Retrograde Alopecia: Hair Loss at the Nape of the Neck and Above the Ears
Last reviewed on 19 July 2026. We review our treatment guides every six months to keep them accurate.
Almost every hair loss guide describes the front and the top of the head. Retrograde alopecia is the opposite. It is thinning that starts low down at the back and the sides, at the nape of the neck and above and behind the ears, and creeps upwards from below. People often notice it after a short haircut, when the hair at the bottom of the back of the head looks wispy, or when the edge above the ear seems to have moved up.
It matters more than its size suggests, because that lower band of hair is the area surgeons rely on for a hair transplant. If you have found this page because you are worried that balding at the back of the head has ruled you out of surgery, the honest answer is that it sometimes changes the plan and often does not, and only an examination of your own donor area can tell you which. This guide sets out what is known, what is not, and what a clinician will actually look for.
For an independent, regularly updated overview of hair loss and its causes, the NHS hair loss page is a reliable starting point. The NHS suggests seeing a GP to get an idea of what is causing your hair loss before thinking about going to a commercial hair clinic, which is sensible advice whatever you read online.
What retrograde alopecia is
Retrograde alopecia is the term used for hair loss that affects the nape of the neck and the sides of the scalp just above the ears. Rather than a hairline moving backwards from the front, the lower and outer parts of the occiput, meaning the bottom and sides of the back of the head, recede upwards towards the centre. The word retrograde simply means backwards, and that is exactly what it describes: the fringe of hair that normally survives is being lost from underneath.
In most cases it is not a separate disease. It usually appears alongside ordinary male or female pattern hair loss, and published descriptions report that the more advanced the pattern loss, the more often and more markedly retrograde alopecia shows up with it. Some authors treat it as a subtype of androgenetic alopecia, others as a separate entity. It shares the same behaviour: a gradual start after puberty, a slow increase in fine vellus-like hairs and a matching fall in normal thick ones.
One reason it goes unrecognised is that the standard charts do not include it. Neither the Norwood scale used to grade male pattern hair loss nor the Ludwig scale used for women describes loss at the occipital and temporal margins at all, so a pattern that falls outside those charts can be recorded as nothing in particular.
Where it shows: above the ears, behind the ears and the nape of the neck
The areas involved are the ones people describe in plain language rather than clinical terms:
The nape of the neck. Alopecia at the nape of the neck is the commonest starting point. The lowest hairline at the back thins and rises, most often in a fairly straight band that runs parallel to the existing occipital fringe.
Above and behind the ears. Alopecia above the ears and behind the ears affects the temporal and lateral scalp, the strip that sits over and just behind the ear. This is often what makes a short back and sides look patchy.
The lower back of the head. As it progresses, thinning moves up towards the external occipital protuberance, the bony bump you can feel at the back of the skull. Interestingly, the hair in the middle of the lower occiput often holds on longest, in much the same way that a central tuft can persist at the front in ordinary pattern loss.
Less common patterns have also been described, including an hourglass shape and an inverted pattern. What all of them share is direction: the loss moves upwards from below, not backwards from the front.
Why the back and sides are meant to be safe
The follicles at the back and sides are considered resistant to the androgens driving pattern hair loss, so they are treated as permanent.
Hair transplant surgery rests on a single biological assumption. The follicles at the back and sides of the head are widely considered to be resistant to androgens, the hormones (chiefly DHT) that drive pattern hair loss, and are therefore treated as permanent. That band is called the safe donor area, and it is the reason a transplanted hair is expected to keep growing in its new position: it carries the characteristics of where it came from, not where it is put. You can read more in our guide to the donor area.
Retrograde alopecia is what it is called when that assumption does not entirely hold, and miniaturisation reaches into the supposedly permanent zone from below. The safe donor area was first mapped in the 1990s and remains the global standard, but it was described as an average, and later work has repeatedly found individual variation that the original definition did not account for.
How common is it?
Retrograde alopecia is far less studied than pattern baldness, the evidence is small and almost entirely in men, and there is no good UK figure.
Less is known here than the confident numbers on the internet suggest, and it is worth saying so plainly. Retrograde alopecia is far less studied than pattern baldness, the published work is small, single-centre and almost entirely in men, and there is no good UK prevalence figure. Two studies give a sense of the range:
In a cross-sectional study of 1,000 men attending a hospital hair clinic with androgenetic alopecia, about 5 percent had retrograde alopecia of some degree, most of them at the mildest grade.
In a separate study of 681 men aged 50 to 55 with more advanced pattern loss, thinning that ran upwards into the donor region was found in around 22 percent, and diffuse thinning of the donor area in a further 8 percent.
The gap between those figures is mostly age and severity: the second group was older and more affected. The practical message from both is the same one their authors drew, which is that the permanent zone is not guaranteed to be permanent in everyone, and it should be looked at rather than assumed.
How retrograde alopecia is assessed
Assessment is done by looking, and looking closely. Published guidance on surgical candidacy is unusually blunt about the method: comb through the entire scalp, examine the donor area as carefully as the thinning area, and use magnification routinely rather than only when something looks wrong.
