy between daily regimens of five milligrams and one milligram. Moreover, there is no significant additional decrease observed in scalp or serum DHT levels with the lower dosage (14).

In a phase III trial, dutasteride at a daily dosage of 0.5mg demonstrated notably greater efficacy compared to placebo, as determined by subject self-assessment and photographic assessments conducted by investigators and panels (18). Notably, there was no significant variance in adverse events between the treatment and placebo groups. However, it’s worth noting that this study was confined to a duration of only 6 months. In a more recent phase III trial, dutasteride at 0.5mg showed statistical superiority over both finasteride at 1mg and placebo after 24 weeks (15)

Platelet-rich plasma (PRP), derived from whole blood, harnesses growth factors and stimulatory mediators for potential therapeutic use. Some hair transplant surgeons utilize PRP to foster the growth of transplanted grafts (16). Moreover, PRP is increasingly employed as a standalone treatment for male androgenetic alopecia (MAA), with recent but limited evidence suggesting favorable regrowth outcomes and minimal side effects (17, 18). The mechanism behind PRP’s efficacy in stimulating hair growth is believed to involve several factors: enhancement of follicle vascularization, inhibition of apoptosis, thereby extending the anagen phase, and acceleration of the transition from telogen to anagen phase (19).

Research indicates that topical ketoconazole shampoo has been demonstrated to enhance hair growth in both humans and rodents when compared to a placebo (20).

Most medical treatments can prevent the progression of hair loss in the early stages. However, once the hair follicle becomes dislodged from its attached erector pili muscle, reversal is not possible. Treatments aimed at reducing androgens in the scalp and increasing microcirculation should not be self-administered at home without expert support. The dose-response relationship should be monitored by a physician, and the treatment should be tailored accordingly. The best response in hair loss is achieved when medical treatments are combined with surgical interventions. Medical treatments may lead to reduced sensitivity of your hair to androgens. This is attributed to downregulation of androgen receptors following treatment. When treatment is gradually discontinued in a planned manner, the number of receptors in the area will decrease, resulting in a stable state of improvement in hair until new receptors are formed.

Surgical Treatment and Planning of Receding Hairline 

In cases of hair loss occurring at the temples, some patients may also experience thinning in the mid-scalp region. Especially in younger patients deciding on hair transplantation for receding hairline, there may be a desire to densify these areas for future considerations. However, this is a misconception, as transplanting hair into weakened areas will both accelerate hair loss in those regions and not achieve the desired density. In such cases, the most suitable treatment plan for patients experiencing early onset frontal hairline recession and thinning is to strengthen the frontal hairline through surgical hair transplantation while keeping other weakened areas under medical treatment. This way, patients can maintain a satisfactory appearance with a full frontal hairline until their late 30s and early 40s, and undergo a second transplantation around their 40s to address almost balding appearance.

Topical minoxidil and finasteride can be a useful adjunct to hair transplant surgery for MAA. Without adjuvant medical therapy to prevent progression of balding process, an unnatural appearance can evolve over time. A successful medical treatment is key to stopping hair loss progression and offering a better guarantee of a sustained long-term transplant outcome. Individuals experiencing hair loss in the temporal and vertex areas, with receding hairlines, should consider the potential progression of their hair loss. Therefore, to achieve long-lasting results from surgical procedures, medical treatments should be combined with surgical interventions. Planning hair transplant surgeries in early stages of hair loss should also consider the possibility of future hair loss progression. Please go ahead and provide a more detailed explanation of the surgical approach we take with patients experiencing frontal hairline recession.

When creating the frontal hairline surgically for receding hairline, achieving near-perfect results may require placing more than 40 follicular units per cm2. Expert hair transplant surgeons can indeed achieve these numbers. In the example below, in the receding hairline procedure performed by us, nearly 50 incisions were made per cm2 to achieve significant density. Additionally, it is essential that these incisions do not compromise the integrity of the skin, cause tearing, or merge with each other.

