10.5826/dpc.1304a263
Background: Severe acute respiratory virus syndrome coronavirus 2 (SARS-CoV-2) was responsible for coronavirus disease (COVID-19) pandemic. As patients recovered from COVID-19 infection, hair loss was increasingly observed as a distressing symptom.
Methods: This was a prospective cross-sectional study of patients with post COVID-19 hair loss between July to December 2021 at a tertiary care centre. Detailed history, clinical examination, trichoscopy and biochemical tests were performed and recorded. COVID-19 disease severity was assessed based on duration of COVID-19 infection and place of management.
Results: The study included 120 patients with mean age being 39.6 years. Majority of the patients were females, treated at home and had COVID-19 infection for &gt;2 weeks. Mean visual analog scale (VAS) score for stress was 5.25. Vitamin D deficiency was present in 56.7% and low ferritin in 30% of cases. Mean time of onset of hair loss post COVID-19 was 49 days. Patients mainly presented with diffuse hair loss. Trichodynia was present in 15.8% of cases. The degree of hair loss was severe in 55.8% of the subjects. Positive hair pull test was seen in 65% of patients. Most common trichoscopic features included single hair follicles’ (81.7%) and vellus hair &gt;10% (60%).
Conclusions: The mean time of onset of hair loss post COVID-19 infection was less than 2 months. Majority patients had diffuse pattern and severe degree of hair loss. Trichoscopy can aid in unmasking co-existing patterned hair loss in patients presenting clinically with diffuse hair loss.&nbsp;
text/xml
2160-9381
3242
en
Niti Khunger
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
hair loss
A Cross-Sectional Study on Post-Coronavirus Disease (COVID-19) Hair Loss at a Tertiary Care Hospital
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-10-31
2023-02-14
2023-10-31
2024-01-16
e2023263
Dermatol Pract Concept
Background: Severe acute respiratory virus syndrome coronavirus 2 (SARS-CoV-2) was responsible for coronavirus disease (COVID-19) pandemic. As patients recovered from COVID-19 infection, hair loss was increasingly observed as a distressing symptom.
Methods: This was a prospective cross-sectional study of patients with post COVID-19 hair loss between July to December 2021 at a tertiary care centre. Detailed history, clinical examination, trichoscopy and biochemical tests were performed and recorded. COVID-19 disease severity was assessed based on duration of COVID-19 infection and place of management.
Results: The study included 120 patients with mean age being 39.6 years. Majority of the patients were females, treated at home and had COVID-19 infection for &gt;2 weeks. Mean visual analog scale (VAS) score for stress was 5.25. Vitamin D deficiency was present in 56.7% and low ferritin in 30% of cases. Mean time of onset of hair loss post COVID-19 was 49 days. Patients mainly presented with diffuse hair loss. Trichodynia was present in 15.8% of cases. The degree of hair loss was severe in 55.8% of the subjects. Positive hair pull test was seen in 65% of patients. Most common trichoscopic features included single hair follicles’ (81.7%) and vellus hair &gt;10% (60%).
Conclusions: The mean time of onset of hair loss post COVID-19 infection was less than 2 months. Majority patients had diffuse pattern and severe degree of hair loss. Trichoscopy can aid in unmasking co-existing patterned hair loss in patients presenting clinically with diffuse hair loss.&nbsp;
Niti Khunger
2023/10/31
10.5826/dpc.1304a263
e2023263
Department of Dermatology and STD, Vardhman Mahavir Medical college and Safdarjung hospital, New Delhi 110029, India
2160-9381
hair loss
en
e2023263
Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, et al. Post-acute COVID-19 syndrome. Nat med. 2021;27(4):601-15. https://doi.org/10.1038/s41591-021-01283-z
A Cross-Sectional Study on Post-Coronavirus Disease (COVID-19) Hair Loss at a Tertiary Care Hospital
https://dpcj.org/index.php/dpc/article/download/3242/2388
       A Cross-Sectional Study on Post-Coronavirus
      Disease (COVID-19) Hair Loss at a Tertiary Care
                         Hospital
   Dhaarna Wadhwa1, Avneet Monga1, Neha Kumar1, Geeti Khullar1, Sanchita Karmakar1,
                                   Niti Khunger1


1 Department of Dermatology and STD, Vardhman Mahavir Medical College and Safdarjung hospital, New Delhi, India



Key words: COVID-19, hair loss, telogen effluvium, trichoscopy, patterned hair loss
Citation: Wadhwa D, Monga A, Kumar N, Khullar G, Karmakar S, Khunger N. Prospective Cross-Sectional Study on Post-Coronavirus
Disease (COVID-19) Hair Loss at a Tertiary Care Hospital. Dermatol Pract Concept. 2023;13(4):e2023263. DOI: https://doi.org/10.5826/
dpc.1304a263
Accepted: June 5, 2023; Published: October 2023
Copyright: ©2023 Wadhwa 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: Geeti Khullar, Department of Dermatology and STD, Vardhman Mahavir Medical college and Safdarjung hospital,
New Delhi110029, India. Telephone: 9592818474 Email: geetikhullar@yahoo.com




