Management of telogen effluvium during the COVID‐19 emergency: Psychological implications

Dear Editor,

Telogen effluvium (TE) is a common form of hair loss characterized by diffuse hair shedding, resulting from the early entry of the hair into the telogen phase. Inducing factors include systemic diseases, stressful events, drugs, nutritional deficiencies, and major surgery. Hair loss occurs 3 months after the causing event and is usually self‐limiting, lasting for about 6 months (acute TE). A chronic form of TE also exists, when the duration of hair loss exceeds 6 months. ¹ , ² Patients with TE, usually women, are often deeply anxious, reporting not sleeping or waking up in the night with their hair as their first thought. The disorder is as frequent and frightening as to make the patient urgently go to the dermatologist. TE may have a profound impact on the patients' mind and would require attention, time, and empathy. ³

During the coronavirus 2019 disease (COVID‐19) emergency, the Italian Government imposed a national quarantine from March 9, 2020 to May 4, 2020 (https://www.gazzettaufficiale.it/eli/id/2020/03/09/20A01558/sg). In that period, 25 female patients with previously diagnosed TE asked for a follow‐up visit, complaining about a worsening of the disease. All the patients were Caucasian, aged between 21 and 54 years (mean age of 36.32 years), with a duration of the disease between 4 and 24 months (mean duration 11.92 months) and in therapy with cosmetic anti‐hair loss lotions or topical minoxidil or topical steroids and/or dietary supplements. The current quarantine condition represents a strong experience for the majority of the people involved and can contribute to worsened psychological reaction (emotional exhaustion, anxiety, irritability, increased anger). ⁴ , ⁵ Increased psychosocial stress may have an impact on the course of many common “stress‐responsive” skin conditions, leading to a real or perceived exacerbation of the disease. ⁴ , ⁶ This is true especially for TE, a disease often induced by stressful events. ³ , ⁷ The importance of the brain‐skin axis has been consistently underlined. ⁴ , ⁷ The relationship between a stressor and any subsequent change in the hair growth cycle has resulted in the designation of a brain‐hair follicle axis. In particular, the release of specific neuropeptides, neurotransmitters, and hormones along this brain‐hair follicle axis may promote noteworthy changes in the hair growth cycle by stimulating the transition of anagen hairs into the telogen phase. A new subspecialty of psychodermatology, called “trichopsychodermatology,” emphasizes the psychosocial aspects of hair disorders. ⁸

According to the latest literature, ⁹ we decided to use teledermatology to avoid moving the patient and to reduce the risk of COVID‐19 infection. Each patient was visited with a real‐time video consultation (one per patient) using a webcam. ⁹ During the consultation, the possible causes of TE worsening were investigated, and each patient was asked about the level of stress from a 1 to 10 scale. We could not perform trichoscopy and pull test for obvious reasons, therefore we prescribed a modified wash test (MWT), as described in details elsewhere. ¹⁰ The number of hairs lost during the test was communicated via email, and active TE was taken into consideration when hair shedding exceeded 100 hairs every 5 days. ³ , ¹⁰

All the patients, during the quarantine, reported having a higher stress level (average value 8.2) and much more attention for the hair loss from the last visit. As an alternative to an outpatient visit, the video consultation allowed patients to reduce their anxiety status related to hair loss and allowed us to update their therapy. All the patients were reassured about their concern that TE could lead to baldness. In particular, 14 patients (56%) with a negative MWT were considered to have a perceived exacerbation of TE and were instructed to continue the ongoing therapies; 5 patients (20%) admitted having stopped therapy in the previous 3 months, the MWT was positive and the therapy was reintroduced; 4 patients (16%) with a positive MWT required a dose adjustment of the therapy; 2 patients (8%) did not perform the MWT and they were so worried about their condition that a psychological counseling was required.

We reported our experience to underline the importance of maintaining a regular follow‐up, as well as psychological support, in patients with TE in this particular historical period. Although the use of teledermatology may have limits, related to the inability to visit the patient and perform specific tests (trichoscopy, pull test), it has proved very useful in the COVID‐19 emergency period for follow‐up visits of patients with TE. The real‐time video consultation allows to interact face‐to‐face with the patients, while the MWT can be useful to monitor TE activity. Increased use of teledermatology programs should be encouraged in the upcoming months to reduce the risk of COVID‐19 infections and to support the care of individuals with TE.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.