ABSTRACT
Although hair loss following severe acute respiratory syndrome-coronavirus-2 (COVID-19) infection is common, there are no reported cases of textural changes in COVID-19-associated alopecia. Here, we describe a case of diffuse hair loss followed by distinct changes in hair morphology 1 year after symptomatic COVID-19 infection. Clinical findings were most consistent with anagen effluvium. Robust inflammatory response following COVID-19 infection may contribute to changes in hair texture.
Keywords: Alopecia, anagen effluvium, COVID-19, hair changes, hair loss, hair texture
INTRODUCTION
There have been numerous reports of hair loss following severe acute respiratory syndrome-coronavirus-2 (COVID-19) infection.[1] However, there have been no reports of changes in hair morphology following COVID-19 infection. Here, we describe a case of COVID-19-associated alopecia with subsequent hair texture change.
CASE REPORT
A 49-year-old male with a history of borderline lepromatous Hansen’s disease (HD), previously complicated by reversal reaction, presented for follow-up in our HD clinic. HD was completely treated 2 years prior. One-year earlier, he was diagnosed with symptomatic COVID-19. Approximately 1–2 months later, he reported the onset of diffuse scalp hair shedding without focal patches of alopecia. This was followed by regrowth with a curly texture throughout the scalp.
Examination revealed curly hair throughout the scalp [Figure 1a]. There were no areas of discrete hair loss, and hair pull tests were negative. An earlier photograph confirmed a lifelong history of straight hair [Figure 1b]. Further workup of alopecia was deferred given stable regrowth. Trichoscopic examination was not performed due to the delayed nature of the presentation.
Figure 1.
“Comparison of hair texture before and after COVID-19 infection.” Textural hair changes in a Hansen’s disease patient after (a) and before (b) COVID-19 infection
DISCUSSION
There have been numerous reports of hair loss associated with COVID-19. A recent review noted 1136 reports of nonscarring alopecia, including telogen effluvium (TE, 84%), alopecia areata (AA, 16%), and anagen effluvium (AE, 0.2%).[1] In this case, the clinical presentation led us to favor AE as the most likely diagnosis. AE results from a cessation of the anagen phase of the hair cycle, occurring days to weeks after the insult.[1,2] In the setting of COVID-19, AE may occur due to increased release of pro-inflammatory cytokines, namely, interleukin (IL)-4 and tumor necrosis factor-alpha (TNF-alpha).[1] COVID-19-associated AA occurs between 10 days and 2 months after infection.[1] The pathogenesis may be due to high levels of IL-17 and type I interferons.[1] In both AE and AA, patients can experience hair textural changes upon regrowth.[2,3] An isolated episode of diffuse AA with complete regrowth and no recurrences makes AA a less likely diagnosis. However, we lack long-term follow-up. While TE is commonly reported following COVID-19, it was thought to be less likely as associated hair texture change has not been reported to our knowledge.[1]
The driving factor for textural changes is unknown, but may be multifactorial as differences in protein composition, growth factors, and cytokine expression can contribute to hair curvature.[3] Furthermore, in this case, it is important to consider that the immunologic milieu of HD may have contributed to the presentation. Patients with borderline lepromatous HD exhibit a Th2 predominance resulting in increased IL-4, 1 L-10, and TGF-β.[4] Although the patient’s HD was fully treated before the onset of alopecia, his history of reversal reaction, characterized by upregulation of TNF-alpha, IL-4, and IFN-gamma, may have further enhanced his inflammatory response to COVID-19 infection.[5]
While the pathogenesis of curly hair regrowth in this patient is unknown, a robust inflammatory insult coupled with history of HD, may have contributed to changes in hair morphology. Further investigation is needed to enhance our understanding of alopecias and associated immunologic phenomena in the setting of COVID-19 infection.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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