10.5826/dpc.1301a36
Introduction: Covid-19 pandemic has been shown to have major acute and chronic impacts on the skin. Various studies, reported that there has been an increase in the number of patients who referred to the outpatient dermatology clinics with the complaint of variable hair diseases, during the era of Covid-19. Hair seems to be substantially affected by both the infection itself and anxiety/stress provoked by the pandemic. Therefore, understanding the impact of Covid-19 on the clinical course of variable hair diseases, has become a major concern in dermatology practice.
Objectives: To examine the frequency and types of various, both new-onset and ingravescent hair diseases observed in health care providers.
Methods: A web-based questionnaire related to the hair diseases seen in health care providers both prior to Covid-19 pandemic and after the start of the pandemic, was formed. The type of both new-onset and pre-existing hair diseases and ongoing hair diseases observed during Covid-19, were questioned.
Results: A total number of 513 participants were included in the study. One hundred seventy cases were diagnosed with Covid-19. During Covid-19 pandemic, 228 reported to have at least one hair disease; the most common one being telogen effluvium, followed by hair greying and seborrheic dermatitis. There was statistically significant relationship between the presence of a new-onset hair disease during the pandemic and being diagnosed with Covid-19 (p=0.004).
Conclusion: Our study shows that Covid-19 infection has a significant impact upon the emergence of new-onset hair diseases.
text/xml
2160-9381
2528
en
Aysel Cakir
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
questionnaires
Effect of COVID-19 on Hair Diseases Observed by Health Care Providers: Analysis of 513 participants
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-04-09
2023-01-31
2023-02-27
e2023036
Dermatol Pract Concept
Introduction: Covid-19 pandemic has been shown to have major acute and chronic impacts on the skin. Various studies, reported that there has been an increase in the number of patients who referred to the outpatient dermatology clinics with the complaint of variable hair diseases, during the era of Covid-19. Hair seems to be substantially affected by both the infection itself and anxiety/stress provoked by the pandemic. Therefore, understanding the impact of Covid-19 on the clinical course of variable hair diseases, has become a major concern in dermatology practice.
Objectives: To examine the frequency and types of various, both new-onset and ingravescent hair diseases observed in health care providers.
Methods: A web-based questionnaire related to the hair diseases seen in health care providers both prior to Covid-19 pandemic and after the start of the pandemic, was formed. The type of both new-onset and pre-existing hair diseases and ongoing hair diseases observed during Covid-19, were questioned.
Results: A total number of 513 participants were included in the study. One hundred seventy cases were diagnosed with Covid-19. During Covid-19 pandemic, 228 reported to have at least one hair disease; the most common one being telogen effluvium, followed by hair greying and seborrheic dermatitis. There was statistically significant relationship between the presence of a new-onset hair disease during the pandemic and being diagnosed with Covid-19 (p=0.004).
Conclusion: Our study shows that Covid-19 infection has a significant impact upon the emergence of new-onset hair diseases.
Aysel Cakir
2023/01/31
10.5826/dpc.1301a36
e2023036
Lokman Hekim Atay Hospital, Dermatology and Venereology Clinic, Ankara, Turkey
2160-9381
questionnaires
en
e2023036
Pathoulas JT, Olson SJ, Idnani A, Farah RS, Hordinsky MK, Widge AS. Cross-sectional survey examining skin picking and hair pulling disorders during the COVID-19 pandemic. J Am Acad Dermatol. 2021;84(3):771-773. doi: 10.1016/j.jaad.2020.11.011.PMID: 33279648; PMCID: PMC7711196.
Effect of COVID-19 on Hair Diseases Observed by Health Care Providers: Analysis of 513 participants
https://dpcj.org/index.php/dpc/article/download/2528/1948
           The Effect of Covid-19 on the Hair Diseases
           Observed in Health Care Providers: Analysis
                       of 513 Participants
                                                  Ecem Bostan1, Aysel Cakir2


1 Cihanbeyli State Hospital, Dermatology and Venereology Clinic, Konya, Turkey
2 Lokman Hekim Atay Hospital, Dermatology and Venereology Clinic, Ankara, Turkey



Key words: Covid-19, hair diseases, surveys, questionnaires
Citation: Bostan E, Cakir A. The Effect of Covid-19 on the Hair Diseases Observed in Health Care Providers: Analysis of 513 participants.
Dermatol Pract Concept. 2023;13(1):e2023036. DOI: https://doi.org/10.5826/dpc.1301a36
Accepted: June 17, 2022; Published: January 2023
Copyright: ©2023 Bostan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Ecem Bostan, Dermatology and Venereology Clinic, Cihanbeyli State Hospital, Atceken Avenue, Hastane Street,
Cihanbeyli/Konya, 42850, Turkey. Telephone: +90 0332 673 40 93 E-mail: bostanecem@gmail.com




