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CASE REPORT
Year : 2022 | Volume
: 26
| Issue : 3 | Page : 8-10
Post SARS-CoV-2 infection and hair loss
Fahad H Alrashidi1, Nojoud Alaroush2
1 Department of Dermatology, College of Medicine, Qassim University, Buraidah, Qassim, Saudi Arabia
2 Division of Dermatology, Security Forces Hospital, Riyadh, Saudi Arabia
Correspondence Address:
Dr. Fahad H Alrashidi
College of Medicine, Qassim University, Buraidah, Qassim
Saudi Arabia
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jdds.jdds_16_21
People affected with severe acute respiratory syndrome coronavirus 2 can have a wide variety of symptoms. Literature and public discussion forums report persistent symptoms among COVID-19 survivors. More than 25% of COVID-19 survivors report hair loss as a persisting issue. The Centers for Disease Control and Prevention state that hair loss as a potential long-term effect of COVID-19 is currently under investigation. This report may be the first case of hair loss in the patient with postCOVID-19 infection in Saudi Arabia.
Keywords: Alopecia, post COVID-19 hair loss, telogen effluvium
In December 2019, a case series of pneumonia with unknown cause manifested in Wuhan, Hubei, China. Novel coronavirus (2019-nCoV) is a new strain which was isolated from lower respiratory tract of affected patients in Wuhan on January 7, 2020. Coronaviruses cause illness ranging from common cold to more severe diseases such as Middle East Respiratory Syndrome and Severe acute respiratory syndrome (SARS).[1]
The symptoms of COVID-19 vary from person to person, and it covers the wide range of clinical manifestations. The most common symptoms are fever, dry cough, fatigue, myalgia, and dyspnea; however, gastrointestinal, neurological, and cutaneous manifestations have been reported. Cutaneous manifestations were not recognized at the early stages of pandemic and have only received recent attention.[2] Studies have shown that cutaneous findings range from “COVID toes” to hair loss, pruritic maculopapular lesions on the trunk and sub-mammary fold, generalized urticaria, target lesions (erythema multiform like), painful eroded and ulcerated papules, small plaques on the upper limbs, purple to blue lesions in the thighs, varicella-like lesions, livedo reticularis on the arm, and cutaneous necrosis.[3] Some of these cutaneous manifestations are seen soon after COVID-19 infection, while other symptoms arise later or in severe infection. Several researchers are also studying the effect of body's immune response to infection, or whether hormones are involved in causing these skin conditions.[2],[3],[4]
Telogen effluvium (TE) is the most common causes of temporary hair loss in women which is characterized by an acute onset of hair shedding usually seen 2–3 months after a triggering event such as acute or chronic illness (especially if there is a fever), surgery, accident, severe stress, unusual diet and weight loss, endocrine disorders (e.g. hypo and hyperthyroidism), jetlag, skin diseases (e.g., erythroderma), excessive sun exposure, pregnancy and childbirth, and nutritional deficiency.[5] Quarantine was reported as a highly stressful period among individuals and TE is a disease often induced by stressful events. Specific neuropeptides, neurotransmitters, and hormones modulate the brain-hair follicle axis which may induce changes in the hair growth cycle by stimulating the conversion of anagen hairs into telogen phase. [6],[7] One study observed TE in 27.9% of patients with COVID-19 and was more frequent in women than men.[7] TE increases 3 months after stressful events, hence Turkmen et al., predicated that number of TE patients would increase in future.[7]
We report a case of TE after SARS coronavirus 2 (SARS-CoV-2) infections in a female. She was worried about her significant hair loss and never had diagnosis of TE before. The aim of this case study is to improve the knowledge of primary care physicians and nondermatology physicians about acute TE (ATE) in postCOVID-19 infection and its management. TE to COVID-19 infection could be a common cause of consultation and that will presumably increase because of ongoing infection and psychological stress due to pandemic.
Case ReportA 17-year-old female presented to Security Forces Hospital, Dermatology Department on December, 2020. Her x was generalized hair loss due to dramatic shedding of hair that started 6 months back. She experienced considerable shedding every time when she brushed her hair, far more than her baseline hair shedding. She was specifically concerned about excessive hair on her clothes and pillows. Furthermore, she reported that she was tested positive on real-time reverse transcription-polymerase chain reaction for SARS-CoV-2 from a nasopharyngeal swab, 8 months back. She neither required any hospitalization nor specific treatment. She experienced only dry cough and fever that lasted for 3 days. Her past medical history before and after COVID-19 infection was unremarkable and there was no history of medications.
On physical examination, a generalized reduction in hair density without any scaling and erythema was seen. Clinical examination showed a negative hair pull test and no female pattern hair loss. Laboratory investigations revealed serum levels of ferritin were 71 ng/mL, Vitamin B12: 429 ng/L, Vitamin D: 42 ng/mL, hemoglobin: 14 g/dL, and thyroid-stimulating hormone: 2.3 mU/L, which were within normal ranges. In addition, cell blood count and liver function tests were within normal limits.
The diffuse hair loss, in this case, may be attributed to the COVID-19 related TE and we hypothesize that the trigger could have been the infection and possibly due to profound inflammatory insult due to the SARS-CoV-2 infection 2 months before his hair loss. No treatment was given and the patient was reassured about the reversible nature of the hair loss and hair would resume normal growth since the inflammatory insult due to COVID-19 had already been resolved.
DiscussionThis case highlights a new manifestation of hair loss in an adult with COVID-19 infection. There are several factors which can lead to an increased hair shedding. Hair loss after infection has been categorized as TE, first described by Kligman in 1961 as a nonscarring alopecia which begins 2–3 months after an initial insult. It is usually a self-limiting disorder that lasts for about 6 months. It is due to an abnormal acute transformation of a large number of scalp anagen hairs to the catagen phase and subsequently entering into the telogen phase which results in the altered ratio of hairs in the anagen to telogen phase. Hair follicles may respond to infection either as an anagen effluvium or TE depending on the type and intensity of the triggering event.[8]
In Spain, Moreno-Arrones et al. (2021) showed that the prevalence of ATE was 89.7% in prior confirmed COVID-19 cases, and days since SARS-CoV-2 detection and hair shedding was 57.1 (±18.3) days.[9] Similarly, our patient also started experiencing hair loss 2 months post COVID-19 infection. Therefore, symptomatic SARS-CoV-2 infection is a risk factor for ATE because the pro-inflammatory cytokines released during infection are thought to be the triggering factor for TE. It was also found that nearly one in 10 patients with subclinical SARS-CoV-2 presented with ATE.[9]
Our case shows that TE can be a late sequel of COVID-19 infection. Domínguez-Santás et al. reported a case of ATE association with SARS-CoV-2 infection in a 42-year-old woman, Spain.[10] Studies have reported an association between TE and other febrile infectious diseases such as dengue, human immunodeficiency virus infection, influenza, typhoid, scarlet fever, pneumonia, tuberculosis, pertussis, and malaria.[11]
Because of the abrupt onset of hair shedding and unclear etiology, TE in postCOVID-19 poses a great psychological burden, especially among females. Clinicians should be well-informed about SARS-CoV-2 infection can be associated with delayed onset of TE and patients should be reassured as its a reversible alopecia which does not require any specific treatment. In the view of increasing pandemic, past SARS-CoV-2 infection should be always kept in mind for every patient who complains of ATE.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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