Ludwig Scale: The 3 Grades and What Each One Misses

The Ludwig scale is the three-grade system used to describe female pattern hair loss. Grade I is thinning on top of the head behind an intact front edge, grade II is pronounced thinning in the same zone, and grade III is near-total loss there. Erich Ludwig published it in 1977. This guide covers what each grade means, which common patterns the scale was never built to capture, and what a grade does and does not predict about treatment.

What is the Ludwig scale?

The Ludwig scale is a three-step picture scale for the female pattern of androgenetic alopecia, published by the German dermatologist Erich Ludwig in the British Journal of Dermatology in 1977 (Ludwig, Br J Dermatol 1977). He built it from 468 women with hair loss, according to a 2016 review of every major hair loss classification (Gupta and Mysore, J Cutan Aesthet Surg 2016).

His stated purpose was early diagnosis, which he called "desirable in view of the therapeutic possibilities by means of antiandrogens". Two other sentences in the abstract matter later. He wrote that female loss differs from the male kind "in its clinical picture and in the sequence of events leading to it", which is why women need their own scale. He also called the male pattern in women "exceptionally observed" and said it could be classified on Hamilton's male scale instead. That second assumption is where the Ludwig scale is weakest.

The same 2016 review names Hamilton-Norwood for men and Ludwig for women as the two systems most commonly used today. For the male pattern, receding temples and a thinning crown, the Norwood stage finder is the matching tool.

The three Ludwig scale grades

Each Ludwig grade describes how much hair is left inside one zone on top of the head, a zone that starts 1 to 3 cm behind the front hairline. The definitions below are Ludwig's, as quoted in the 2016 review. The right-hand column is a plain-language reading, not his.

Grade	Ludwig's definition	What it usually looks like along a centre part
I	"Perceptible thinning of the hair on the crown, limited in the front by a line situated 1-3 cm behind the frontal hairline"	Part wider than it used to be, ponytail thinner, scalp easier to see under overhead light
II	"Pronounced rarefaction of the hair on the crown within the area seen in Grade I"	Scalp clearly visible along and either side of the part in ordinary light
III	"Full baldness (total denudation) within the area seen in Grades I and II"	Little or no hair inside the zone, with the front fringe and sides still present

The American Academy of Dermatology uses the same everyday cues for spotting the condition: "Is your part widening? Have you noticed that your ponytail is thinner these days?" (AAD, female pattern hair loss).

Two assumptions hold across all three grades. The front hairline stays where it was. And the only thing that changes is density inside the zone, so the scale has nothing to say about the sides, the back or the temples.

How common is female pattern hair loss by age?

Female pattern hair loss becomes more common with every decade: about 6% of women under 50 had it in a UK clinic sample, rising to 38% at 70 and over. The four studies below defined it differently, so the table shows what each one actually counted.

Study	Who was examined	What was counted	Result
Birch et al, Br J Dermatol 2001	377 women aged 18 to 99 seen at a UK dermatology clinic for unrelated problems	Clinical diagnosis of female pattern hair loss	6% under 50, 38% at 70 and over
Su et al, J Am Acad Dermatol 2013	26,226 Taiwanese women aged 30 and over, community survey	Female pattern hair loss, defined in the abstract as Ludwig grade >I	11.8% overall (95% CI 11.5% to 12.2%), rising with age
Gan and Sinclair, J Investig Dermatol Symp Proc 2005	Adults from one Australian town, 396 examined	Mid-frontal hair loss	57% of women aged 80 and over
Norwood, Dermatol Surg 2001	1,006 white women aged 20 and over, examined by a hair transplant surgeon	Female pattern hair loss	"Quite common beginning in the late 20s", peaking after 50 (the abstract gives no figures)

All four are snapshots. None followed the same women from one grade to the next, so they cannot say how fast a grade I becomes a grade II.

What the Ludwig scale misses

The Ludwig scale describes one pattern well and has at least four blind spots. This is the part of the scale that matters most to someone trying to grade themselves, because a pattern the scale does not describe still gets forced into one of its three boxes.

Receding temples are not rare in women

Ludwig treated frontal recession in women as exceptional. Population data says otherwise. In a survey of 564 women from the general population, recession of the frontal and frontoparietal hairline was found in 13% before menopause and 37% after it (Venning and Dawber, J Am Acad Dermatol 1988). In the Australian town study, 64.4% of the women examined had some bitemporal loss.

The current literature has moved with the data. The 2016 Cochrane review of female pattern hair loss states that "the frontal hair line may or may not be preserved" (van Zuuren et al, Cochrane 2016), and the AAD lists "hair near your temples may recede" as a sign. The 2016 classification review notes that women with a male-type pattern "could not be classified" on Ludwig's system. When the temples are the main change, the receding hairline self-check describes what to look for along that edge.

