COVID-19 and Alopecia

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused around 50 million confirmed cases of coronavirus disease 2019 (COVID-19) and roughly 1.230 million deaths to date throughout the world. The elevated prevalence and escalated rate of COVID-19 morbidity and mortality have given rise to a global health emergency.

COVID-19 and Alopecia Prevalence

The prevalence of AGA in males and females was 79% and 42%, respectively. In a similar age-matched population of males the frequency of AGA was 31%–53%, while the maximum prevalence of AGA in a female population over the age of 70 was 38%. The outcomes revealed a considerable proportion of AGA in patients admitted with COVID-19.

Association of COVID-19 to Alopecia

The COVID-19 pandemic is associated with stressors; those who were infected with the virus were under immense psychosocial and physiologic stress. Moreover, the body responds to SARS-CoV-2 infection by creating a pro-inflammatory state, which leads to tissue damage and other sequelae. Pro-inflammatory cytokines are released and anticoagulation mechanisms are impaired, which may provoke hair loss via the systemic inflammatory response and/or microthrombi in the hair follicles.

It has been reported that those with more severe COVID-19 infections had higher levels of pro-inflammatory cytokines, which may correlate to a higher risk of hair loss given the pro-inflammatory state. In addition, the coagulation cascade becomes activated in response to COVID-19 infection, and there is decreased concentration of anticoagulant proteins due to decreased production and increased consumption. These factors can lead to microthrombi formation, which may occlude hair follicle blood supply. Microthrombi and systemic inflammation represent two possible mechanisms to explain how COVID-19 infection could provoke Telogen effluvium TE. Topical minoxidil was prescribed in 50% of our patients; there is not strong evidence to suggest that it is efficacious for TE. Educating the patient on the self-limiting natural course of the condition is a crucial component of management. The hair will eventually stop shedding and begin to grow back, but it may take up to 18 months for hair thickness to return to baseline.

COVID-19 has been associated with exacerbation of underlying autoimmune disease as well as triggering new conditions. Alopecia areata (AA) has been noted to flare in relationship to the infection or stress of quarantine and/or fear of infection. Some patients were seen in consultation with new onset AA in August 2020 with rapidly progressive disease after the pandemic started. All of them were unresponsive to 1–2 months of topical, intralesional, and/or nutritional treatments.

Onset and Peak of Alopecia

In some adults it was reported that there was a noticeable hair loss subsequent to COVID-19. Hair loss started suddenly with clumps of hair falling out while combing or brushing approximately two months after the onset of COVID-19 symptoms and lasted for up to 6 months.

Noticeable hair loss, reported by approximately 20% of COVID-19 survivors, has been associated with a more severe course of illness. The number of subjects in the study, however, was too low to draw conclusions about this association. TE typically affects less than half of the scalp and lasts for approximately 6 months; a hair that falls out is replaced by a new, growing hair.

Advise and Suggestions for Hair Loss

• Patients should maintain hair hygiene and habits (avoid pony tails continuously and clean scalp, Further care of scalp must be taken according to its kind i.e., oily or dry)
  
• Take care of work behavior (should maintain mental work load, outdoor physical labor, avoid high stress)
  
• Dietary management (should avoid too much of alcohol and smoking rather include vitamins in diet)
  
• Avoid late night activity and get proper sleep (sufficient time with good quality of sleep)
  
• Topical Minoxidil 2%–5% 1 ml twice daily recommended as first line treatments
  Inclusion of essential amino acids, iron supplements.
  

Vitamin D3 Deficiency in Alopecia Patients

Pandemic-related confinement helps to contain the transmission of the novel COVID-19 but restricts children's exposure to sunlight, thereby possibly affecting their 25-hydroxyvitamin D [25(OH)D] levels, a higher prevalence of 25-hydroxyvitamin D deficiency and lower 25-hydroxyvitamin D levels was seen in patients suffering hair loss. It is therefore suggested to increase vitamin D3.

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