Journal of Dermatology & Dermatologic Surgery

: 2019  |  Volume : 23  |  Issue : 2  |  Page : 81--85

Headcover and male-pattern hair loss: A cross-sectional study

Mohammed I AlJasser1, Mohammed Alshaya2, Khaled Alabduljabbar3, Sara I Altraif3, Sultan Aleshaiwi3, Emad Masuadi4,  
1 Division of Dermatology, College of Medicine; King Abdullah International Medical Research Center; Research Unit, Department of Medical Education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arbia
2 Division of Dermatology, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
3 Division of Dermatology, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arbia
4 Research Unit, Department of Medical Education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arbia

Correspondence Address:
Dr. Mohammed I AlJasser
Division of Dermatology, King Saud Bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh 11481
Saudi Arbia


Background: Androgenetic alopecia (AGA) is the most common form of alopecia. The interaction of genetics and environmental factors likely plays a role in its pathogenesis. Several environmental factors have been studied in relation to the severity of AGA; however, the effect of headcover has not been properly assessed. Objectives: The objective of this study is to assess the severity of male-pattern hair loss (MPHL) in relation to headcover. Methods: Adult males with varying degrees of MPHL were recruited during the period from May 2016 to August 2017. Data included demographics and type of headcover. The total duration of headcover was calculated for every participant in years. Assessment of MPHL was performed using the Norwood–Hamilton classification. Results: A total of 865 participants with MPHL were enrolled. No statistically significant difference in the severity of MPHL was found between participants who covered their head frequently as compared to those who did not (P = 0.952). Multivariate logistic regression analysis showed that age was the only factor associated with increased severity of MPHL. Conclusions: Males who cover their head do not appear to have increased overall severity of MPHL.

How to cite this article:
AlJasser MI, Alshaya M, Alabduljabbar K, Altraif SI, Aleshaiwi S, Masuadi E. Headcover and male-pattern hair loss: A cross-sectional study.J Dermatol Dermatol Surg 2019;23:81-85

How to cite this URL:
AlJasser MI, Alshaya M, Alabduljabbar K, Altraif SI, Aleshaiwi S, Masuadi E. Headcover and male-pattern hair loss: A cross-sectional study. J Dermatol Dermatol Surg [serial online] 2019 [cited 2020 Jan 23 ];23:81-85
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Androgenic alopecia (AGA) or patterned hair loss is the most common type of alopecia. It is characterized by hair loss affecting the superior part of the scalp while sparing the lateral and posterior aspects. The prevalence of AGA increases with age, and up to 50% of males will have some degree of AGA by the age of 50 years.[1]

Hair loss in AGA occurs due to progressive miniaturization of hair follicles. The exact cause of these changes is still poorly understood. AGA develops in genetically predisposed individuals. Males with a paternal history of male-pattern hair loss (MPHL) are significantly more likely to have MPHL than those with negative paternal family history.[2] Furthermore, positive family history is associated with more severe AGA.[3],[4] Genetic abnormalities in AGA are a most likely part of a multifactorial process that requires environmental factors in order for the disease to manifest.

Studies on the relationship between environmental factors and AGA are limited. Androgens play a major role in the pathogenesis of AGA.[1] Smoking and drinking alcohol are associated with more severe AGA.[4] Other factors related to lifestyle such as poor sleep, frequent consumption of soybean drink, and high body mass index (BMI) are observed more frequently in patients with more severe AGA.[5],[6]

One lifestyle that is common in our community is to cover the head (for example, with a hat). Interestingly, we have noticed that many people in the community, especially males, ask physicians if covering the head worsens AGA. This question was only addressed partially by one previous study on female twins.[7] Pressure created by the upper scalp weight of the skin on hair follicles might hypothetically contribute to the development of AGA.[8],[9] Covering the head might further increase the pressure on hair follicles and theoretically worsens AGA. Therefore, we hypothesized that a higher frequency of headcover use might be associated with more severe MPHL. The aim of this study was to assess the severity of MPHL in relation to headcover.


The study has been performed according to the Declaration of Helsinki principles and was approved by the Institutional Ethics Committee at King Abdullah International Medical Research Center (IRBC/328/16).