  ABSTRACT             Introduction: Severe acute respiratory virus syndrome coronavirus 2 (SARS-CoV-2) was responsible
                       for coronavirus disease (COVID-19) pandemic. As patients recovered from COVID-19 infection, hair
                       loss was increasingly observed as a distressing symptom.
                       Methods: This was a cross-sectional study of patients with post COVID-19 hair loss b    ­ etween July
                       to December 2021 at a tertiary care center. Detailed history, clinical examination, trichoscopy and
                       biochemical tests were performed and recorded. COVID-19 disease severity was assessed based on
                       duration of COVID-19 infection and place of management.
                       Results: The study included 120 patients with a mean age of 39.6 years. The majority of the patients
                       were females treated at home and had COVID-19 infection for >2 weeks. The mean visual analog scale
                       (VAS) score for stress was 5.25. Vitamin D deficiency was present in 56.7% and low ferritin in 30%
                       of cases. The mean time of onset of hair loss post COVID-19 was 49 days. Patients mainly presented
                       with diffuse hair loss. Trichodynia was present in 15.8% of cases. The degree of hair loss was severe in
                       55.8% of the subjects. Positive hair pull test was seen in 65% of patients. Most common trichoscopic
                       features included single hair follicles (81.7%) and vellus hair >10% (60%).
                       Conclusions: The mean time of onset of hair loss post COVID-19 infection was less than 2 months.
                       Majority patients had diffuse pattern and severe degree of hair loss. Trichoscopy can aid in unmasking
                       co-existing patterned hair loss in patients presenting clinically with diffuse hair loss.




Original Article | Dermatol Pract Concept. 2023;13(4):e2023263                                                                     1
Introduction                                                       between July to December 2021. Consecutive patients aged
                                                                   18-60 years, who presented with hair loss and had a preced-
Severe acute respiratory virus syndrome coronavirus 2 (SARS-       ing and recent COVID-19 infection, confirmed by detection
CoV-2) caused the coronavirus disease 2019 (COVID-19)              of viral RNA by real time reverse transcriptase polymerase
pandemic, which created public health care crisis worldwide.       chain reaction were included. Detailed clinical history re-
Besides pulmonary, it also leads to cardiovascular, gastro-        lated to pre-COVID-19 hair loss, severity and duration of
intestinal, neurological, hematological and dermatological         COVID-19 infection, associated stress, co-morbid illnesses
manifestations [1]. Even though immediate complications            like diabetes, hypertension and asthma and predisposing
of COVID-19 infection are well defined, its delayed sequa-         factors like pre-existing medical, surgical, metabolic illness,
lae are now being increasingly reported, and are a cause of        anemia, stress and drug intake were recorded in a pre-de-
significant concern. Post-acute COVID-19 syndrome is char-         signed questionnaire. Severity of COVID-19 infection was
acterized by persistent symptoms beyond 4 weeks, which             arbitrarily decided by the authors based on the place of treat-
is further classified into subacute phase (symptoms pres-          ment (at home or hospitalized) and duration of COVID-19
ent from 1-3 months after acute COVID-19 infection) and            infection (≤ 2 weeks or >2 weeks). Degree of hair loss was
chronic or post-COVID-19 syndrome (symptoms present or             classified according to average hair shed per day as mild
persisting after 3 months of onset of acute COVID-19 infec-        (<50), moderate (50-100) and severe (>100). Psychological
tion and not attributable to alternative diagnosis) [2].           stress due to COVID-19 infection was recorded on a visual
    The association between telogen effluvium (TE) and             analogue scale (VAS) of 0 to10. Hair pull test was done by
COVID-19 infection is stronger than other forms of hair            grasping around forty hair between index finger and thumb
loss [3]. TE is categorized as either acute when it lasts for      on frontal, mid scalp, vertex, temporal and occipital regions.
less than 6 months or chronic when it lasts for more than 6        Trichoscopy was performed using DermLite DL4 handheld
months. It is a common cause of diffuse non-scarring hair          dermoscope for anisotrichosis, single hair units, vellus hair
loss that occurs 3-4 months after any acute illness like high      percentage, interfollicular distance, yellow dots, black dots
grade fever, medical or surgical causes, medications, stress       and perifollicular pigment and scale. Biochemical investi-
or nutritional deficiencies. However, post COVID-19 TE has         gations were done to rule out concurrent thyroid disorders,
been reported after 1-3 months of onset of infection, earlier      iron, Vitamin D and Vitamin B12 deficiencies. The study
than classic TE.                                                   was approved by institutional ethics committee (S.No IEC/
    Androgenetic alopecia, alopecia areata, fibrosing alope-       VMMC/SJH/Project/2021-10/CC-196) and informed con-
cia in a patterned distribution are other types of hair loss re-   sent was taken from all study subjects.
ported post COVID-19 infection [3]. Androgenetic alopecia
has been suggested to be a poor prognostic factor for severe       Data Collection and Statistical Analysis
COVID-19 infection in some studies [4,5]. However, results         Statistical analysis was performed using IBM SPSS statistics
from recent studies refute this observation [6,7]. Alopecia        version 17.0 (IBM Corp.). Baseline characteristics were an-
areata (including totalis and universalis) may be exacerbated      alyzed using descriptive statistics. The parametric data was
or induced by COVID-19 infection. Fibrosing alopecia has           described as percentages and mean ± standard deviation.
also been reported as isolated cases [3,8]. The mechanisms of      Comparison between groups was done using Student t test,
hair loss remain unclear, although autoimmune abnormali-           chi-square test, Wilcoxon-Mann-Whitney U test, Kruskal
ties, immune imbalances and prolonged residual infection of        Wallis test and Fishers exact test. Analysis was carried out at
hair follicle may be involved [3].                                 5% level of significance and P-value < 0.05 was considered
                                                                   statistically significant.
Objectives
The aim of this study was to assess the clinical, hematological,   Results
biochemical and trichoscopic features in patients presenting
with post COVID-19 hair loss and to compare them with the          Demographic Factors and Associated Diseases
severity of COVID-19 infection and degree of hair loss.            A total of 120 patients were included in the study. Mean age
                                                                   of the patients was 39.6±12.4 years. Age distribution was bi-

