Telogen Effluvium Following Coronavirus Disease-2019 Infection: A Retrospective Study of 113 Cases

ABSTRACT

Background:

Telogen effluvium (TE) is self limiting diffuse hair loss occurring 3–4 months after a triggering event. There is scarcity of data on TE as possible sequelae of COVID-19.

Methods:

We assessed 113 cases of TE occurring after SARS-CoV-2 infection as a retrospective study.

Results:

Most of the patients belonged to the age group 18–30 years and were females (85.8%). Most of the patients (92%) had acute TE. The median duration of hair loss was 2 months. Trichodynia and pruritus were the common associated complaints. Hair pull test was positive in 54.9% patients. Trichoscopy showed short regrowing hairs in 61.2% patients and empty hair follicles in 77.9% patients. Ferritin, vitamin D and Vitamin B12 deficiency was seen in 27.4%, 38.1% and 20.4% patients respectively. TE was seen more commonly with symptomatic COVID infection (93% patients).

Conclusion:

TE occurring after SARS-CoV-2 infection calls for assessment of micronutrient deficiency, as there appears to be an association between COVID-19 infection and nutritional deficiency. Although acute TE is the most common presentation, relapse in chronic TE might also occur as sequelae of COVID-19 infection.

INTRODUCTION

Classic telogen effluvium (TE) is self-limited and acute, defined as lasting <6 months, and occurs approximately 3–4 months after a triggering event. The cutaneous involvement of coronavirus disease-2019 (COVID-19) has been largely studied, but only few studies have focused on TE as possible sequelae of COVID-19. We assessed 113 cases of TE occurring after SARS-CoV-2 infection to investigate patterns related to COVID-19. This study was planned to bring out the various factors associated with post-COVID TE.

MATERIALS AND METHODS

A retrospective observational study was planned based on the records of patients suffering from new-onset diffuse hair loss in patients previously infected with SARS-CoV-2 (diagnosed with positive reverse transcription–polymerase chain reaction on nasopharyngeal swab) and clinically diagnosed with TE from April 2021 to October 2021. Data of TE patients were assessed including demographic details, duration of disease, COVID severity, treatment history, and associated stress. Clinical evaluation included hair pull test, trichoscopy. The degree of self-perceived stress was measured and analyzed in patients with the help of the Perceived Stress Scale (PSS).[1] Trichoscopic pictures were systematically taken at the vertex and frontal region, with a polarized dermoscope (Dermlite DL4). The investigations including serum hemoglobin, ferritin, Vitamin D levels, Vitamin B12, and thyroid-stimulating hormone were performed in patients.

RESULTS

A total of 113 patients were diagnosed with post-COVID-19 TE out of which 97 (85.8%) were females. Demographic and clinical characteristics of each patient are summarized in Table 1, and most of the patients belonged to the age group 18–30 years, with mean age of 34.7 ± 11.0 years. As per the COVID-19 course of infection, 105 (93%) patients were symptomatic. Among symptomatic patients, 102 (90.3%) patients had fever, 31 (27.4%) had severe disease requiring hospitalization, oxygen requirement was there in 19 (16.8%) patients, and 14 (12.4%) patients needed intensive care unit care. Treatment history included usage of steroids in 30 (26.5%) patients, anticoagulants in 31 (27.4%) patients, and antivirals in 30 (26.5%) patients.

Table 1.

Demographic, clinical, and laboratory findings of patients with postcoronavirus disease telogen effluvium

Characteristics of patients	Frequency (%)
Age of patients (years)
<18	3 (2.7)
18-30	55 (48.7)
31-40	32 (28.3)
41-50	15 (13.3)
>50	8 (7.1)
COVID-related symptoms	105 (93)
Duration of complaints (months)
<1	22 (19.5)
1-3	68 (60.2)
3-6	14 (12.4)
Relapse in chronic TE	9 (8)
Trichodynia	52 (46)
Pruritus	43 (38.1)
Anxiety	6 (5.3)
Hair pull test	62 (54.9)
Anemia	32 (28.3)
Vitamin D deficiency	43 (38.1)
Vitamin B12 deficiency	23 (20.4)

TE - Telogen effluvium, COVID - Coronavirus disease

The median duration of hair loss was 2 months (range 1 week–2 years). Most of the patients (92%) had acute TE, whereas nine patients with chronic TE complained of relapse after COVID-19 infection [Figure 1]. Trichodynia was a complaint in 52 (46%) patients, whereas 43 (38.1%) patients complained of pruritus. Anxiety associated with hair loss was diagnosed through PSS in 6 (5.3%) patients. Visible decrease in hair density was found in 75 (66.4%) patients [Figure 2]. Hair pull test was positive in 62 (54.9%) patients. Trichoscopy showed short regrowing hairs in 69 (61.2%) patients, empty hair follicles in 88 (77.9%) patients, and erythema in 22 (19.5%) patients [Figure 3]. Trichoscopy showed variable but typical TE pattern. Trichoscopy of shed hair was positive in all patients. Ferritin deficiency was seen in 31 (27.4%) patients, Vitamin D deficiency in 43 (38.1%) and Vitamin B12 deficiency in 23 (20.4%) patients. Hypothyroidism was detected in six patients.

