Thinning crown: when it is worth assessing

The crown, the area at the top of the back of the head where the hair forms its whorl, is one of the first to thin in male baldness. It is also the one that is least seen: nobody looks at their own crown in the mirror. Many men only notice it in a photograph taken from above, when the barber comments on it, or when someone makes a joke. By then, the loss has usually been happening for some time.

The good news is twofold. First, not every "open" crown is baldness: the whorl always lets some scalp show. Second, when it is baldness, the crown is the area that responds best to treatments with evidence. There is also a third point, less well known: crown baldness is associated, in studies, with higher cardiovascular risk, which is a good reason to look at your health as a whole.

Why the crown is a typical area for baldness

In male baldness, the follicles most sensitive to dihydrotestosterone (DHT) are concentrated in two areas: the front (temples and hairline) and the crown (vertex). This is where miniaturisation begins: hairs grow progressively thinner and shorter, until they become almost invisible. The sides and back, which are less sensitive, remain. For the mechanism, see Male pattern baldness: what it is and how to recognise it.

On the Hamilton-Norwood scale (Norwood, 1975), there are men in whom the crown is the first area to thin, with the front almost intact (grade III vertex), and others in whom the temples recede first. Over time, the two areas tend to move closer and, in the more advanced grades, to join.

Why it goes unnoticed

• We cannot see it: only with two mirrors, photographs or someone's help.
• Longer hair on top disguises it for years.
• Light can mislead: under overhead light, everyone seems to have a more open crown; under side light, the loss is hidden.
• Progress is slow, and a change of a few per cent a year is not noticeable from one day to the next.

To learn how to observe and photograph the crown methodically, see How to see your crown: the two-mirror method and Photos every 3 months: how to track the crown.

Normal whorl or the start of baldness?

The hair on the crown grows in a spiral from a point, the whorl. At that point, the hairs come out in different directions and it is normal to see a small circle of scalp, especially with wet or short hair or strong overhead light. Some people have two whorls. None of this is baldness.

Signs to watch for

• Someone commented that "it is opening up at the back".
• In photographs from above, the visible area of scalp is larger than one or two years ago.
• The hair on the crown feels thinner to the touch and does not "hold" a style.
• The temples are also rising.

What is not baldness

A round, smooth patch that appeared within weeks may be alopecia areata. Redness, scaling, spots, pain or shiny, smooth skin suggest an inflammatory or scarring alopecia. Both should be assessed without delay. See Alopecia areata: what it is and how to recognise it.

Crown and health: the association with cardiovascular risk

For more than two decades, observational studies have linked crown baldness with coronary disease (Lotufo et al., 2000). In 2013, a meta-analysis published in BMJ Open (Yamada et al., 2013) brought together six studies with almost 40,000 men:

• Crown baldness was associated with a higher risk of coronary disease, in proportion to its extent: about 18% higher risk in mild baldness, 36% in moderate and 48% in extensive.
• Isolated recession of the front hairline showed a much weaker association.
• The association was stronger in younger men (under 55 to 60).

How to interpret

• Association is not causation. Baldness does not cause heart disease, and treating baldness does not reduce cardiac risk. The hypotheses involve common factors, such as sensitivity to androgens, insulin resistance, chronic inflammation or shared genetic factors.
• The increase in risk is relative and moderate, much lower than that of factors such as smoking, high blood pressure, high cholesterol or diabetes.
• It is an opportunity, not a cause for alarm. The authors themselves suggest that men with crown baldness, especially younger ones, should review their cardiovascular risk factors.

In practice: if your crown is thinning, take the opportunity to measure your blood pressure, have cholesterol and sugar tests with your GP, stop smoking and keep up regular physical activity. Good for the heart and for the rest of you.

When it is worth getting assessed

Why the crown is worth treating early

The crown is the area where medical treatments have the best results.

• Oral finasteride: in the registration trials, with more than 1,500 men with crown baldness, most of those treated had no further visible loss after two years, while in the placebo group the loss progressed in most (Kaufman et al., 1998). It has known adverse effects, including sexual ones and, according to the European Medicines Agency (2025), suicidal thoughts of unknown frequency; any change in mood requires stopping and seeking medical help.
• Topical minoxidil: approved and effective, especially on the crown; applied directly to the area.
• Other options, such as low-dose oral minoxidil (off-label) or finasteride spray, are discussed at the consultation.

A transplant on the crown is possible, but it is usually a lower priority than the front and requires the baldness to be stable, because the crown can keep widening and leave the transplanted hair "isolated".

As with all baldness, the realistic aim is to halt progression and recover some volume. Results are assessed at 6 to 12 months and require maintenance (European guideline: Kanti et al., 2018).

At the consultation

At Luxmed, the hair medicine consultation includes:

• Clinical history: onset, progression, family history, medicines and supplements (including testosterone or anabolic steroids).
• Examination of the crown, temples, sides and back, with classification on the Norwood scale.
• Trichoscopy: shows whether the hairs around the whorl are miniaturised, distinguishes a normal whorl from early baldness and rules out other causes.
• Standardised photographs of the crown, to compare accurately at later consultations.
• Treatment plan agreed with you, with clear information about benefits, risks and expectations.

If your crown is thin and you have not yet reviewed your cardiovascular risk, we suggest that you also do so with your GP.

This article is for information purposes and does not replace a medical consultation. The results of any treatment vary from person to person.

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