Conclusion

The manifestation of receding hairline at an early or middle age serves as an important early warning sign for long-term control strategies for hair loss. When determining the diagnosis and treatment approach, various algorithms incorporating factors such as age, additional medical conditions, and the ratio of hair loss to baldness in the affected area should be utilized to create a detailed treatment plan. Particularly in the repair of the frontal hairline, errors in hair transplantation are more noticeable, which can worsen the affected individual’s psychosocial well-being. Therefore, be cautious when choosing your hair transplant clinic.

AUTHOR: Dr. Ergen

REFERENCES:

(1) https://www.aad.org/public/diseases/hair-loss/treatment/male-pattern-hair-loss-treatment

(2) Passchier J. Quality of life issues in male pattern hair loss. Dermatology. 1998;197(3):217–218.

(3) Tabolli S, Sampogna F, di Pietro C, Mannooranparampil TJ, Ribuffo M, Abeni D. Health Status, Coping Strategies, and Alexithymia in Subjects with Androgenetic Alopecia. American Journal of Clinical Dermatology. 2013;14(2):139–145.

(4) Cotton SG, Nixon JM, Carpenter RG, Evans DW. Factors discriminating men with coronary heart disease from healthy controls. Br. Heart J. 1972;34(5):458–464.

(5) Herrera CR, D’Agostino RB, Gerstman BB, Bosco LA, Belanger AJ. Baldness and coronary heart disease rates in men from the Framingham Study. Am. J. Epidemiol. 1995;142(8):828–833.

(6) Schnohr P, Lange P, Nyboe J, Appleyard M, Jensen G. Gray hair, baldness, and wrinkles in relation to myocardial infarction: the Copenhagen City Heart Study. Am. Heart J. 1995;130(5):1003–1010.

(7) Agac MT, Bektas H, Korkmaz L, Cetin M, Erkan H, Gurbak I, Hatem E, Celik S. Androgenetic alopecia is associated with increased arterial stiffness in asymptomatic young adults. Journal of the European Academy of Dermatology and Venereology. 2015;29(1):26–30.

(8) Lotufo PA, Chae CU, Ajani UA, Hennekens CH, Manson JE. Male pattern baldness and coronary heart disease: the Physicians’ Health Study. Arch. Intern. Med. 2000;160(2):165–171.

(15) Harcha WG, Martínez JB, Tsai T-F, Katsuoka K, Kawashima M, Tsuboi R, Barnes A, Ferron-Brady G, Chetty D. A randomized, active- and placebo-controlled study of the efficacy and safety of different doses of dutasteride versus placebo and finasteride in the treatment of male subjects with androgenetic alopecia. Journal of the American Academy of Dermatology. 2014;70(3):489–498.e3.

(16) Rose PT. The latest innovations in hair transplantation. Facial Plast. Surg. 2011;27(4):366–377.

(17) Takikawa M, Nakamura S, Nakamura S, Ishirara M, Kishimoto S, Sasaki K, Yanagibayashi S, Azuma R, Yamamoto N, Kiyosawa T. Enhanced Effect of Platelet-Rich Plasma Containing a New Carrier on Hair Growth. Dermatologic Surgery. 2011;37(12):1721–1729.

206.

(18) Gentile P, Garcovich S, Bielli A, Scioli MG, Orlandi A, Cervelli V. The Effect of Platelet-Rich Plasma in Hair Regrowth: A Randomized Placebo-Controlled Trial. Stem Cells Transl. Med. 2015;4(11):1317–1323.

(19) Li ZJ, Choi H-I, Choi D-K, Sohn K-C, Im M, Seo Y-J, Lee Y-H, Lee J-H, Lee Y. Autologous Platelet-Rich Plasma: A Potential Therapeutic Tool for Promoting Hair Growth. Dermatologic Surgery. 2012;38(7):1040–1046.

(20) Inui S, Itami S. Reversal of androgenetic alopecia by topical ketoconzole: relevance of anti-androgenic activity. J. Dermatol. Sci. 2007;45(1):66–68.