  ABSTRACT             Introduction: The Covid-19 pandemic has been shown to have major acute and chronic impacts on
                       the skin. Various studies reported that there has been an increase in the number of patients referred to
                       outpatient dermatology clinics with the complaint of variable hair diseases during the era of Covid-19.
                       Hair seems to be substantially affected by both the infection itself and anxiety/stress provoked by the
                       pandemic. Therefore, understanding the impact of Covid-19 on the clinical course of variable hair
                       diseases has become a major concern in dermatology practice.
                       Objectives: To examine the frequency and types of various hair diseases, both new-onset and in-
                       gravescent, observed in healthcare providers.
                       Methods: A web-based questionnaire related to the hair diseases seen in healthcare providers both prior
                       to the Covid-19 pandemic and after the start of the pandemic was created. The type of both new-onset
                       and pre-existing hair diseases and ongoing hair diseases observed during Covid-19 were investigated.
                       Results: A total number of 513 participants were included in the study. One hundred seventy cases
                       were diagnosed with Covid-19. During the Covid-19 pandemic, 228 reported having at least one
                       hair disease; the most common one being telogen effluvium, followed by hair greying and seborrheic
                       dermatitis. There was a statistically significant relationship between the presence of a new-onset hair
                       disease during the pandemic and being diagnosed with Covid-19 (p=0.004).
                       Conclusion: Our study shows that Covid-19 infection has a significant impact on the emergence of
                       new-onset hair diseases.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023036                                                                          1
Introduction                                                      (II) Covid-19 infection; (III) hair diseases seen prior to the
                                                                  onset of the Covid-19 pandemic; (IV) hair diseases observed
The Covid-19 pandemic has been shown to have a negative           during the Covid-19 pandemic. The online questionnaire
influence on both skin diseases and the dermatological life       was carried out among HCPs and a virtual snowball sam-
quality of healthcare providers (HCPs) [1]. Skin serves as one    pling method was used.
of the first-line-of-defense components of the body against          IBM SPSS for Windows Version 20.0 was used for the
numerous pathogens by forming a physical barrier [2]. Con-        statistical analysis. For descriptive analysis, numerical
tinuous use of personal hygiene equipment impairs the skin        variables were given as mean ± standard deviation (range:
barrier, causing skin problems such as drying, lichenifica-       minimum-maximum) and categorical variables were shown
tion and itching further aggravating a previously-existing        as percentages and frequencies. Chi-Square test was used to
dermatological disease or resulting in the development of a       analyze the relationships between the categorical variables.
new-onset skin disorder [1].                                      P values of <0.05 were considered statistically significant.
    Hair is a skin appendage whose cycle is frequently af-
fected by various external factors including nutritional de-
ficiencies, endocrinopathies, major surgical operations and
                                                                  Results
systemic diseases [3]. In a normal hair cycle, approximately      A total number of 513 HCPs were included in the study.
90% of the hairs are in the anagen phase [4]. The catagen         The mean age was 34.84 ± 8.90 years (minimum:19, max-
phase begins when the anagen phase ends and approximately         imum:66). Three hundred fifty-eight (69.8%) of the partic-
5% of all hair shafts are in the catagen phase at any given       ipants were female whereas 155 (30.2%) were male. Two
time [4]. In the anagen phase, hair follicles continue to grow    hundred forty-one (47%) respondents reported having
whereas in the catagen phase, hair follicles start to dwin-       Covid-19 related symptoms; whereas 272 (53 %) didn’t ex-
dle and hair growth stops [5]. The telogen phase or ‘resting      hibit any symptoms. Three hundred twenty-nine (63.2%)
phase’ lasts about three months and 10-15% of all hairs are       participants had a history of close contact with someone
in the telogen phase in a normal hair cycle [4,5]. Following      with a confirmed diagnosis of Covid-19. Covid-19 real-time
the telogen phase, hair shafts fall out. Telogen effluvium (TE)   polymerase chain reaction test (RT-PCR) was performed on
presents itself in the form of excessive hair shedding result-    445 (86.7 %) respondents; 156 (35.1%) cases tested positive,
ing from the rapid entry of anagen hairs into the telogen         whereas 289 (64.9%) tested negative. Additionally, 14 cases
phase [3].                                                        who did not give RT-PCR test or tested negative, were diag-
    The normal cycle of hair growth is influenced and             nosed with Covid-19 via radiological imaging. So, a total of
disrupted by various internal and external factors in-            170 cases were accepted to have a confirmed d
                                                                                                              ­ iagnosis of
cluding severe systemic infections such as Covid-19 [6].          Covid-19. Only 12 patients were required to be hospitalized
Covid-19-induced mild and severe TE cases have continued          for severe Covid-19 infection.
to be reported in increasing numbers from the start of the           During the online questionnaire, participants were
pandemic [6,7]. Alopecia areata (AA), an autoimmune hair          asked if they had any other contributing factors during the
disorder; seborrheic dermatitis (SD), a chronic inflammatory      Covid-19 pandemic that might have played a role in the
skin disease; trichotillomania, a psychodermatologic hair         development or worsening of their hair diseases. Thirty-six
disorder are some other entities that are increasingly ob-        (7%) cases had a pregnancy, one (0.2%) respondent was re-
served in the era of Covid-19 [8-10]. Both adverse psycho-        ceiving chemotherapy, 21 (4.1%) were dieting, 12 (2.3%)
social effects of the pandemic and cytokine storm induced in      had a major surgical operation, 20 (3.9%) had intentional/
the setting of Covid-19 infection are implicated in the devel-    unintentional loss of more than 5% of their own weight in
opment of these hair diseases [6].                                a period of 6 months during the Covid-19 pandemic. Lastly,
    In our study, we aimed to investigate the frequencies and     162 (31.6%) participants reported feeling stressed, which
types of both new-onset and pre-existing variable hair dis-       had a major impact on their lives during the Covid-19 pan-
eases observed in HCPs during the Covid-19 pandemic.              demic. Two hundred fifty-four (49.5%) respondents had at
                                                                  least one hair disease prior to the start of the Covid-19 pan-
Methods                                                           demic. The frequencies and percentages of different types of
                                                                  hair diseases observed in the pre-Covid-19 era are shown
Local ethics committee approval was obtained for the pres-        in Table 1.
ent study (the date and decision number: November 19                 Of 513 patients, only 40 patients had new-onset hair
2021, 2021/028). A web-based survey consisting of 22 ques-        disease that developed during the Covid-19 pandemic. Out
tions (Supplementary file 1) was created using Google forms.      of 40 patients, 25 (62.5%) had new-onset TE, 12 (30%)
The survey included four sections: (I) personal information;      reported increased hair greying, 6 (15%) had new-onset



