Sir,
After contacting coronavirus disease 2019 (COVID-19), an increasing number of patients are reported to experience hair loss, including telogen effluvium (TE), alopecia areata (AA), and androgenic alopecia (AGA). We here reported a case of AA occurred immediately after the COVID-19 infection with high fever.
A 38-year-old man presented to the dermatologic department because of the rapid onset of multiple patches of alopecia on his scalp. The patient had been diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection thanks to the COVID-19 antigen rapid test on December 19, 2022. He had a fever of over 39 degrees Celsius for 2 days with joint pain. During the fever, he was treated with paracetamol once. Immediately after the fever subsided, the patient noted a patch of hair loss on the right parietal region, which rapidly expanded. Later, he had recovered from SARS-CoV-2 infection, according to the negative COVID-19 antigen rapid test. However, the area of hair loss is still growing.
Physical examination revealed several asymptomatic patches of alopecia on the scalp and beard area [Figure 1]. The pull test was positive, and the surface of patches was smooth. Dermoscopy showed the presence of black dots, yellow dots, exclamation mark hairs, broken hairs, and vellus hairs [Figure 2]. Personal history and family history were negative for AA and auto-immune diseases.
Figure 1.
Several asymptomatic patches of alopecia on the (a) scalp and (b) beard
Figure 2.
Dermoscopy showed the presence of black dots (red circle), yellow dots (blue circle), exclamation mark hairs (blue arrow), broken hairs (red arrow), and vellus hairs (stars) (a, b) (×50)
Laboratory examinations including blood routine, liver, and kidney functions were within normal ranges. The thyroid function tests were slightly abnormal, and further testing is being done.
The clinical and dermoscopy features supported the AA diagnosis.
The patient was treated with triamcinolone acetonide injections, oral prednisone acetate 10mg/d and compound glycyrrhizin 150mg/d, and topical steroids for the patches. After nearly 5 months of regular treatment, the condition had significantly improved, with only a small amount of alopecia remaining at the hairline and in the beard area, which did not affect the patient’s daily life. As a result, the patient chose to discontinue medication. After 1 year of follow-up, the small patch of baldness at the hairline and in the beard area showed no expansion and remained stable.
Research on the relationship between COVID-19 infection and AA remains controversial. According to a cross-sectional analysis by a questionnaire, among 59 participants who tested positive for COVID-19, 25/59 (42.4%) reported AA symptoms. In addition, 77/113 (68.1%) reported AA symptoms among 113 participants who received at least one COVID-19 vaccination.[1] The findings could support the speculation of causative association. However, a retrospective cohort study showed that the diagnosis of COVID-19 was not substantially linked to the emergence of AA even after correctly controlling for confounders.[2]
In the published literature, the interval between SARS-CoV-2 infection and AA ranges from 2 to 8 weeks. According to Christensen R E et al.’s systematic review, including seven new-onset case reports of AA following confirmed infection with SARS-CoV-2, AA may be triggered by COVID-19 but most frequently occurs 1 to 2 months after infection.[3]
As for the age of reported patients, although most of the patients including our case are adults, it is interesting to find that there are also case reports about paediatric alopecia areata following COVID-19 infection.[4]
To our knowledge, this is the first report of AA immediately after SARS-CoV-2 infection with high fever, indicating clearer temporal correlation.
AA, as a complex polygenic condition, is thought to be triggered by a cytokine storm caused be COVID-19 infection.[5] Since febrile illness can also act as an environmental trigger for AA, we speculate that the high fever associated with COVID-19 may also be a trigger factor.[5]
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.
Acknowledgement
The patients in this manuscript have given written informed consent to the publication of their case details.
Funding Statement
Nil.
References
- 1.Nguyen B, Tosti A. Alopecia areata after COVID-19 infection and vaccination: A cross-sectional analysis. J Eur Acad Dermatol Venereol. 2023;37:e7–8. doi: 10.1111/jdv.18491. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kim J, Hong K, Gómez Gómez RE, Kim S, Chun BC. Lack of evidence of COVID-19 being a risk factor of alopecia areata: Results of a national cohort study in South Korea. Front Med (Lausanne) 2021;8:758069. doi: 10.3389/fmed.2021.758069. doi:10.3389/fmed. 2021.758069. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Christensen RE, Jafferany M. Association between alopecia areata and COVID-19: A systematic review. JAAD Int. 2022;7:57–61. doi: 10.1016/j.jdin.2022.02.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Herzum A, Viglizzo G, Gariazzo L, Garibeh E, Occella C. Pediatric alopecia areata following COVID-19 infection. J Cosmet Dermatol. 2023;22:734–6. doi: 10.1111/jocd.15618. [DOI] [PubMed] [Google Scholar]
- 5.Pratt CH, King LE, Messenger AG, Christiano AM, Sundberg JP. Alopecia areata. Nat Rev Dis Primers. 2017;3:17011. doi: 10.1038/nrdp.2017.11. [DOI] [PMC free article] [PubMed] [Google Scholar]