The Christmas tree pattern

Many women lose density fastest at the front of the part, not the crown. Elise Olsen described a "Christmas tree" pattern in 1994, where a centre part widens towards the forehead in a triangle (as summarised in the 2016 classification review), and later called the midline part an important physical clue to diagnosis (Olsen, J Am Acad Dermatol 1999). A 2019 expert statement from the Androgen Excess and PCOS Society names it as one of the two typical patterns of female pattern hair loss, alongside Ludwig's crown-outward thinning (Carmina et al, J Clin Endocrinol Metab 2019). Ludwig's zone stops short of the front, so this pattern has no proper grade.

Grade I overlaps with normal hair

Hair density in women is spread along a normal curve, and most women diagnosed with female pattern hair loss sit within its lower half. The UK clinic study measured it directly: average density fell from 293 hairs per cm² at age 35 to 211 at age 70, and the density of women classed as Ludwig I overlapped with that of women classed as having no hair loss. Hair diameter explained part of the difference. In other words, a grade I call is a judgement about someone near the low end of a normal range. The Taiwanese survey listed a related limitation: the "validity and reliability" of its classification "may be not perfect".

It grades a shape, not a cause

A Ludwig grade says nothing about why hair is thinning. Central centrifugal cicatricial alopecia (CCCA) starts in the centre of the scalp and spreads outward, the same direction as Ludwig's pattern, but it destroys follicles and replaces them with scar tissue. The AAD says it is more common in Black women, usually begins in middle age, and that starting treatment early can prevent it spreading (AAD, CCCA). Diffuse shedding after illness or childbirth can also widen a part.

The women's minoxidil label reflects this. It tells users not to start if the loss is sudden or patchy, follows childbirth or comes with no family history (women's 5% foam label, DailyMed). The 2019 expert statement goes further: it calls checking for androgen excess "mandatory" in every woman with this diagnosis, with iron, thyroid, vitamin D, zinc and prolactin tests optional but recommended.

Ludwig vs Savin vs Sinclair vs Olsen scales

The Ludwig scale is the simplest of the scales in common use, and the later ones each add something it lacks. The 2016 review concludes that every classification has limitations: some do not describe the full course of hair loss, others are too detailed for practical use.

Scale	Year	Steps	How it is read	What it adds to Ludwig	What it still misses
Ebling and Rook	1975 (two years before Ludwig)	5	Drawings	Same first two stages, then frontotemporal recession and a male-like stage V	Christmas tree
Ludwig	1977	3	Drawings of the crown zone	The baseline	Temples, Christmas tree, fine steps
Olsen	1994, 1999	3 density grades	Look along a centre part	Frontal accentuation (Christmas tree)	Temples
Savin	Early 1990s	8 crown images plus a frontal category	Computer-generated images	Finer steps, frontal recession	Christmas tree
Sinclair	2004	5	Photographs of a centre part, 1 is normal	A version patients can score themselves	Anything away from the part

The Savin scale turns up in research because its finer density steps suit trial entry criteria: the phase III trial of once-daily 5% foam in women enrolled women at Savin grades D3 to D6 (Bergfeld et al, J Drugs Dermatol 2016).

What a Ludwig grade predicts about treatment

A higher grade means fewer full-thickness follicles, which plausibly limits what treatment can bring back. But in an uncontrolled study that tested it, the Ludwig grade did not predict who would respond.

Follicles by grade. Frontal scalp biopsies from 42 women complaining of hair loss, graded on a five-point clinical scale, showed what the grades mean underneath (Messenger and Sinclair, Br J Dermatol 2006):

Grade	Total follicles per cm²	Terminal (full-thickness) follicles per cm²	Share in resting phase
1 (no obvious loss)	317	263	13.7%
5 (severe loss)	243	96	31.4%

Terminal follicles fell by almost two-thirds, but the total fell by just under a quarter. At grade 5, about three-quarters of the grade 1 follicle count was still there, but fewer than half of those follicles were terminal. The authors concluded that miniaturisation "progresses to follicular deletion" at the severe end. The study did not test treatment response.

Ludwig grade did not predict response. In an uncontrolled study of 80 women aged 12 to 79 with biopsy-confirmed miniaturisation, given oral antiandrogens (spironolactone 200 mg or cyproterone acetate) for at least 12 months, 44% regrew hair, 44% held steady and 12% kept losing (Sinclair et al, Br J Dermatol 2005). Age, menopause, hormone levels and Ludwig stage did not predict who improved. The only significant predictor was a different measure, the midscalp clinical grade, and there a higher (worse) grade went with a greater response. The authors noted that without a placebo group, the result cannot be separated from the natural course of the condition.

What the treatment evidence covers. Topical minoxidil is the only drug the 2016 Cochrane review found support for in women, on mainly moderate to low quality evidence. Pooled across six trials (mostly 2% minoxidil), 157 of 593 women on minoxidil (26%) reported moderate to marked regrowth against 77 of 555 on placebo (14%). In separate head-to-head trials, 2% and 5% showed no significant difference (Cochrane 2016). The women's 5% foam label gates use on a picture scale printed on the carton, telling buyers not to use it if their loss "is different than that shown", and it says results may take 3 to 6 months of once-daily use. The minoxidil results hub covers the timeline, and minoxidil at 3 months covers the early checkpoint from the foam trial.