This cross-sectional study was conducted at public places (mainly shopping malls and coffee shops) during the period from May 2016 to August 2017. Informed consent was obtained from all enrolled participants. Adult Saudi males with any degree of patterned hair loss were interviewed. Exclusion criteria included the presence of the following within the past six months: any treatment for baldness, high fever (>38°C), severe emotional distress, or anticancer treatment. The following data were collected: demographics, BMI, family history of AGA, perception of factors that might cause and/or worsen MPHL, and type of headcover. Types of headcover included shemagh, sun cap, military hat, and helmet. Shemagh is the national headcover for males. It is usually worn over a white hat that is firmly attached to the scalp. The duration of headcover was calculated for each type of headcover using the following formula:

Duration of head cover (hours) = hours per day × days per week × 52 × years of head cover use

The total duration of headcover (in hours) for each participant was obtained by summing the duration of using each type of headcover. Finally, the total duration in hours was converted to years. Participants were categorized based on their BMI into normal (BMI < 25), overweight (BMI 25–29.9), and obese (BMI ≥30). Assessment of MPHL was performed using the Norwood–Hamilton classification.[10] The severity of MPHL was further categorized into mild (I–II), moderate (III–IV), and severe (V–VII).

The sample size was calculated based on the proportion of headcover across the three levels of severity of MPHL. To achieve a power of 80% in detecting at least 10% difference in proportion of headcover between the levels of severity of MPHL and with a 5% level of significance, the required sample size was 808. Calculation was done using PiFace ( To accommodate for no responses, 10% extra was added to the sample size to become 890. Convenient sampling was performed with stratification based on the frequency of headcover.

Data analysis was done using the Statistical Package for the Social Sciences (SPSS) version 21 software (SPSS Inc., Chicago, IL, USA). Descriptive statistics including frequencies and percentages were used to describe categorical variables. Mean and standard deviation were generated for numerical data. Univariate and multivariate logistic regression analyses were used to test the relationship between headcover status and MPHL severity. A test with P ≤ 0.05 was considered statistically significant.


A total of 865 participants were enrolled [Table 1] and [Table 2]. The mean age was 36 ± 10.8 years. Family history of AGA was positive in approximately 80% of participants. Approximately 20% of participants thought that covering the head causes and/or worsens MPHL. The majority used shemagh as a headcover [Figure 1].{Table 1}{Table 2}{Figure 1}

Univariate analysis showed that the severity of MPHL did not differ with regard to headcover status (P = 0.952) [Table 3]. A statistically significant difference in the severity of MPHL was found in relation to age, duration of baldness, marital status, and job (P < 0.001 for all variables). Age and duration of baldness were found to be highly correlated (r = 0.68, P < 0.001). Therefore, the duration of baldness was not included in the multivariate regression analysis in order to avoid collinearity. Multivariate regression analysis showed that age was the only factor associated with MPHL severity [Table 4].{Table 3}{Table 4}


The exact cause of AGA is unknown. Knowledge of environmental factors associated with exacerbation of AGA is important; however, studies in this regard are limited. Ustuner theorized that pressure on hair follicles against the skull by the skin leads to AGA.[8],[9] This is expected to be more at the top of the scalp due to the gravity effect. With increasing age and elevation of testosterone levels at puberty, subcutaneous fat thickness decreases and hair follicles undergo more pressure.[8] We hypothesized that frequently covering the head would be associated with more pressure on hair follicles and subsequently more severe AGA.

Surprisingly, our study showed that the frequent use of headcover is not associated with more severe MPHL. Interestingly, headcover was found to be associated with less hair loss in a study of AGA in female twins.[7] However, this was only assessed in 18 participants, and details on headcover were not mentioned. Subcutaneous blood flow is reduced in MPHL.[11] Frequently covering the head might increase the local temperature and subsequently increases blood flow to the scalp. This might oppose the pressure effect by the headcover.

Exposure to ultraviolet light might be associated with aggravation of AGA. Keratinocytes release inflammatory mediators and reactive oxygen species after exposure to ultraviolet radiation. This potentially results in microscopic follicular inflammation that could negatively affect hair growth.[12] The prevalence of MPHL was found to be two times higher in Asian policemen as compared to the general population.[13] This was attributed to possibly more stress and exposure to sunlight in policemen. Furthermore, there was a higher risk of developing AGA in policemen who practiced less sun protection and got exposed to sunlight for longer durations. Prolonged exposure to ultraviolet radiation has been shown to be a significant risk factor in Asian females with AGA.[14] Given that ultraviolet radiation is a potential aggravating factor for AGA, headcover could decrease the progression of AGA by photoprotection. Scalp photoprotection might neutralize the pressure effect secondary to covering the head.

Age was the only factor that was independently associated with more severe MPHL. This is in agreement with previous studies.[14],[15] BMI was not found to be associated with MPHL in our study. This is consistent with results of some previous studies.[16],[17],[18] However, other studies showed a strong association BMI and severity of MPHL.[6],[15]

There are some limitations to our study. One limitation is the cross-sectional design. Furthermore, recall bias could have possibly affected the accuracy of the duration of headcover use. Those limitations would be potentially minimized with a prospective cohort study design.


Our study showed that the overall MPHL severity did not differ with headcover use. Additional studies are required to provide better counseling to patients with MPHL regarding headcover.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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