2                                                                     Original Article | Dermatol Pract Concept. 2023;13(1):e2023036
female-pattern hair loss (FPHL), 3 (7.5%) had new-onset                the specified hair disease whereas 9 (3.5 %) claimed that the
male-pattern hair loss (MPHL), 4 (10%) reported trichody-              severity of the hair disease decreased. Of 121 patients who re-
nia, 2 (5%) reported new-onset SD, 2 (5%) reported new-on-             ported an increase in the severity of the pre-existing hair dis-
set trichotillomania and 1 (2.5%) reported new-onset scalp             ease during the Covid-19 pandemic, 51 (42.1%) had TE, 37
psoriasis. Of these 40 patients, only 20 (50%) were diagnosed          (30.6%) had hair greying, 29 (24%) were diagnosed with SD,
with Covid-19. The mean duration between the emergence of              16 (13.2%) had symptoms of trichodynia, 16 (13.2%) had
the new-onset hair disease and Covid-19 diagnosis was 1.24             FPHL, 12 (9.9 %) were diagnosed with MPHL, 7 (5.8%) had
± 0.83 months (minimum: 0.25, maximum:3). Of 25 patients               trichotillomania, 5 (4.1%) were suffering from scalp psoria-
with new-onset TE during the Covid-19 pandemic, 22 (88 %)              sis, 2 (1.7 %) had AA and only 1 (0.8 %) patient had alopecia
had been tested for SARS-CoV-2 infection. Fourteen (63.6%)             totalis. Again, of 121 individuals who reported an increase
out of 22 patients had a positive RT-PCR result. For these             in the severity of the hair disease and 40 who had new-on-
patients, the mean time interval between the diagnosis of              set hair disease during the Covid-19 pandemic, 138 (85.7%)
Covid-19 and the approximate commencement of the acute                 thought that stress and anxiety played a role either in the
TE was 1.13 ± 0.66 months (minimum: 0.3, maximum:3).                   development of the new-onset hair disease or deterioration
During the era of Covid-19, 228 (44.4 %) reported having               of the pre-existing disease.
any hair disease (including pre-existing, ongoing and new-on-                 A statistically significant relationship was found between
set ones); the frequencies and percentages of different types          Covid-19 RT-PCR positivity and the presence of any hair
of hair diseases observed in the Covid-19 era are shown in             disease during the Covid-19 pandemic (p=0.009) (Table 2).
Table 1. Of 228 individuals with a history of any hair disease         In addition, a statistically significant relationship was pres-
during Covid-19, 34 (14.9%) had been diagnosed by a physi-             ent between Covid-19 RT-PCR positivity and the presence
cian. Participants who had the same hair disease prior to the          of any new-onset hair disease during the Covid-19 pandemic
Covid-19 pandemic and during the Covid-19 pandemic were                (p=0.002). The distribution of Covid-19 RT-PCR results in
asked to express their opinion about the course of the hair            relation to the presence of any new-onset hair disease during
disease during the Covid-19 pandemic. Out of 259 respon-               the Covid-19 pandemic is shown in Figure 1. The distribu-
dents, 129 (49.8 %) indicated that there was no change, 121            tion of Covid-19 infection status in relation to the presence
(46.7%) reported an increase in the sign and symptoms of               of any hair disease during the Covid-19 pandemic is shown


