Ludwig Scale: Female Hair Loss Stages I to III

The Ludwig scale is a three-grade system for female pattern hair loss, published by Ludwig in the British Journal of Dermatology in 1977 after he observed 468 women. Grade I is perceptible thinning on the crown, grade II is pronounced thinning in the same area, and grade III is total baldness in that area. It is the system most often used to describe pattern hair loss in women.

The area is the same in all three grades; the density changes. Grade I is perceptible thinning on the crown, limited at the front by a line 1 to 3 cm behind the frontal hairline. Grade II is pronounced rarefaction within that area, and grade III is full baldness within it.

A female hair loss scale gives the patient and the provider a shared way to describe where the thinning is and how far it has gone, and to compare photos over time. The three most used are Ludwig (three grades), Savin (eight stages with a frontal subtype) and Sinclair (five patient-rated photographs of the central part). None of them says what caused the hair loss.

The Savin scale, from 1992, is a set of nine pictures that show eight stages of increasing crown balding plus a special subcategory for frontal recession. It gives finer steps than Ludwig's three grades and is reported to be fairly consistent between investigators using it. A 2016 review notes that it also does not capture the progressive frontal loss seen in the Christmas tree pattern.

The Sinclair scale, from 2004, is a self-report measure with five color photographs of the scalp with the hair parted in the center. Photograph 1 is a normal scalp and photographs 2 to 5 show increasingly severe loss. The patient circles the number that looks most like her own part. It is simple enough to use with patients and to track change.

The Norwood scale was built for men and describes temple recession and vertex loss. Women with a male pattern, including frontal or temple recession, could not be classified with the Ludwig scale, so a clinician may use Ebling and Rook's five stages or the Savin scale instead. For the male scale, see the Norwood scale tool on this site.

No. The Ludwig scale describes a pattern of thinning; it does not identify a cause. Hair thinning in women has several possible causes, and a provider has to examine the scalp and review the history to tell them apart. Use the grade as a plain-language description to bring to that visit.