Methods                                                            modal, with 54.1% in the age group of 41-60 years and 25%
                                                                   in the age group of 21-30 years. There were 103 (85.8%)
This cross-sectional study was conducted at a tertiary care        females and 17 (14.2%) males. Of the total patients, 104
center in North India during the post COVID-19 pandemic            (87%) were treated for COVID-19 infection at home. The




2                                                                       Original Article | Dermatol Pract Concept. 2023;13(4):e2023263
duration of illness was ≤ 2 weeks among 68 (56.7%) patients           Table 1. Demographic factors & associated
and > 2 weeks in 52 (43.3%) patients. Only 12 (10%) pa-                diseases in patients with post COVID-19
tients had co-morbid illnesses and 50 patients (41.7%) had                              hair loss.
underlying predisposing factors for TE. Mean VAS score for
                                                                                   Variable                       Result
stress was found to be 5.25±2.8. Vitamin D deficiency was
                                                                    Age (in years) [Range, Mean ± SD] [19-60, 39.6 ± 12.4
detected in 68 (56.7%) patients, low serum ferritin in 36                                             years]
(30%), low hemoglobin in 24 (20%) and Vitamin B12 de-                 11-20                           6 (5%)
ficiency in 18 (15%) patients. Raised Thyroid Stimulating             21-30                           30 (25%)
Hormone (TSH) levels were noted in 14 (11.7%) patients.               31-40                           19 (15.8%)
                                                                      41-50                           37 (30.8%)
Table 1 shows the demographic factors and associated dis-
                                                                      51-60                           28 (23.3%)
eases among study participants.
                                                                    Gender (F: M ratio)                   6.05:1
                                                                    Females (F); Males (M)                103 (85.8%);
Clinical and Trichoscopic Findings                                                                        17 (14.2%)
Of 120 participants, 45 (37.5%) had pre COVID-19 hair               Patients treated for COVID-19 at      104 (86.7%);
loss. The most common pattern of hair loss among them               Home; Hospital                        16 (13.3%)
was diffuse type in 26 patients (21.7%). Mean time of on-           Duration of COVID-19 infection        68 (56.7%)
set of hair loss post COVID-19 infection was observed to             ≤ 2 weeks                            52 (43.3%)
be 49 ± 30.7 days, with no significant difference between            >2 weeks
males (43.71 days) and females (50.18 days) (P-value =              Co-morbid illness                     12 (10%)
0.684). Trichodynia was reported by 19 (15.8%) and scalp              Diabetes Mellitus                   5 (4.2%)
                                                                      Hypertension                        4 (3.3%)
itch by 13 (10.8%) patients. Mild, moderate and severe hair
                                                                     Asthma                               1 (0.8%)
loss (Figure 1) was seen in 6.7%, 37.5% and 55.8% of pa-
                                                                      Diabetes and Hypertension           2 (1.7%)
tients respectively. Hair pull test was found to be positive
                                                                    Predisposing factors                  50 (41.7%)
among 78 (65%) patients. The most common pattern of post              Medical/Metabolic/Anemia/           40 (33.3%)
COVID-19 hair loss was diffuse type in 80 (66.7%) patients.         Surgery                               4 (3.3%)
The most common trichoscopic finding observed was single              Stress                              8 (6.7%)
hair follicle unit in 98 (81.7%) patients. Table 2 shows the          Drugs                               2 (1.7%)
clinical and trichoscopic features (Figures 2 and 3) in pa-           Others