         Table 1. Frequencies and percentages of different types of hair diseases in the pre-Covid-19
                                       and Covid-19 pandemic eras.
            Type of Hair Disease                         Pre-Covid-19 (n, %)                                Covid-19 (n,%)
 Male pattern hair loss                                          36 (13.9)                                    29 (12.7)
 Alopecia areata                                                   13 (5)                                       3 (1.3)
 Female pattern hair loss                                        30 (11.6)                                    33 (14.5)
 Alopecia totalis                                                 1 (0.4)                                       1 (0.4)
 Telogen effluvium                                               108 (41.7)                                   111 (48.7)
 Seborrheic dermatitis                                           63 (24.3)                                    52 (22.8)
 Scalp psoriasis                                                  9 (3.5)                                       9 (3.9)
 Trichodynia                                                     35 (13.5)                                     32 (14)
 Trichotillomania                                                 18 (6.9)                                      16 (7)
 Increased hair greying                                          72 (27.8)                                    71 (31.1)
 Total                                                           259 (100)                                    228 (100)



Table 2. Statistically significant relationship was found between the Covid-19 RT-PCR positivity and
              having at least one hair disease during the Covid-19 pandemic (p=0.009).
                                              Presence of any hair disease during Covid-19 pandemic                          Total
      Covid-19 RT-PCR Results                    Not present n (%)                              Present                      n (%)
 Negative                                             169 (70.4)                               120 (58.5)                  289 (64.9)
 Positive                                              71 (29.6)                               85 (41.5)                   156 (35.1)
 Total                                                 240 (100)                               205 (100)                   445 (100)



Original Article | Dermatol Pract Concept. 2023;13(1):e2023036                                                                          3
                                                           132

                                          140

                                          120
        COVID-19 RT-PCR RESULTS




                                          100

                                           80                                 49

                                           60
                                                                                                                    17             19
                                           40

                                           20

                                            0
                                                         Not present                                                Present
      Negative RT-PCR Result
                                                           PRESENCE OF ANY NEW-ONSET HAIR DISEASE DURING COVID-19 PANDEMIC
      Positive RT-PCR Result




Figure 1. The distribution of Covid-19 RT-PCR results in relation to the presence of any new-onset hair disease during the Covid-19 pandemic.



                                                Not diagnosed with Covid-19        Diagnosed with Covid-19 by RT-PCR testing or radiological imaging




                                          250             204


                                          200
              COVID-19 INFECTION STATUS




                                                                                                                    139

                                          150
                                                                                                                                    89
                                                                              81

                                          100


                                           50


                                            0
                                                          Not present                                               Present

                                                                 PRESENCE OF ANY HAIR DISEASE DURING COVID-19 PANDEMIC



Figure 2. The distribution of Covid-19 infection status in relation to the presence of any hair disease during the Covid-19 pandemic.


in Figure 2. A statistically significant relationship was found                                  difference between developing new-onset hair disease and
between being diagnosed with Covid-19 and having any spe-                                        having at least one contributing factor that may be related
cific hair disease during the Covid-19 pandemic (p=0.011).                                       to the pathogenesis of the new-onset hair disorder (p=0.119).
Again, there was a statistically significant relationship be-
tween the presence of any new-onset hair disease and the di-
                                                                                                 Discussion
agnosis of Covid-19 (p=0.004). The distribution of Covid-19
infection status in relation to the presence of any new-onset                                    From the start of the Covid-19 pandemic, numerous cuta-
hair disease is shown in Table 3.                                                                neous manifestations of the infection itself along with the
    The distribution of having a new-onset hair disease with                                     occupational skin problems which result from the continu-
regard to the presence of one or more contributing factors for                                   ous use of personal protective equipment have been reported
hair disease development (Supplementary File 1-­Question 13)                                     in the literature [11,12]. Urticaria, maculopapular eruption,
is shown in Table 4. There was no statistically significant                                      angioedema, vesicular eruption, pityriasis rosea, erythema



4                                                                                                     Original Article | Dermatol Pract Concept. 2023;13(1):e2023036
  Table 3. The distribution of Covid-19 infection status in relation to the presence of any new-onset
                             hair disease during the Covid-19 pandemic.
                                                                      Presence of any new-onset hair disease
      Diagnosed with Covid-19 by RT-PCR testing or                          during Covid-19 pandemic                          Total
                 ­radiological imaging                               Not present n (%)                Present                 n (%)
 No                                                                      156 (72.9)                   20 (50)            176 (69.3)
 Yes                                                                      58 (27.1)                   20 (50)            78 (30.7)
 Total                                                                   214 (100)                   40 (100)            254(100)



  Table 4. The distribution of having a new-onset hair disease with regard to the presence of one or
                       more contributing factors for hair disease development.
                                                                 Presence of at least one precipitating factor
       Presence of any new-onset hair disease                               linked to hair disease                           Total
             during Covid-19 pandemic                            Not present n (%)                Present                    n (%)
 Not present                                                         145 (86.8)                   69 (79.3)            214 (84.3)
 Present                                                              22 (13.2)                   18 (20.7)             40 (15.7)
 Total                                                               167 (100)                    87 (100)              254 (100)



