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| EDITORIAL |
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| Year : 2021 | Volume
: 39
| Issue : 4 | Page : 167-168 |
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Hair loss and COVID-19
Kai-Che Wei1, Chao-Chun Yang2
1 Department of Dermatology, Kaohsiung Veterans General Hospital; Department of Cosmetic Applications and Management, Yuhing Junior College of Health Care and Management, Kaohsiung; Department of Dermatology, National Yang Ming Chiao Tung University, Taipei, Taiwan
2 Department of Dermatology, College of Medicine, National Cheng Kung University Hospital; International Center for Wound Repair and Regeneration, National Cheng Kung University, Tainan, Taiwan
| Date of Submission | 17-Nov-2021 |
| Date of Acceptance | 17-Nov-2021 |
| Date of Web Publication | 29-Dec-2021 |
Correspondence Address:
Dr. Chao-Chun Yang
Department of Dermatology, National Cheng Kung University Hospital, No. 138 Sheng Li Rd., Tainan 704
Taiwan
 Source of Support: None, Conflict of Interest: None  | 6 |
DOI: 10.4103/ds.ds_52_21
How to cite this article:
Wei KC, Yang CC. Hair loss and COVID-19. Dermatol Sin 2021;39:167-8 |
The coronavirus disease 2019 (COVID-19) has become the most emergent health issue globally.[1] SARS-CoV-2, the pathogen of COVID-19, directly infects multiple tissues and organs, possibly involving skin and hair follicles, and profoundly affects the immune system.[2] A significant percentage of COVID-19 patients reported that alopecia occurred during or after infection.[3] The hair follicles may be directly infected by the virus or affected indirectly by the systemic changes in immune or hormonal systems. In addition, it is reasonable to speculate that alopecia may influence or predict the severity and course of COVID-19. There have been an increasing number of reports focusing on the clinical presentations and the pathophysiology of COVID-19-associated hair diseases.
| Telogen Effluvium | |  |
The association between telogen effluvium (TE) and COVID-19 is stronger than other forms of hair loss. TE is nonscarring alopecia and usually occurs 2–3 months following the triggering insult, such as medications, metabolic or hormonal changes, major stresses, or severe systemic infections. COVID-19-associated TE (CATE) has been frequently reported, and the incidence is estimated to be about one-quarter and even up to two-third of patients.[3] CATE is more common in females and associated with disease severity of COVID-19 and underlying AGA.[3] However, the diagnosis of CATE was mostly made by clinical history, which was reported by patients, and therefore, it might not be accurate and objective.
CATE generally occurred at 1–2 months following COVID-19, which was earlier than the classic TE. Similarly, an earlier onset of hair shedding within 1–2 months has also been observed in TE triggered by dengue fever, an infection caused by an RNA virus.[4] Hair shedding in CATE lasted for 1–6 months, and the median duration was 47.5 days in one case series.[5]
The mechanisms of CATE remain unclear. The hair follicles may be involved by direct infection to the hair follicle stem cells or dermal papilla cells. Infection of dermal papilla cells by dengue virus led to the production of pro-inflammatory cytokines and cell death.[6] SARS-CoV-2 virus could have potentially caused similar impacts on hair dermal papilla cells. The hair follicles could also be overwhelmed as a bystander by the cytokine storm of COVID-19. For example, the interleukin 6, which was elevated in the blood from COVID-19 patients,[7] was known to inhibit hair shaft elongation and proliferation of matrix cells. CATE may also be elicited by the psychological stress or medication related to COVID-19.