Side effects are worth knowing at any grade. Across placebo-controlled trials of minoxidil solution in 1,333 women, 4% of all participants (placebo arms included) spontaneously reported unwanted facial or body hair, more often on 5% than on 2% and least on placebo, against 0.5% in post-marketing reports (Dawber and Rundegren, J Eur Acad Dermatol Venereol 2003). The foam label says to stop and ask a doctor for scalp irritation, unwanted facial hair, chest pain, a racing heart, dizziness or swollen hands and feet. The full picture is in minoxidil side effects, and the twice-daily solution versus once-daily foam question is in minoxidil foam vs solution.

The other options have weaker or negative evidence in women:

• Finasteride is not approved for women and is contraindicated in pregnancy because it may cause genital abnormalities in a male fetus (Propecia label). In 137 postmenopausal women, 1 mg a day for a year did no better than placebo (Price et al, J Am Acad Dermatol 2000).
• Spironolactone is used off-label, and Cochrane listed it among treatments still needing randomised trials. A 2023 pooled analysis of trials and observational studies reported menstrual disturbance in 11.85% of women and facial hair growth in 6.93% (Aleissa, Cureus 2023). Its label says to avoid it in pregnancy because of a potential risk to a male fetus (Aldactone label).
• Low-dose oral minoxidil is also off-label. In a meta-analysis of studies without control groups in people treated for alopecia, blood pressure did not change significantly but heart rate rose slightly, 5.0% reported symptoms of low blood pressure, and unwanted hair growth was the most frequent side effect, behind 34.6% of discontinuations (Chen et al, J Am Acad Dermatol 2025). Doses and risks are in oral minoxidil for hair loss.
• Add-ons sold at every grade have the thinnest evidence. In the largest microneedling trial, 245 women on 2% minoxidil, adding clinic microneedling made no difference on any endpoint (see derma roller hair).

Ludwig grade and hair transplant candidacy

A Ludwig grade alone does not make anyone a transplant candidate. A stable donor area and a defined target area do. Female pattern loss is often diffuse, so donor quality has to be measured rather than assumed, and continuing loss around a grafted area can leave a result that looks isolated later.

The hair transplant guide for women covers candidacy by type of hair loss, FUE against FUT, and why surgery is described in the literature as an exceptional option for this diagnosis rather than a first one. For prices, the hair transplant cost calculator works from graft count and country.

How to place yourself on the Ludwig scale at home

A repeatable photo of a centre part is the most useful self-check, because every scale above is read along the part. The method that keeps photos comparable:

1. Dry, unstyled hair, parted down the middle from the front hairline to the crown.
2. Overhead light in the same room every time.
3. Phone held level, directly above, at the same height.
4. One photo of the front third and one of the crown, every six months, not every week.

Then compare the two photos. If the front of the part is wider than the back, that is the Christmas tree pattern and the Ludwig scale will under-describe it. If the temples have moved, the male scale fits better.

A home grade may come out lower than a clinician's. When 44 women on a waiting list for treatment rated their own loss on a photographic scale, they underestimated its severity compared with their clinicians; 30 women already in treatment rated it the same as their clinicians did (Biondo et al, Br J Dermatol 2004).

Frequently Asked Questions

What are the 3 stages of the Ludwig scale?

Grade I is visible thinning on top of the head in a zone that starts 1 to 3 cm behind the front hairline. Grade II is pronounced thinning in the same zone. Grade III is complete or near-complete loss inside that zone, with the front edge still present.

Is the Ludwig scale the same as the Norwood scale for women?

It is the female counterpart, but it measures something different. The Norwood scale tracks a receding hairline and a bald crown in men, while the Ludwig scale tracks loss of density on top of the head behind an intact front edge. Women whose temples recede are better described by a male-type scale, which population studies suggest is far more common than Ludwig assumed.

Can you go back a Ludwig grade?

Sometimes, partly. In pooled trials about 26% of women on topical minoxidil reported moderate to marked regrowth against 14% on placebo (Cochrane 2016). The trials did not report results as Ludwig grade changes, so how often a woman moves down a grade is unknown. A biopsy study that graded severity on its own five-point scale found fewer full-thickness follicles in more severe loss.

Is Ludwig grade 1 normal?

Not exactly, but it overlaps with normal. In a UK study, the hair density of women classed as Ludwig I overlapped with that of women classed as having no hair loss, and density falls with age in everyone. Telling early pattern loss from low normal density is a clinical judgement, which is why a scalp examination by a dermatologist matters more than a self-assigned grade.

The bottom line

The Ludwig scale is good shorthand and a poor diagnosis. It gives three words for one common pattern, it misses the receding temples and the front-heavy Christmas tree that many women have, and its grade did not predict who responded to antiandrogens in an uncontrolled study that tested it. The six-monthly part photos above are the most useful thing to bring to an appointment. A dermatologist can check them against a scalp examination, blood tests where indicated and, when needed, a biopsy, which are what tell female pattern hair loss apart from the conditions that imitate it.