multiforme, chilblain-like acral lesions and cutaneous small           relationship with hair cortisol concentration as a biomarker
vessel vasculitis are among the reported cutaneous manifes-            of stress was sought. In a study population of 234 HCPs,
tations of Covid-19 infection [11]. HCPs have worked so                40% showed hair cortisol concentration outside of the nor-
hard to provide effective and adequate care for patients with          mal range [16]. In this study, positive correlation between
Covid-19 infection. Since effective health care requires opti-         hair cortisol concentration versus perceived stress and di-
mum protection, continual use of personal protective equip-            rect correlation between hair cortisol concentration versus
ment such as gloves, goggles, masks and hand disinfectants             emotional exhaustion were also found [16]. This study again
has become an irrevocable rule for all HCPs. Besides the               underlies the fact that HCPs are exposed to emotional stress
skin diseases observed in the setting of hyperinflammation             and burnout syndrome during the pandemic and hair is
and immune system activation, occupational skin problems               largely influenced by the psychosocial impacts of Covid-19.
including irritant/allergic contact dermatitis, acne, itching,         In correlation with this research, in our study of 161 partic-
xerosis, pressure-related skin injuries, skin erythema, ret-           ipants who either reported an increase in the severity of the
roauricular dermatitis and secondary cutaneous infections              pre-existing hair disease or had new-onset hair disease during
continue to be a major concern, especially for HCPs [11,12].           the Covid-19 pandemic, 138 (85.7%) thought that stress and
    Hair is a part of the integumentary system which has               anxiety contributed to the development of the new-onset hair
its own growth cycle and this cycle is greatly influenced by           disease or progression of the pre-existing disease.
intrinsic and extrinsic factors. Diverse drugs, stress, anxiety,          Cases of TE and trichodynia have been observed to in-
chronic illnesses, high fever, extreme loss weight, smoking            crease in number from the start of the pandemic [6,17].
and iron deficiency may all disrupt the normal hair cycle and          Rizzetto et al [6] reported three cases of TE observed after
cause the hair shafts to enter the telogen phase prematurely           severe SARS-CoV-2 infection. Furthermore, Mieczkowska et
which results in excessive hair shedding [13]. Although all            al [18] described a case series consisting of 10 women who
humanity is likely to be largely affected by a chaotic emer-           were diagnosed with Covid-19 via RT-PCR and antibody
gency situation such as a pandemic, those who work on                  test. These patients didn’t have any other triggering factor
the front lines to fight against the infection and struggle            that would induce TE and TE started 3 to 7 months after
to provide the utmost care for the patients are more likely            Covid-19 infection. In another retrospective study by Cline
to have unfavorable psychosocial impacts [14]. During the              et al [19], it is found that there was a >400 % increase in
era of Covid-19, HCPs have been shown to exhibit signs of              the number of patients diagnosed with TE between July and
post-traumatic stress disorder, depression, anxiety, insomnia,         August 2020 when compared to the number of patients diag-
burnout syndrome and somatization [15]. In a study by Ibar             nosed with TE between November 2019 and February 2020.
et al [16], chronic stress and anxiety among health work-              In another multi-centered study, 214 patients who were
ers during the Covid-19 pandemic were examined and the                 diagnosed with acute TE after SARS-CoV-2 infection were