Figure 1.

Daily shed hair brought by a 25-year-old female with acute telogen effluvium

Figure 2.

35-year-old female with acute telogen effluvium and visible decrease in hair density

Figure 3.

Trichoscopy of a 37-year-old female showing empty hair follicles and short regrowing hair (Dermlite DL4, polarized, ×10)

DISCUSSION

While the focus of COVID infection is mainly life-threatening acute manifestations, virus-induced late sequelae such as cutaneous manifestations have also been described. TE is characterized by diffuse hair loss within months of a significant systemic stressor due to premature follicular transition from the anagen (active growth phase) to the telogen (resting phase).

There are previous articles that recorded a relationship between COVID-19 and hair fall. Domínguez-Santás et al.[2] were the first to report a case of acute TE, occurring 3 months after SARS-CoV-2 infection, and have been followed by additional authors, who described TE after COVID-19[3,4] In a large-scale study (538 cases) in Wuhan, China,[5] investigating clinical sequelae of COVID-19, the prevalence of alopecia as a sequelae was detected in 28.6% of patients. Moreno-Arrones et al. evaluated 191 patients with acute TE (ATE) that had prior SARS-CoV-2 infection, 78.5% of whom were females; 75% of the patients had received various therapies for COVID-19. They suggested that proinflammatory cytokines released during the infection condition may initiate TE.[6] Sharquie and Jabbar in their study from Iraq highlighted the relation between COVID-19 and ATE.[7] Starace et al. had studied 128 patients of TE and classified them into early-onset (<4 weeks) and late-onset (>12 weeks) TE.[8]

Most of our patients belonged to the younger age group. This might be due to more concern for hair loss in this group which also explains the majority of females. Furthermore, long hair in females is more easily noticed during hair shedding as compared to males who have short hair.[9] Around one-fourth of our patients had severe COVID-19 infection. Various pathogenic mechanisms have been described for TE after SARS-CoV-2 infection including direct viral damage to hair follicles and, immune-mediated microthrombotic events within the follicular vasculature and a cytokine storm.[8] Cytokine storm can initiate the development of TE by damaging the matrix cells, and usually, the high levels of interferons have already been confirmed to be associated with ATE[10,11] Chronic TE usually has alternating periods of spontaneous remissions with episodes of relapses. The most common presentation in our study was acute TE while post-COVID TE may also present as relapse of chronic TE as seen in few of our patients.

Trichodynia and pruritus were important complaints in our study. Starace et al. also reported trichodynia associated with TE in 42.4% of the cases.[8] The COVID-19 pandemic had an impression on social life of people, making patients more susceptible to depression and anxiety, which can be a factor causing TE. However, anxiety was diagnosed in only few of our patients despite visible decrease in hair density in majority of them.

The significance of hair pull test in ATE depends on the distance between the onset of hair loss and the trichological visit. In case of delayed visits, the test can be negative in view of the regression phase of TE which explains the negative hair pull test in up to 45% of TE patients in our study. The trichoscopic findings may also vary due to the same reason. Trichoscopic features in our study were largely the same as classic TE except scalp erythema found in 19.5% of patients.

About one-fourth of our patients had a deficiency of micronutrients, suggesting its possible association or contribution to the severity of hair loss. Nonetheless, the association of COVID infection with the deficiency of these nutrients is not much studied. Therefore, it mandates the need to look for these tests even in the scenario of otherwise obvious post-COVID-19 TE. Drug-induced TE is another possibility that should be considered in moderate and severe cases. Watras et al. shed light on the role of anticoagulants, including enoxaparin in TE.[12] They described that TE started 3 weeks after drug administration. In our study, many patients had onset of TE weeks after the infection, therefore, the possibility of drug-induced TE cannot be ruled out.

The limitations of this study were the lack of any control group and the follow-up of the patients.

CONCLUSION

TE is more common with symptomatic COVID infection. Trichodynia and pruritus are common complaints in this condition. The assessment for micronutrient deficiency should be done, as there appears to be an association between COVID-19 infection and nutritional deficiency. Relapse in chronic TE might also occur as sequelae of COVID-19 infection.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.