tients with COVID-19 hair loss.                                     Mean VAS score                        5.25 ± 2.8
    Significant comparative findings between study parameters       Vitamin D deficiency                  68 (56.7%)
and degree of hair loss are enlisted in Table 3. Comparison of      Low ferritin                          36 (30%)
clinical and trichoscopic features of hair loss between patients    Low hemoglobin                        24 (20%)
treated for COVID-19 infection at home (Group 1) and at hos-        Vitamin B12 deficiency                18 (15%)
pital (Group 2) are summarized in Table 4; and for patients         Raised TSH                            14 (11.7%)
with duration of COVID-19 infection for ≤ 2 weeks (Group 3)         Family member with COVID-19           57 (47.5%)
and for > 2 weeks (Group 4) are summarized in Table 5.              associated hair loss

                                                                   SD = standard deviation; TSH = Thyroid Stimulating Hormone;
Conclusions                                                        VAS = Visual Analog Scale.


COVID-19 infection was a cause of global pandemic and
there has been extensive research to guide diagnosis, man-         older age groups (49 years) have been affected, which could
agement and prevention of the same. However, post recov-           possibly be due to geographical variation in the prevalence
ery symptoms have been equally harrowing, with survivors           of COVID-19 infection [10-12]. There was a female prepon-
showing varied symptoms ranging from fatigue, dyspnea,             derance in the present study, as seen in other studies as well,
headache, attention deficit to hair loss. Post COVID-19 hair       possible explanations being, longer hair length and higher
loss has been reported to be one of the five most common           vulnerability of female hair follicles due to role of estrogen
post recovery symptoms [9].                                        and progesterone hormones in the pathophysiology of hair
    The mean age of patients reported in our study (39.6           loss [1,2,8,10,12-15]. Higher prevalence of anemia (20%)
years) was similar to that reported by Sharquie et al (41.3        and low ferritin levels (30%) in our patients, who were pre-
years). However, both younger (mean age 31 years) and              dominantly females, can also be a contributing factor, as was




Original Article | Dermatol Pract Concept. 2023;13(4):e2023263                                                                  3
                   Figure 1. Daily hair count of seven days from a patient with severe degree of diffuse hair loss.




    Table 2. Clinical and trichoscopic findings                        also observed by Babaei et al who reported the presence of
                   of hair loss.                                       iron deficiency anemia in 13.8% of their patients [12].
                 Variable                           Result                 The mean VAS score for stress in our study was 5.25,
 Pattern of Pre-COVID-19 hair loss               45 (37.5%)            which was comparatively lower than that reported by Rivetti
   Diffuse                                       26 (21.7%)            et al (8.2) [16]. Stress, however, has been noted to induce
   FPHL                                           9 (7.5%)             as well as increase the hair loss during and post COVID-19
   MPHL                                           8 (6.7%)
                                                                       pandemic. We also found that the mean VAS score was
   AA                                             2 (1 .7%)
                                                                       significantly higher in patients who were hospitalized for
 Pattern of Post-COVID-19 hair loss
                                                                       COVID-19 infection and who had infection for more than
   Diffuse                                       81 (67.5%)
   FPHL                                           24 (20%)             2 weeks, hence, correlating with the severity of infection.
   MPHL                                           9 (7.5%)             However, it was not significantly associated with the degree
   Diffuse and FPHL                               4 (3.3%)             of hair loss. The relationship between stress and hair cycle
   Diffuse and MPHL                               1 (0.8%)             changes has given rise to the concept of “brain-hair folli-
   Diffuse and AA                                 1 (0.8%)
                                                                       cle axis”, wherein the release of specific neuropeptides and
 Time of onset of hair loss post                                       hormones along this axis may promote changes in the hair
 COVID-19 infection                              2-196 days,
                                                                       growth cycle by shifting the hair from anagen to telogen,
   Range, Mean ± SD                             49 ± 30.7 days
                                                                       promoting hair loss [16]. An unexpected finding was that
 Trichodynia                                     19 (15.8%)
                                                                       47.5% of study population had a family member with post
 Scalp itch                                      13 (10.8%)
                                                                       COVID-19 hair loss, indicating its high prevalence and illus-
 Degree of hair loss
                                                                       trating the importance of taking a good family history.
   Mild                                           8 (6.7%)
   Moderate                                      45 (37.5%)                Pre COVID-19 hair loss was observed more frequently in
   Severe                                        67 (55.8%)            our patients (37.5%) compared to a study by Abdulwahab
 Positive hair pull test                           78 (65%)            et al (15.5%). The latter reported a greater number of cases