The tool for this is trichoscopy, also called scalp dermoscopy, which is a magnified look at the scalp with a dermatoscope. What it is being used to find is miniaturisation: the gradual shrinking of follicles so that they produce hairs that are progressively shorter and finer. Two measurements matter in the donor area:
Hair shaft diameter diversity. A healthy scalp shows fairly uniform hair thickness, with fine hairs making up no more than about a fifth of the total. Variation in shaft diameter above roughly 20 percent, sometimes called anisotrichosis, is the classic trichoscopic sign of pattern hair loss. Finding it in the donor area, rather than only on top, is the finding that defines retrograde involvement.
Donor compared with recipient. The comparison is the point. Miniaturisation on top with a clean, uniform donor area is ordinary pattern loss. Miniaturisation in both, particularly reaching the sides and the back, is a different situation and changes what surgery can safely achieve.
Density is measured at the same time, in follicular units per square centimetre, since a donor area can be thin without being miniaturised. Where the findings are unusual, published guidance is to pause for a dermatology opinion and, if needed, a scalp biopsy before any surgery is planned, rather than to proceed and hope.
One published proposal grades retrograde alopecia by how far up it reaches, using the occipital bump and the top of the ear as landmarks, and links each grade to whether the safe donor area is affected. At the lower grades the thinning sits below the donor zone and does not touch it. At the middle grades it encroaches, and the affected hair has to be excluded from harvesting. At the highest grade the donor area is considered fully involved. It is a single small study rather than an agreed standard, but it captures the logic your surgeon will be applying.
Other causes of hair loss at the nape and behind the ears
Retrograde alopecia is not the only reason hair goes missing at the back and sides, and the alternatives are managed completely differently. Getting this right matters more than the label, because two of the conditions below can be made worse by surgery.
Frontal fibrosing alopecia
A scarring hair loss that runs as a band along the hair margin. It is most often described in post-menopausal women, though younger women, men and all ethnic groups can be affected, and it is reported to be becoming more common. It usually affects the front and sides, but an atypical pattern involves the whole hair margin, front and back, so it can appear at the occipital rim. Clues include skin in the affected band that looks pale, shiny and undamaged by sun with no visible follicle openings, redness or scale around individual hairs, single lonely hairs left standing in the bald zone, itch or pain, and loss or thinning of the eyebrows, which often comes first. Because the follicles scar, hair does not return unless treatment starts early, and grafting is only considered once the disease has settled. If any of that sounds familiar, this is a dermatologist's job, not a hair clinic's. See DermNet on frontal fibrosing alopecia.
Traction alopecia
Hair loss caused by prolonged or repeated pull on the hair: tight ponytails and buns, braids, cornrows, dreadlocks, weaves, extensions, relaxers and rollers, or simply the weight of very long hair. It most often affects the front and sides, but where it appears depends entirely on how the hair is worn, so it can show at the edges and at the nape. A useful clue is the fringe sign, where a line of hair is retained right at the rim while the scalp behind it thins. Caught early it is reversible by changing the styling; left long enough the follicles are destroyed and the loss becomes permanent. See DermNet on traction alopecia.
Alopecia areata
An autoimmune condition in which hair is lost quite suddenly in well-defined round or oval patches of otherwise normal-looking skin. It has a variant, called ophiasis, that produces band-like loss along the occipital and temporal margins, which is exactly the territory retrograde alopecia occupies, so the two can look similar at a glance. The differences are speed and texture: alopecia areata comes on over days to weeks and leaves smooth, completely bald skin, whereas retrograde alopecia thins over years. It is a medical condition with medical treatments, and transplant surgery is not appropriate while it is active. See DermNet on alopecia areata.
Diffuse unpatterned alopecia
A form of hair loss in which miniaturisation is not confined to the top of the head but involves the temporal, parietal and occipital scalp as well, so there is no reliably stable area to take hair from. It is the reason careful donor assessment exists. Published candidacy guidance is unambiguous that where there is no safe donor area, a transplant will not produce an enduring result and should not be done, and that medication rather than surgery is the treatment.
Retrograde alopecia in women
Retrograde alopecia in women is real but poorly documented: the published studies of it were carried out in men, so anyone quoting a female prevalence figure is guessing. What can be said is more useful than a number. Female pattern hair loss normally spares the back and sides, producing diffuse thinning over the top of the scalp with the posterior and lateral margins intact. So a woman losing hair at the nape of the neck or above and behind the ears is showing something outside the usual pattern, and that is a reason to be assessed rather than reassured.
The most important thing to exclude is frontal fibrosing alopecia, which is far more common in women, can involve the back of the hair margin as well as the front, and is scarring, so time genuinely matters. Traction alopecia from tight styling is the other frequent explanation at the edges and the nape. Both need a dermatologist rather than a hair loss product, and a GP referral is the route to one.
What retrograde alopecia means for a hair transplant
This is the question most people arrive with, so here is the direct answer: it depends on how far up it reaches, and it is a judgement your surgeon makes after examining you, not something that can be settled from a photograph.