Original Article | Dermatol Pract Concept. 2023;13(1):e2023036                                                                        5
evaluated [20]. The mean age was 47.4 years and 78.5 % of        and/or increased grey hair prior to the pandemic. Out of 37
all patients were female, 86.4 % developed a fever during the    patients, only 5 required hospitalization for Covid-19.
infection. Additionally, 20.8 % of patients required hospi-         AA is an autoimmune, inflammatory, non-cicatricial
talization and the mean time interval between the Covid-19       alopecia which is characterized by relapsing and recurring
diagnosis and significant hair shedding was 57.1 days [20].      episodes of patchy or diffuse hair loss. In the hyperinflam-
In our study cohort, only 40 patients developed new-onset        matory state of Covid-19, plasma levels of tumor necrosis
hair disease during the Covid-19 pandemic and the most fre-      factor- α, interferon- γ, interleukin-2 and interleukin-1β
quently observed new-onset hair disease was TE. Of these         which are also involved in the pathogenesis of AA, rise sub-
25 patients with TE, 22 were tested for SARS-CoV-2 infec-        stantially [27]. In a study by Rudnicka et al [28], 32 patients
tion. Fourteen out of 22 patients had been diagnosed with        with mild-to-moderate AA were evaluated 1-6 weeks before
Covid-19. In our research, the mean time interval between        Covid-19 infection and 3 months after the infection [28]. It
the diagnosis of Covid-19 and the start of hair shedding was     was found that Covid-19 infection didn’t have any negative
found to be 1.13 ± 0.66 months.                                  impact on the clinical course of AA [28]. In another study
    Trichodynia is defined as a painful sensation in the scalp   with 392 AA patients, 42.5 % had disease relapse about
often accompanied by TE [21]. Di Landro et al [17] observed      2 months after Covid-19 infection whereas disease relapse
39 patients who presented with TE after Covid-19 infection.      was observed in 12.5 % of all participants without a con-
Of 39 patients, 7 patients also suffered from severe tricho-     firmed diagnosis of SARS-CoV-2 infection [29]. In our study,
dynia. In this study, the mean age was 64.6 years and both       no new-onset AA was identified, but only 2 (15.4%) out of
the excessive hair shedding and trichodynia resolved within      13 patients with a pre-existing diagnosis of AA reported an
2 to 4 months. The authors argued that the hyperinflamma-        increase in the severity of symptoms.
tory environment developing in the setting of SARS-Cov-2            SD is a chronic inflammatory skin disorder character-
infection, was the most probable cause of TE and tricho-         ized by erythema, greasy scaling and itching which most
dynia since interleukin-6, interleukin-1ß and tumor necro-       commonly occurs in the scalp, eyebrows, ears and face [30].
sis factor-α were shown to induce transition to the catagen      A study by Veraldi et al [30], showed that disease severity
phase in hair follicles [17,22]. In our research, 4 new-­onset   increased in 46.5 % of the patients diagnosed with SD. These
trichodynia cases were detected whereas 16 participants          patients reported wearing anti-Covid-19 masks for 6 to 10
reported exacerbation in trichodynia symptoms during the         hours a day and 35 % of the patients with worsening SD
Covid-19 pandemic.                                               were health workers [30]. It was asserted that the high tem-
    MPHL is a common hair disease which is characterized         perature and humidity induced by the use of face masks cause
by patterned, progressive thinning of hair, seen in geneti-      abnormalities in microbiota and enhance sweating, thereby
cally susceptible men. The presence of MPHL is thought           provoking an irritant reaction and itching [30]. In line with
to be correlated with severe Covid-19 infection [23]. The        the results of this study, 29 (90.6%) out of 32 participants
priming of SARS-CoV-2’s spike protein requires transmem-         with a previous diagnosis of SD, reported an increase in the
brane protease, serine 2 (TMPRSS2) activity [23]. TMPRSS2        severity of symptoms of the disease during the pandemic.
gene transcription is dependent upon androgen receptor           The higher percentage of participants in our study is not sur-
activity, so it seems plausible that men are more vulnerable     prising since we have included only HCPs in our study.
to SARS-CoV-2 infection and fatality rates are rare before          Trichotillomania is characterized by repetitive urges
puberty [23]. Lee et al [24] evaluated 1605 patients who         to pull out hair from the scalp, eyebrows or other parts
tested negative for Covid-19 and 336 patients who were           of the body [31]. Low self-confidence, social anxiety, ma-
diagnosed with Covid-19. The two groups didn’t have any          jor depression and psychosocial dysfunction are associated
difference in terms of mean age and body mass index [24].        with trichotillomania [31]. In a study by Pathoulas et al
In this study, it was shown that Covid-19 positivity cor-        [32], 460 patients presented with a self-reported diagnosis
related with the increasing baldness score (determined by the    of body-focused repetitive behaviors, 181 patients had a
Hamilton-Norwood scale) [24]. In another study, 41 Cauca-        hair-pulling disorder, whereas 141 reported both hair-pull-
sian males who were hospitalized with a diagnosis of SARS-       ing and skin-picking disorders. A majority of the patients re-
CoV-2 pneumonia were evaluated [25]. Twenty-nine (71%)           ported an increase in their symptoms during Covid-19 [32].
had clinically evident androgenetic alopecia (Hamilton Nor-      Our results showed that 38.9% of the individuals with a di-
wood scale > 2) and 12 (29%) patients had a Hamilton Nor-        agnosis of trichotillomania prior to the pandemic reported
wood scale of 1 or 2 [25]. In another study by Muller Ramos      having incremental symptoms during Covid-19.
et al [26], it was proven that alopecia and grey hair are cor-      In conclusion, if we were to look at the results of our
related with Covid-19 severity. In our study, of 170 patients    study altogether, we want to highlight that a statistically
diagnosed with Covid-19, 21.8 % reported having MPHL             significant relationship exists between being diagnosed with