 Hair Density Decreased                          109 (90.8%)           of TE and alopecia areata vis-à-vis the present study. We,
                                                                       however, observed a higher proportion of patients with pat-
 Scalp features (on clinical examination)
 Scaling                                          11 (9.2%)            terned hair loss [2]. Interestingly, majority of our cases with
 Erythema                                          1 (0.8%)            pre-existing hair loss had mild to moderate degree of hair
 Pustule                                           1 (0.8%)            loss post COVID-19 infection.
 Trichoscopic features                                                     Current hair loss in our study was predominantly dif-
 Single hair follicle                            98 (81.7%)            fuse type, followed by patterned type with overlap of diffuse,
 Vellus hair >10%                                 72 (60%)             patterned and/or alopecia areata in a few cases. In contrast,
 Empty hair follicle                             61 (50.8%)            Abdulwahab et al reported greater number of cases of TE
 Anisotrichosis                                  52 (43.3%)
                                                                       and alopecia areata and lesser number of cases with pat-
 Increased interfollicular distance              50 (41.2%)
                                                                       terned hair loss [2]. Meanwhile, Babaei et al in their study
 Perifollicular scaling                          33 (27.5%)
 Perifollicular pigment                          17 (14.2%)            found androgenetic alopecia as the most common concom-
 Yellow dot                                      15 (12.5%)            itant pattern with TE [12]. Another study on hair loss post

AA = Alopecia areata; FPHL = Female pattern hair loss;
                                                                       COVID-19 infection reported majority cases of TE and only
MPHL = Male pattern hair loss; SD = standard deviation.                few cases of alopecia areata and fibrosing alopecia [8]. We



4                                                                           Original Article | Dermatol Pract Concept. 2023;13(4):e2023263
                    Figure 2. Trichoscopy showing numerous empty hair follicles (blue asterisk), increased interfollic-
                    ular distance, single hair follicles, multiple short regrowing hair (yellow arrow) and few vellus hair
                    (red circle) suggestive of telogen effluvium (DermLite DL4 ×20).




                    Figure 3. Trichoscopy showing anisotrichosis, single hair follicles, empty hair follicles (blue aster-
                    isk), increased interfollicular distance, single hair follicles, multiple vellus hair (red circle), perifol-
                    licular brown pigmentation (green arrow) suggestive of patterned hair loss (DermLite DL4 ×20).




noted a relatively higher percentage of patterned hair loss,                with trichodynia (3 weeks), however we observed no such
possibly because of high prevalence of pre-existing patterned               difference [22]. The mean time of onset of hair loss post
hair loss in our study population. Another possible explana-                COVID-19 infection is earlier than the classic TE, possi-
tion could be that COVID-19 infection exacerbated or trig-                  bly because of pathogenetic mechanisms implicated in post
gered patterned hair loss [17].                                             COVID-19 hair loss [10]. These include intense release of
    The mean time of onset of hair loss post COVID-19 in-                   pro inflammatory cytokines including IL-6, IL-4, IL-10, ma-
fection in our study was 49 days, which was comparable to                   trix metalloproteinase (MMP) 1 and 3, which induce cata-
that found in other studies (7-9 weeks) [8,10,12-14,18-21].                 gen, cause premature anagen release, have cytotoxic effects
Starace et al observed earlier onset of hair loss in patients               on keratinocytes, inhibit stem cells and decrease hair growth



Original Article | Dermatol Pract Concept. 2023;13(4):e2023263                                                                         5
       Table 3. Significant comparative findings of study parameters based on degree of hair loss.
                                                   Group A                  Group B                     Group C
                                                Mild hair loss        Moderate hair loss            Severe hair loss
                  Variable                          (N = 8)                  (N = 45)                   (N = 67)            P-value
 Age (Years)                                    39.00 ± 14.22            36.27 ± 11.92               41.94 ± 12.15           0.048
 Gender                                           3 (37.5%)                10 (22.2%)                   4 (6.0%)             0.008
   Male                                           5 (62.5%)                35 (77.8%)                  63 (94.0%)
   Female
 Place of management                              6 (75.0%)                41 (91.1%)                  57 (85.1%)            0.395
   Home                                           2 (25.0%)                 4 (8.9%)                   10 (14.9%)
   Hospitalized
 Duration of COVID-19 infection                   3 (37.5%)                33 (73.3%)                  32 (47.8%)            0.011
  ≤ 2 Weeks                                       5 (62.5%)                12 (26.7%)                  35 (52.2%)
  > 2 Weeks
 Pre-existing Hair Loss                           5 (62.5%)                22 (48.9%)                  18 (26.9%)            0.020
   Yes                                            3 (37.3%)                23 (51.1&)                  49 (73.1%)
   No
 VAS score                                       3.62 ± 2.62               5.00 ± 2.72                 5.61 ± 2.83           0.099

AA = Alopecia areata; FPHL = Female pattern hair loss; MPHL = Male pattern hair loss; VAS: =Visual analogue scale.



