Ahmad's NPRT System: A Practical Innovation for Documenting Male Pattern Baldness

Abstract

Various classifications for male pattern baldness are mentioned in the literature. The ‘Norwood's classification is the most commonly used but it has certain limitations. The new system has included ‘three’ extra features which were not mentioned in any other classification. It provides an opportunity to document the full and correct picture while documenting male pattern baldness. It also aids in assessing the treatment for various degrees of baldness.

INTRODUCTION

More than 50% of the men experience some degree of hair loss in their lives.[1] With increase in the population, the total number of men with baldness will keep on increasing. The increase in the male population has resulted in changes in male hair loss patterns (e.g., the total population of men in 2015 is more than the total population of men and women in 1950).[2] There have been a few classifications for male pattern hair loss described in the literature. The first attempt was made in 1950 by Beek in male White patients and in 1951 by Hamilton in White and Chinese population.[3,4] The most commonly used is Hamilton–Norwood classification presented in 1974.[5] The change in the patterns may be due to environmental changes, climate changes, racial changes, dietary factors, etc.[6] As noted by Hamilton, the basis of male pattern baldness is the hormonal factor along with the genetic pre-disposition and age.[7] Because of the isolation of genes responsible for male pattern hair loss, there may be redistribution/mix-up of the genetic materials from different races as a process of evolution, which can result in a change in the expression of these genes.

The Norwood classification is considered to be ‘gold standard’ for categorising male pattern hair loss. There have been certain other classifications due to the versatility of baldness patterns.[8,9,10] With an experience of over a decade, the author has attempted to develop a system for documenting the features of male pattern baldness, improving the ‘gold standard’ and adding certain details to the points not mentioned earlier in Norwood's classification.

PROPOSED CLASSIFICATION

The new classification comprises four points.

Norwood classification

The Norwood grades serve the main part of the classification, and the types remain as I–VII and variants as IIIa, IIIv and IVv [Figure 1].

Figure 1.

Norwood–Hamilton classification (adopted from Norwood OT. Male pattern baldness; classification and incidence. Southern Med J 1975;68 (11):1359-65)

Temporal peaks/points

Denoted by the letter ‘P’, the different grades are being proposed from ‘0’ to ‘3’ with the letter ‘P’ [Figure 2].

Figure 2.

Temporal points/peaks (P)

• P0 indicates ‘no’ hair loss at the temporal points

• P1 indicates the temporal point (apex of the peak) is located not less than the junction of one-third and two-third of the distance between the outer canthus to tragus

• P2 denotes that the temporal point is located not less than the half of the distance between the outer canthus to tragus

• P3 denotes the reverse of P1 i.e., the temporal point is located at the distance <two-third and one-third between the outer canthus to tragus.

Reverse thinning

It is denoted by the letter ‘R’. It is the hair loss in the occipital area and above the ears (mastoid area), which may be combined with loss of peaks [Figure 3]. The following grades are proposed. ‘Reverse thinning’ means more skin is visible than hair.

Figure 3.

Reverse thinning (R)

• R0 denoted ‘no’ reverse thinning

• R1 indicates ‘mild reverse thinning’ i.e., the density is decreased considerably and is limited only to 1 cm above ears and/or occipital area

• R2 indicates ‘moderate reverse thinning’ i.e., the hair loss/decreased density is more than 1 cm, but <2 cm

• R3 indicates ‘severe reverse thinning’ and involves the decrease in density/hair loss more than 2 cm above the ears and/or above the line joining both ear lobes.

Overall thinning

It is denoted by the letter ‘T’ [Figure 4].

Figure 4.

Overall thinning (T)

• T0 indicates ‘no’ thinning

• T1 indicates the ‘mild’ loss in density (<25%) i.e., more skin is visible than hair

• T2 indicates the ‘moderate’ loss in density (more than 25% but <50%) i.e., much skin is visible than hair

• T3 indicates ‘severe’ loss of density (more than 50%) i.e., too much skin is visible than hair.

The density can be measured at the level of external occipital protuberance. The density of 100 hair/cm² is taken normal.

After the Hamilton–Norwood classification, a few limitations were observed, for example, it puts more emphasis only on vertex classification, the temporal regression is not discussed. To address the limitations, a few other classifications have been developed.[8,9,10,11,12] Bouhanna developed a multifactorial classification.[13] These classifications were based on the study of Caucasians of different ages. The basic and specific pattern (BASP) classification was developed by Lee et al. in Asian population in 2007.[10] The BASP classification has various points which are difficult to memorise. In spite of the claim, it is more complicated and has limitations too. It has not been able to get a worldwide acceptance mainly due to its complexity of the description of various points. It lacks the descriptions which are required for the physicians, and it does not encompass the versatility of different patterns. It also has limitations that certain points are confused with Norwood scale.[14] Similarly, temporal points have also been classified by Brandy and Mayer and Perez-Meza, but these have not been able to get incorporated in the Norwood scale.[15,16] The various differences in the hair loss pattern, not relating to a specific pattern in Norwood scale, are termed ‘non-specific’ patterns and these non-specific patterns need a classification system.

The classification system presented addresses all the lacking issues in the previous classifications. It seems to be less complicated and can be easily memorised. It maintains the ‘gold standard’ to which various points are added. The Norwood scale is mentioned, and these three points are expressed in bracket, for example, Type VI (P1, T2 and R2) or VI (P2, T0 and R0), etc.

The current system has the advantage of combining and documenting various assessment points at the same time and can predict the future loss in baldness. It also helps in planning the surgical procedure as well. The author has been using this current method for more than a year after developing it. It was found to be very useful, especially when the patients with Norwood Type VI or VII and having advanced thinning (T3 or R3) visit the clinic for hair restoration, which are difficult to be documented.

CONCLUSION

The current system is easy and needs further studies to improve on the standard classification for male pattern baldness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.