6                                                                    Original Article | Dermatol Pract Concept. 2023;13(1):e2023036
Covid-19 and having at least one specific hair disease during            10. Alpalhão M, Gaibino N, Filipe P. Seborrheic dermatitis in
the Covid-19 pandemic. Additionally, there seems to be a sta-                COVID-19: a case report. Int J Dermatol. 2020;59(12):1543-
                                                                             1544. doi: 10.1111/ijd.15256. PMID: 33095515.
tistically significant relationship between having a new-onset
                                                                         11. Mawhirt SL, Frankel D, Diaz AM. Cutaneous Manifestations in
hair disease during the pandemic and being diagnosed with
                                                                             Adult Patients with COVID-19 and Dermatologic Conditions Re-
Covid-19. Our study indicates that hair is vulnerable to the                 lated to the COVID-19 Pandemic in Health Care Workers. Curr
direct effects of SARS-CoV-2 infection and indirect effects of               Allergy Asthma Rep. 2020;20(12):75. doi: 10.1007/s11882-020-
the pandemic (psychosocial impacts, skin problems resulting                  00974-w. PMID: 33047260; PMCID: PMC7549735.
from the use of personal protective equipment etc.). We be-              12. Wilcha RJ. Does Wearing a Face Mask During the COVID-19
                                                                             Pandemic Increase the Incidence of Dermatological Conditions
lieve that the underlying etiopathological mechanisms of the
                                                                             in Health Care Workers? Narrative Literature Review. JMIR
trichological effects of Covid-19 are also possibly related to
                                                                             Dermatol. 2021;4(1):e22789. doi: 10.2196/22789. PMID:
other pre-existing, ongoing and new-onset (post-Covid-19)                    34028470; PMCID: PMC8104277.
systemic as well as dermatological manifestations.                       13. Rossi A, Magri F, Sernicola A, et al. Telogen Effluvium after
    Our research has some limitations since not all the par-                 SARS-CoV-2 Infection: A Series of Cases and Possible Pathoge-
ticipants were diagnosed by a dermatologist. The severity of                 netic Mechanisms. Skin Appendage Disord. 2021;21(5):1-5. doi:
                                                                             10.1159/000517223. PMID: 34373830; PMCID: PMC8339054.
the hair disease was not directly evaluated by a physician
                                                                         14. Rodríguez BO, Sánchez TL. The Psychosocial Impact of COVID-19
using a score or scale, so the results might have been subjec-
                                                                             on health care workers. Int Braz J Urol. 2020;46(suppl.1):195-200.
tive. Prospective, randomized-controlled studies with larger                 doi: 10.1590/S1677-5538.IBJU.2020.S124. PMID: 32618464;
sample sizes are needed to confirm our results.                              PMCID: PMC7719993.
                                                                         15. Salazar de Pablo G, Vaquerizo-Serrano J, Catalan A, et al. Im-
                                                                             pact of coronavirus syndromes on physical and mental health
References                                                                   of health care workers: Systematic review and meta-analysis.
                                                                               J Affect Disord. 2020;275:48-57. doi: 10.1016/j.jad.2020.06.022.
 1. Daye M, Cihan FG, Durduran Y. Evaluation of skin problems                  PMID: 32658823; PMCID: PMC7314697.
    and dermatology life quality index in health care workers who        16.   Ibar C, Fortuna F, Gonzalez D, et al. Evaluation of stress, burn-
    use personal protection measures during COVID-19 pandemic.                 out and hair cortisol levels in health workers at a University
    Dermatol Ther. 2020;33(6):e14346. doi: 10.1111/dth.14346.                  Hospital during COVID-19 pandemic. Psychoneuroendocrinol-
    PMID: 32985745; PMCID: PMC7536955.                                         ogy. 2021;128:105213. doi: 10.1016/j.psyneuen.2021.105213.
 2. Toncic RJ, Jakasa I, Hadzavdic SL, et al. Altered Levels of Sphin-         PMID: 33845387; PMCID: PMC8015376.
    gosine, Sphinganine and Their Ceramides in Atopic Dermatitis         17.   Di Landro A, Naldi L, Glaser E, Paus R, Tosti A. Pathobiol-
    Are Related to Skin Barrier Function, Disease Severity and Local           ogy questions raised by telogen effluvium and trichodynia in
    Cytokine Milieu. Int J Mol Sci. 2020;21(6):1958. doi: 10.3390/             COVID-19 patients. Exp Dermatol. 2021;30(7):999-1000. doi:
    ijms21061958. PMID: 32183011; PMCID: PMC7139865.                           10.1111/exd.14352. PMID: 33838048; PMCID: PMC8250761.
 3. Asghar F, Shamim N, Farooque U, Sheikh H, Aqeel R. Telogen Ef-       18.   Mieczkowska K, Deutsch A, Borok J, et al. Telogen effluvium: a
    fluvium: A Review of the Literature. Cureus. 2020;12(5):e8320.             sequela of COVID-19. Int J Dermatol. 2021;60(1):122-124. doi:
    doi: 10.7759/cureus.8320. PMID: 32607303; PMCID:                           10.1111/ijd.15313. PMID: 33226117; PMCID: PMC7753411.
    PMC7320655.                                                          19.   Cline A, Kazemi A, Moy J, Safai B, Marmon S. A surge in the