The reason it carries weight is that donor hair is finite and cannot be replaced. The safe donor area amounts to only around a quarter of the scalp's surface, and roughly half of that can be harvested before the donor area itself starts to look thin, so the usable supply is a fixed budget spent once. A graft taken from a zone that is quietly miniaturising is a graft that may thin or disappear years later, in its new position, after you have paid for it and after that donor hair has been used up. That is why surgeons look at the donor area at least as hard as the area you want filled.
In practice, the responses available to a surgeon are roughly these, and which one applies is their call:
Proceed as normal. Where the thinning sits low, below the donor zone, and the donor hair above it is uniform and dense, retrograde alopecia may make no difference to the plan at all.
Narrow the safe zone and take grafts higher. Where it encroaches, the affected hair is excluded from harvesting and the donor area is redrawn more conservatively. This usually means fewer grafts are available than a straightforward case would allow, and expectations are set accordingly.
Stabilise first, then reassess. Where loss is still moving quickly, published guidance is to treat medically for six to twelve months and reassess rather than operate into an unstable picture, particularly in younger men.
Advise against surgery. Where miniaturisation is widespread across the donor area, a transplant cannot produce a lasting result, and the right advice is not to have one. Some patients are also offered a limited plan instead, for example covering the front only at a modest density, which is a reasonable option provided the limits are understood and accepted from the start.
None of that is a rejection of you, and it is worth saying that being turned down, or asked to wait, is often the more skilled answer. Published guidance sets a fairly high bar for who should be operated on, and being told to stabilise first is a sign that the donor area is being taken seriously rather than spent.
Treatment for retrograde alopecia
There is no treatment proven specifically for retrograde alopecia. No randomised trial has tested a therapy in this pattern, and any product marketed as a retrograde alopecia treatment is borrowing evidence from somewhere else. That is worth knowing before you spend money.
What is generally tried is the treatment used for pattern hair loss in general, on the reasoning that retrograde alopecia usually travels with it. The NHS lists minoxidil and, for men, finasteride as the main treatments for male pattern baldness. Minoxidil can also be used for female pattern baldness; women should not use finasteride. The NHS is candid that these treatments do not work for everyone, work only for as long as they are used, and are not all available on the NHS. They are a conversation to have with a doctor rather than something to start on your own, and the realistic aim is holding on to what you have rather than regrowing what has gone.
If the cause turns out to be something else, the treatment is different in kind. Scarring hair loss such as frontal fibrosing alopecia is treated with anti-inflammatory and immune-modifying medicines under a dermatologist, and early treatment is what protects the follicles that remain. Traction alopecia is treated first by changing how the hair is worn. Alopecia areata has its own treatments, including steroid injections and, in severe cases, newer tablets. This is the practical reason for getting the diagnosis right before buying anything.
If you want a wider view of how thinning is spotted and slowed elsewhere on the scalp, our guide to spotting and stopping a balding crown covers the same ground for the top of the head.
Frequently asked questions
What is retrograde alopecia?
Retrograde alopecia is hair loss affecting the nape of the neck and the sides of the scalp just above and behind the ears, which recedes upwards rather than backwards from the front. It usually occurs alongside ordinary male or female pattern hair loss and tends to be more prominent the more advanced that loss is. It matters chiefly because it affects the band of hair used as the donor area in a hair transplant.
Can you still have a hair transplant with retrograde alopecia?
Often, yes, but it depends on how high the thinning reaches. If it sits low and the donor hair above it is dense and uniform, it may not change the plan. If it encroaches on the donor zone, a surgeon will usually narrow the safe area, take grafts higher and offer fewer of them. If miniaturisation is widespread across the back and sides, a transplant cannot give a lasting result and the honest advice is not to have one. Only an examination with magnification of your own donor area can tell you which of those applies.
Is there a treatment for retrograde alopecia?
There is no treatment proven specifically for retrograde alopecia, and it is more honest to say so than to imply one exists. In practice clinicians use the same medical treatments as for pattern hair loss, which the NHS names as minoxidil and, for men, finasteride. They do not work for everyone and only work while they are used. If the real cause is a scarring alopecia, traction or alopecia areata, the treatment is entirely different, which is why a diagnosis should come before any purchase.
Does retrograde alopecia affect women?
It is described in women, but the published studies were done in men, so there is no reliable figure for how often. The useful point is that female pattern hair loss usually leaves the back and sides alone, so thinning at the nape of the neck or above the ears in a woman is outside the expected pattern and should be assessed. The priority is to exclude frontal fibrosing alopecia, a scarring hair loss that is much more common in women and can involve the back of the hair margin, because with scarring conditions early treatment is what preserves the remaining follicles.
Why am I losing hair above and behind my ears?
Thinning above and behind the ears can be retrograde alopecia, particularly if it has come on slowly over years alongside loss on top, and if the hairs there are becoming finer rather than simply fewer. It can equally be traction from tight or heavy hairstyles, a band of alopecia areata along the scalp margin, or a scarring alopecia. Speed is the most useful clue you have on your own: years of gradual fining points one way, weeks of smooth patchy loss points another. Either way it is worth a GP appointment, and a scalp examination under magnification will usually settle it.
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