         Table 4. Comparison of clinical and trichoscopic features of hair loss between Group 1
                            (treated at home) and Group 2 (hospitalized).
                                                                                     Group 1              Group 2
                                   Variable                                          (N = 104)            (N = 16)          P-value
 Age (years)                                                                        38.1± 12.2           49.2± 8.6           0.001
 Mean time of onset of hair loss post COVID-19 infection (days)                     48.9 ± 31.5         51.9 ± 25.9          0.427
 Duration
  ≤ 2 weeks                                                                         65 (62.5%)           3 (18.8%)           0.001
  > 2 weeks                                                                         39 (37.5%)          13 (81.2%)
 Mean VAS score                                                                      4.8 ± 2.8          7.06 ± 2.38          0.005
 Pattern of current hair loss
   Diffuse                                                                          69 (66.3%)           12 (75%)            0.810
   MPHL                                                                             20 (19.2%)            4 (25%)
   FPHL                                                                              9 (8.7%)              0 (0%)
   Diffuse and FPHL                                                                  4 (3.8%)              0 (0%)
   Diffuse and AA                                                                    1 (1.0%)              0 (0%)
   Diffuse and MPHL                                                                  1 (1.0%)              0 (0%)
 Degree of hair loss
   Mild                                                                              6 (5.8%)            2 (12.5%)           0.395
   Moderate                                                                         41 (39.4%)            4 (25%)
   Severe                                                                           57 (54.8%)          10 (62.5%)
 Trichoscopic features
 Single hair follicle                                                               83 (79.8%)          15 (93.8%)           0.299
 Vellus hair >10%                                                                   58 (55.8%)          14 (87.5%)           0.016
 Empty hair follicles                                                               48 (46.2%)          13 (81.2%)           0.009
 Anisotrichosis                                                                     44 (42.3%)           8 (50.0%)           0.563
 Increased Interfollicular distance                                                 40 (38.5%)          10 (62.5%)           0.069
 Perifollicular scaling                                                             30 (28.8%)           3 (18.8%)           0.552
 Perifollicular pigment                                                             14 (13.5%)           3 (18.8%)           0.699
 Yellow dots                                                                        11 (10.6%)            4 (25%)            0.115

AA = Alopecia areata; FPHL = Female pattern hair loss; MPHL = Male pattern hair loss; VAS: =Visual analogue scale.



6                                                                         Original Article | Dermatol Pract Concept. 2023;13(4):e2023263
 Table 5. Comparison of clinical and trichoscopic features between Group 3 (duration of COVID-19
           infection ≤ 2 weeks) and Group 4 (duration of COVID-19 infection > 2 weeks).
                                                                                   Group 3              Group 4
                                                                                  ≤ 2 weeks            >2 weeks
                                   Variable                                         (N = 68)            (N = 52)       P-value
 Age (years)                                                                      35.9± 11.82        44.48 ± 11.49      0.001
 Mean time of onset of hair loss post COVID-19 infection (days)                   50.3 ± 34.2          47.9 ± 25.6      0.901
 Place of management
   Home                                                                           65 (95.6%)           39 (75.0%)       0.001
   Hospitalized                                                                    3 (4.4%)            13 (25.0%)
 Mean VAS score                                                                    4.60±2.80           6.10±2.60        0.004
 Pattern of current hair loss
   Diffuse                                                                        44 (64.7%)           37 (71.2%)       0.336
   MPHL                                                                           13 (19.1%)           11 (21.2%)
   FPHL                                                                            6 (8.8%)             3 (5.8%)
   Diffuse and FPHL                                                                4 (5.9%)              0 (0%)
  Diffuse and MPHL                                                                1 (1.5%)              0 (0%)
   Diffuse and AA                                                                   0 (0%)              1 (1.9%)
 Degree of hair loss
   Mild                                                                            3 (4.4%)             5 (9.6%)        0.011
   Moderate                                                                       33 (48.5%)            12 (23%)
   Severe                                                                         32 (47.1%)           35 (67.3%)
 Trichoscopic features
 Single hair follicle                                                             56 (82.4%)           42 (80.8%)       0.824
 Vellus hair >10%                                                                 38 (55.9%)           34 (65.4%)       0.292
 Empty hair follicles                                                             34 (50.0%)           27 (51.9%)       0.835
 Anisotrichosis                                                                   28 (41.2%)           24 (46.2%)       0.586
 Increased Interfollicular distance                                               27 (39.7%)           23 (44.2%)       0.618
 Perifollicular scaling                                                           15 (22.1%)           18 (34.6%)       0.127
 Perifollicular pigment                                                           10 (14.7%)           7 (13.5%)        0.846
 Yellow dots                                                                       8 (11.8%)           7 (13.5%)        0.781

AA = Alopecia areata; FPHL = Female pattern hair loss; MPHL = Male pattern hair loss; VAS: =Visual analogue scale.