 4. Harland DP. Introduction to Hair Development. Adv Exp Med                  incidence of telogen effluvium in minority predominant com-
    Biol. 2018;1054:89-96. doi: 10.1007/978-981-10-8195-8_8.                   munities heavily impacted by COVID-19. J Am Acad Dermatol.
    PMID: 29797270.                                                            2021;84(3):773-775. doi: 10.1016/j.jaad.2020.11.032. PMID:
 5. Stenn KS, Paus R. Controls of hair follicle cycling. Physiol Rev.          33310111.
    2001;81(1):449-494. doi: 10.1152/physrev.2001.81.1.449.              20.   Moreno-Arrones OM, Lobato-Berezo A, Gomez-Zubiaur A, et
    PMID: 11152763.                                                            al. SARS-CoV-2-induced telogen effluvium: a multicentric study.
 6. Rizzetto G, Diotallevi F, Campanati A, et al. Telogen efflu-               J Eur Acad Dermatol Venereol. 2021;35(3):e181-e183. doi:
    vium related to post severe Sars-Cov-2 infection: Clinical                 10.1111/jdv.17045. PMID: 33220124; PMCID: PMC7753386.
    aspects and our management experience. Dermatol Ther.                21.   Rebora A. Trichodynia: a review of the literature. Int J Dermatol.
    2021;34(1):e14547. doi: 10.1111/dth.14547. PMID: 33190397;                 2016;55(4):382-4. doi: 10.1111/ijd.13204. PMID: 26696219.
    PMCID: PMC7744849.                                                   22.   Hussain N, Agarwala P, Iqbal K, et al. A systematic review of
 7. Abrantes TF, Artounian KA, Falsey R, et al. Time of onset                  acute telogen effluvium, a harrowing post-COVID-19 mani-
    and duration of post-COVID-19 acute telogen effluvium. J                   festation. J Med Virol. 2022;94(4):1391-1401. doi: 10.1002/
    Am Acad Dermatol. 2021;85(4):975-976. doi: 10.1016/j.                      jmv.27534. PMID: 34931698.
    jaad.2021.07.021. PMID: 34302903; PMCID: PMC8294706.                 23.   Wambier CG, Goren A. Severe acute respiratory syndrome coro-
 8. FIvenson D. COVID-19: association with rapidly progressive                 navirus 2 (SARS-CoV-2) infection is likely to be androgen medi-
    forms of alopecia areata. Int J Dermatol. 2021;60(1):127. doi:             ated. J Am Acad Dermatol. 2020;83(1):308-309. doi: 10.1016/j.
    10.1111/ijd.15317. PMID: 33226118; PMCID: PMC7753616.                      jaad.2020.04.032. PMID: 32283245; PMCID: PMC7151476.
 9. Öner Ü. Children with trichotillomania in COVID-19 outbreak.         24.   Lee J, Yousaf A, Fang W, Kolodney MS. Male balding is a
    J Cosmet Dermatol. 2021;20(7):1967-1968. doi: 10.1111/                     major risk factor for severe COVID-19. J Am Acad Derma-
    jocd.14200. PMID: 33950551; PMCID: PMC8242538.                             tol. 2020;83(5):e353-e354. doi: 10.1016/j.jaad.2020.07.062.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023036                                                                                 7
      Erratum in: J Am Acad Dermatol. 2021 ;85(3):799. PMID:             29. Rinaldi F, Trink A, Giuliani G, Pinto D. Italian Survey for the Eval-
      32707256; PMCID: PMC7373684.                                           uation of the Effects of Coronavirus Disease 2019 (COVID-19)
25.   Goren A, Vaño-Galván S, Wambier CG, et al. A preliminary ob-           Pandemic on Alopecia Areata Recurrence. Dermatol Ther (Hei-
      servation: Male pattern hair loss among hospitalized COVID-19          delb). 2021;11(2):339-345. doi: 10.1007/s13555-021-00498-9.
      patients in Spain - A potential clue to the role of androgens in       PMID: 33580408; PMCID: PMC7880634.
      COVID-19 severity. J Cosmet Dermatol. 2020;19(7):1545-1547.        30. Veraldi S, Angileri L, Barbareschi M. Seborrheic dermatitis and
      doi: 10.1111/jocd.13443. PMID: 32301221.                               anti-COVID-19 masks. J Cosmet Dermatol. 2020;19(10):2464-
26.   Müller Ramos P, Ianhez M, Amante Miot H. Alopecia and                  2465. doi: 10.1111/jocd.13669. PMID: 32790897; PMCID:
      grey hair are associated with COVID-19 Severity. Exp Derma-            PMC7436393.
      tol. 2020;29(12):1250-1252. doi: 10.1111/exd.14220. PMID:          31. Diefenbach GJ, Tolin DF, Hannan S, Crocetto J, Worhunsky P.
      33098701.                                                              Trichotillomania: impact on psychosocial functioning and qual-
27.   Zhong J, Tang J, Ye C, Dong L. The immunology of COVID-19: is          ity of life. Behav Res Ther. 2005;43(7):869-84. doi: 10.1016/j.
      immune modulation an option for treatment? Lancet Rheumatol.           brat.2004.06.010. PMID: 15896284.
      2020;2(7):e428-e436. doi: 10.1016/S2665-9913(20)30120-X.           32. Pathoulas JT, Olson SJ, Idnani A, Farah RS, Hordinsky MK,
      PMID: 32835246; PMCID: PMC7239618.                                     Widge AS. Cross-sectional survey examining skin picking
28.   Rudnicka L, Rakowska A, Waskiel-Burnat A, Kurzeja M, Olsze-            and hair pulling disorders during the COVID-19 pandemic.
      wska M. Mild-to-moderate COVID-19 is not associated with               J Am Acad Dermatol. 2021;84(3):771-773. doi: 10.1016/j.
      worsening of alopecia areata: A retrospective analysis of 32 pa-       jaad.2020.11.011.PMID: 33279648; PMCID: PMC7711196.
      tients. J Am Acad Dermatol. 2021;85(3):723-725. doi: 10.1016/j.
      jaad.2021.05.020. PMID: 34051315; PMCID: PMC8149466.




8                                                                             Original Article | Dermatol Pract Concept. 2023;13(1):e2023036