| Androgenetic Alopecia | | |
The debate on the presence of AGA as a prognostic factor for COVID-19 infection is interesting and has gained an attention. The morbidity and mortality of COVID-19 infection are higher in male or elderly patients. Therefore, it was initially speculated that AGA might increase the risk of COVID-19 severity. Some earlier small-scale studies did support this speculation by showing that the presence of AGA was associated with a higher severity and poorer outcome in male COVID-19 patients. However, results from recent studies argued against the speculation and showed that AGA in both women and men was not related to an increased COVID-19 severity.[8] The genetic association analysis also did not reveal an association between male AGA with COVID-19.[9]
| Alopecia Areata | | |
Exacerbation of preexisting alopecia areata (AA) or induction of new-onset AA by COVID-19 has been increasingly reported. In a questionnaire study conducted in Italy, 42.5% of the AA patients reported relapse of hair loss after contracted COVID-19.[10] The relapse of AA occurred at about 2 months after COVID-19. New-onset AA also occurred 1–2 months after COVID-19. COVID-19 could be linked to AA through the following mechanisms, including antigen mimicry between virus and hair follicles, cytokine shift caused by COVID-19, and tissue destruction in COVID-19 which further exposed autoantigens. AA could also be accentuated by the psychological stress during the COVID-19 pandemic.
| Other Alopecia | | |
Other hair loss conditions associated with COVID-19 include anagen effluvium, fibrosing alopecia in a pattern distribution, and post-COVID syndrome. Prolonged hair loss or abnormal hair shedding were reported in those who have post-COVID-19 syndrome or “prolong COVID-19 syndrome.”[3] The mechanisms remain unclear, although autoimmune abnormalities, immune imbalances, and prolonged residual infection of COVID-19 localized to the hair follicle may be involved.
| Conclusion | | |
In summary, COVID-19 may be associated with TE and AA, but less likely to be associated with AGA and other forms of alopecia. Hair loss associated with COVID-19 usually occurred a few months after the infection, and therefore, the cause, SARS-CoV-2, was sometimes not properly attributed. This unawareness might cause excessive anxiety to the patients and the patients might receive unnecessary investigations or treatments. Physicians, especially dermatologists, should be aware of this spectrum of COVID-19 involving the hair. Further studies to elucidate the mechanisms of hair involvement in COVID-19 also help understand this threatening global health issue with profound and versatile adverse outcomes.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Lee CH. Role of dermatologists in the uprising of the novel corona virus (COVID-19): Perspectives and opportunities. Dermatol Sin 2020;38:1-2.  [Full text] |
| 2. | Yildiray Y, Ayse P. Cutaneous manifestations of coronavirus disease in Turkey: A prospective study. Dermatol Sin 2021;39:74-8. [Full text] |
| 3. | Lopez-Leon S, Wegman-Ostrosky T, Perelman C, Sepulveda R, Rebolledo PA, Cuapio A, et al. More than 50 long-term effects of COVID-19: A systematic review and meta-analysis. Sci Rep 2021;11:16144. |
| 4. | Chu CB, Yang CC. Dengue-associated telogen effluvium: A report of 14 patients. Dermatol Sin 2017;35:124-6. |
| 5. | Abrantes TF, Artounian KA, Falsey R, Simão JC, Vañó-Galván S, Ferreira SB, et al. Time of onset and duration of post-COVID-19 acute telogen effluvium. J Am Acad Dermatol 2021;85:975-6. |
| 6. | Wei KC, Huang MS, Chang TH. Dengue virus infects primary human hair follicle dermal papilla cells. Front Cell Infect Microbiol 2018;8:268. |
| 7. | Grifoni E, Valoriani A, Cei F, Lamanna R, Gelli AM, Ciambotti B, et al. Interleukin-6 as prognosticator in patients with COVID-19. J Infect 2020;81:452-82. |
| 8. | Torabi S, Mozdourian M, Rezazadeh R, Payandeh A, Badiee S, Darchini-Maragheh E. Androgenetic alopecia in women and men is not related to COVID-19 infection severity: A prospective cohort study of hospitalized COVID-19 patients. J Eur Acad Dermatol Venereol 2021;35:e553-6. |
| 9. | Tanha HM, Medland S, Martin NG, Nyholt DR. Genetic correlation analysis does not associate male pattern baldness with COVID-19. J Am Acad Dermatol 2021;85:971-3. |
| 10. | Rinaldi F, Trink A, Giuliani G, Pinto D. Italian survey for the evaluation of the effects of coronavirus disease 2019 (COVID-19) pandemic on alopecia areata recurrence. Dermatol Ther (Heidelb) 2021;11:339-45. |
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