[5,10]. Moreover, anticoagulant proteins are decreased                   Trichodynia was present in 15.8% and scalp itch in
in COVID-19 infection, causing microthrombi formation                10.8% of our study subjects. On the other hand, Starace
which obstruct the hair follicle blood supply resulting in           et al observed trichodynia in 58.4% and trichodynia with
hair loss. Increased stress hormones, oxidative stress and hy-       TE in 42.4% of patients. They also found an association of
poxia during COVID-19 infection are all potential culprits           trichodynia with dysgeusia and anosmia, postulating an un-
[5]. Furthermore, direct viral damage to hair follicle has also      derlying neurogenic pathogenesis for all [22]. Trichodynia
been hypothesized [10]. Co-existing anemia, deficiency of            corresponds to a complex symptom comprising scalp pain,
Vitamin D and Vitamin B12, increased TSH and high stress             pruritus or burning sensation on touching the scalp, which
level may also contribute. A significant proportion of our           may be a sign of severity or a warning symptom of imminent
study population (43.3%) had COVID-19 infection for > 2              hair shedding [15.22].
weeks, causing more sustained inflammation, possibly re-                 Females showed a greater degree of hair loss compared
sulting in earlier onset of hair loss. However, we noticed no        to males (61.2% of females versus 23.5% of males), the dif-
significant difference in onset of hair loss post COVID-19           ference being statistically significant. Older study subjects
infection amongst patients with or without hospitalization           had more severe hair loss as has been previously reported
or duration of COVID-19 infection (≤ or > 2 weeks). Babaei           [12]. Degree of hair loss also correlated with duration of
et al reported early onset of hair loss in patients with hypo-       COVID-19 infection in our study, as majority of patients
thyroidism, younger age group and females [12].                      with COVID-19 infection for >2 weeks had severe hair loss.



Original Article | Dermatol Pract Concept. 2023;13(4):e2023263                                                                   7
This can be possibly explained by sustained inflammatory            pigment, which has been reported in patterned hair loss, was
or viral damage. Hospitalization, however, did not have any         seen in 14.2% of study subjects [23,25]. Even though clin-
impact on the degree of hair loss in our study. The effect of       ically, scalp seborrhea and erythema were present in only
hospitalization or COVID-19 severity on hair loss has been          9.2% of cases; perifollicular scaling on trichoscopy was
controversial. Even though studies have found that more             seen in 27.5% of cases. It has been speculated previously
than a fourth of the patients with acute TE post recovery           that COVID-19 infection can exacerbate or precipitate seb-
were hospitalized during COVID-19 infection, others have            orrheic dermatitis [29]. Lv et al also reported scalp inflam-
reported that approximately 1 in 10 patients had subclini-          mation, capillary ectasia and seborrhea on trichoscopy [28].
cal infection or majority had only mild infection [8,14,18].           Another interesting finding in the present study was that
Therefore, it is imperative that clinicians enquire about pre-      patients who were hospitalized for COVID-19 infection had
ceding COVID-19 infection in last 1-3 months in all patients        significantly greater number of empty hair follicles and vel-
with sudden hair loss in the context of the pandemic [18,21].       lus hair. These findings are suggestive that severe COVID-19
    Trichoscopic evaluation is essential in all patients with       infection led to higher release of pro-inflammatory cyto-
hair loss as it helps to uncover and guide towards clinically       kines, thereby resulting in a significant increase in diffuse
indistinguishable causes, like, differentiating diffuse alope-      and possibly patterned hair loss. Association between hos-
cia areata from TE and patterned hair loss in early stages.         pitalization for COVID-19 infection and patterned hair loss
Even though, acute TE does not have any specific findings           has been hypothesized in previous studies, which suggested
on trichoscopy, the most common features described are: de-         androgen mediated SARS-CoV-2 vulnerability, and gave the
creased density of hair, empty hair follicles, numerous short       eponym of Gabrin sign to visually identify people at an in-
regrowing hair of normal thickness and single hair follicles        creased risk of hospitalization and negative outcomes. The
[10,15,18,19,21,23,24].The commonest presenting com-                Gabrin sign suggests that patients with higher degree of
plaint in our study was decreased hair density (in 90.8% of         male pattern baldness are at higher risk of developing severe
patients), which on trichoscopy was seen as increased inter-        COVID-19 symptoms and may require hospitalization [4,5].
follicular distance in 41.2% of study subjects. Empty hair          This has, however, been argued against, and it has been sug-
follicle, another common trichoscopic finding in TE (which          gested by few studies that patterned baldness in both women
may also be seen in patterned hair loss), was observed in           and men is not related to COVID-19 severity [3,6,7].
50.8% of our cases. Also, single hair follicle, which has been         Hair loss has been a significant complaint in the
previously reported in TE and patterned hair loss was seen in       post-acute COVID-19 syndrome, both in the subacute and
43.3% of our patients [25]. Similar findings on trichoscopy         chronic phase. The underlying cause has been documented
have been described in case reports and small case series           to be TE (anagen effluvium as well as chronic TE), precipi-
[10,13,19,24,26,27].                                                tation and exacerbation of alopecia areata, or patterned hair
    Anisotrichosis or hair diameter variability of 20% favors       loss [2,30]. Our findings also suggest the same, with 67%
patterned hair loss over TE. Even though only 31.7% of              of patients presenting in the subacute phase and 13% in the
study subjects clinically had patterned hair loss, anisotricho-     chronic phase, reiterating the need of awareness in both pa-
sis on trichoscopy was seen in 43.3% of patients, predicting        tients and dermatologists alike.
that a significant proportion may eventually develop pat-              The limitations of our study included the study popula-
terned hair loss in addition to diffuse hair loss. In contrast to   tion being limited to the patients specifically seeking derma-
our finding, a few case reports have reported the absence of        tologist consultation at a tertiary care hospital and therefore,
anisotrichosis [20,26,28].                                          not representative of the general population. In addition,
    An interesting finding in our study was the presence of         there was a lack of control group of patients with COVID-19
vellus hair in 60% of patients, even though clinically major-       infection who did not suffer from hair loss. Histopatholog-
ity had diffuse hair loss suggestive of TE. Similarly, vellus       ical confirmation of diagnosis was not carried out, which
hair in fronto-temporal region have been reported in a single       may have led to misdiagnosis of a particular type of hair loss.
case of TE post COVID-19 infection [24]. On the contrary,              In conclusion the present study elucidates the clinical,
some studies observed absence of miniaturized hair in post          biochemical and trichoscopic features in patients present-
COVID-19 TE [19,20]. As vellus hair are classically seen in         ing with post COVID-19 hair loss. Given the severe stress
patterned hair loss and alopecia areata, our patients with          and anxiety that hair loss can have, along with potential
vellus hair could represent overlap of TE with patterned hair       long-term sequelae of diffuse and patterned hair loss, der-
loss or alopecia areata [25].                                       matologists need to be aware of this distressing effect of
    Yellow dots, which are a feature of alopecia areata and         COVID-19 infection. Future areas of research include his-
patterned hair loss, was seen in only 12.5% and perifollicular      topathological examination of hair follicles, genetic studies




8                                                                       Original Article | Dermatol Pract Concept. 2023;13(4):e2023263
for susceptibility to hair loss and studies evaluating the roles         10. Rossi A, Magri F, Sernicola A, et al. Telogen Effluvium after
of hormones (estrogen, progesterone and androgens) and in-                   SARS-CoV-2 Infection: A Series of Cases and Possible Patho-
                                                                             genetic Mechanisms. Skin Appendage Disord. 2021;21(5):1-5.
flammatory cytokines on the extent and duration of hair loss.
                                                                             DOI: 10.1159/000517223. PMID: 34373830. PMCID:
                                                                             PMC8339054.
Acknowledgements                                                         11. Sharquie KE, Jabbar RI. COVID-19 infection is a major cause
                                                                             of acute telogen effluvium. Ir J Med Sci. 2022;191(4):1677-
The authors would like to acknowledge the help rendered                      1681. DOI: 10.1007/s11845-021-02754-5. PMID: 34467470.
                                                                             ­PMCID: PMC8407603.
by Dr Prateek Sharma (Ex -senior resident Department of
                                                                         12. Babaei K, Kavoussi H, Rezaei M, Kavoussi R. Characteris-
Dermatology and STD, Vardhman Mahavir Medical College
                                                                              tics of telogen effluvium in COVID-19 in western Iran (2020).
and Safdarjung Hospital) and Dr Namita Srivastava (Stat-                      An Bras Dermatol. 2021;96(6):688-692. DOI: 10.1016/j
istician cum lecturer, Department of Community Medicine,                      .abd.2021.05.006. PMID: 34593265. PMCID: PMC8440166.
Vardhman Mahavir Medical College and Safdarjung Hospi-                   13. Roda Â, Oliveira-Soares R. Acute telogen effluvium in patients
tal) in the preparation of the manuscript.                                    recently infected with SARS-CoV-2. J Port Soc Dermatol Vene-
                                                                              reol. 2021;79(1),21-25. DOI: 10.29021/spdv.79.1.1299.
                                                                         14. Moreno-Arrones OM, Lobato-Berezo A, Gomez-Zubiaur A, et
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10                                                                        Original Article | Dermatol Pract Concept. 2023;13(4):e2023263
