Dear Editor,
In early 2020, the World Health Organization declared a pandemic following mass transmission of the COVID‐19 virus. Numerous reports suggested a link between COVID‐19 and hair loss. 1 Our purpose was to comprehensively synthesize the different hair loss patterns, clinical characteristics, and patient demographics of individuals experiencing post‐COVID‐19 hair loss.
Methods:
The EMBASE and PubMed databases were searched for articles pertaining to “COVID‐19” and “alopecia” or “hair loss.” A total of 208 results were screened, and 28 studies were included (Figure 1). The quality of evidence provided by the included studies was established in Table 1.
Figure 1.
Preferred reporting items for systematic reviews and meta‐analyses (PRISMA) and the search algorithm adopted in the article selection process
Table 1.
Quality of the included studies evaluated based on the levels of evidence defined by the Oxford Centre for Evidence‐Based Medicine
| Author | Level of evidence |
|---|---|
| Flvenson et al. | 4 |
| Capalbo et al. | 4 |
| Sgubbi et al. | 4 |
| Rudnicka et al. | 2b |
| Rossi et al. | 4 |
| Ferreira et al. | 4 |
| Hayran et al. | 4 |
| Ozcan et al. | 4 |
| Trueb et al. | 2b |
| Mieczkowska et al. | 4 |
| Moreno‐Arrones et al. | 1b |
| Olds et al. | 4 |
| Rizzetto et al. | 4 |
| Vastarella et al. | 4 |
| Aksoy et al. | 2b |
| Babaei et al. | 2c |
| Domínguez‐Santás et al. | 4 |
| Abrantes et al. | 4 |
| Cline et al. | 2b |
| Landro et al. | 4 |
| Starace et al. | 4 |
| Rossi et al. | 2c |
| Miola et al. | 4 |
| Lv et al. | 4 |
| Deng et al. | 4 |
| Roda et al. | 4 |
| Sharquie et al. | 4 |
| Shanshal, Mohammed | 2c |
A total of 1080 patients experienced one of four hair loss patterns: telogen effluvium (TE), alopecia areata (AA), anagen effluvium (AE), and fibrosing alopecia (FA). The majority (n = 1,036, 95.92%) presented with acute TE, while the remainder of patients presented with acute or worsening AA (n = 38, 3.52%), AE (n = 4, 0.37%), or FA (n = 2, 0.19%) following infection. Patients with AE, AA, TE, and FA experienced hair loss symptoms a mean of 10, 38, 56, and 90 days following infection, respectively. The three most common COVID‐19 symptoms were dyspnea (n = 298/424, 70%), myalgia/arthralgia (n = 59/424, 14%), and anosmia/ageusia (n = 42/424, 10%). Of the studies that examined hospitalization status of TE patients, 90% of TE patients (n = 412/458) were hospitalized for COVID‐19 infection. Minoxidil, either oral (n = 23/258, 9%) or topical (n = 86/258, 33%), was the most commonly prescribed hair loss treatment. Resolution of hair loss was unreported in 922 (88.99%) of the TE patients. Of the 103 (9.94%) TE patients who reported TE resolution, all recovered within 12 days to 6 months following the onset of hair loss. The remaining 11 (1.06%) TE patients reported no recovery of hair loss, with follow‐up times ranging from 0 to 9 months following the onset of hair loss. Table 2 provides an overview of patient demographics and clinical characteristics.
Table 2.
Clinical characteristics of patients with hair loss following COVID‐19 infection
| Male (%) | Female (%) | Time from COVID‐19 infection to hair loss (MEAN DAYs) | Race (n, %) | Hospitalized for COVID‐19 (n, %) | COVID‐19 symptoms (n, %) | COVID‐19 treatments (n, %) | Hair loss treatments (n, %) | |
|---|---|---|---|---|---|---|---|---|
| Alopecia areata (n = 38) | 37 | 63 | 38 | Caucasian (3/3, 100%) | (1/6, 17%) | Cough (2/3, 66%), Ansomia/Aguesia (2/3, 66%), Fever (1/3, 33%) | Paracetamol (2/3, 66%), Hydroxychloroquine (1/3, 33%), Antibiotics (1/3, 33%) | Triamcinolone (13/34, 38%), Oral Steroids (10/34, 29%), Cyclosporine (10/34, 29%), Methotrexate (6/34, 18%) No treatment (4/34, 12%), Azathioprine (1/34, 3%), Oral nutricosmetics (1/34, 3%), Clobetasol (1/34, 3%) |
| Fibrosing alopecia (n = 2) | 50 | 50 | 90 | NR | NR | Dyspnea (2/2, 100%), Fatigue/Asthenia (2/2, 100%), Anosmia/Aguesia (2/2, 100%), Chest Pain (1/2, 50%), Sore Throat (1/2, 50%) | Hydroxychloroquine (1/2, 50%), Favipiravir (1/2, 50%) | Topical minoxidil (2/2, 100%), Triamcinolone (2/2, 100%) |
| Telogen effluvium (n = 1,036) | 19 | 81 | 56 |
Caucasian (8/30, 27%) Black (7/30, 23%) Hispanic (5/30, 17%) Middle‐Eastern (1/30, 3%) Other (9/30, 30%) |
(412/458, 90%) | Dyspnea (293/415, 71%), Myalgia/Arthralgia (58/415, 14%), Ansomia/Aguesia (38/415, 9%), Cutaneous manifestations (27/415, 7%), GI symptoms (27/415, 7%), Fatigue/Asthenia (24/415, 6%), No treatment (20/415, 5%), Cough (15/415, 4%), Chest pain (18/415, 4%) Headache (12/415, 3%), Coryza (6/415, 1%), Fever (6/415, 1%) | Paracetamol (209/318, 66%), Anticoagulant (147/318, 49%), Antibiotics (134/318, 42%), Favipiravir (62/318, 20%), NSAIDS (13/318, 19%), Lopinavir/ritonavir (56/318, 18%), Steroid (53/318, 17%), Tocilizumab (29/318, 9%), Remdesivir (10/318, 3%), Hydroxychloroquine (11/318, 3%) | Oral nutricosmetics (94/222, 42%), Topical minoxidil (84/222, 38%), Oral minoxidil (23/222, 10%), No treatment (20/222, 9%), Clobetasol (16/222, 7%), PRP injection (8/222, 4%), Dutasteride (4/222, 2%), Triamcinolone (1/222, 0.5%), Fluocinolone oil (1/222, 0.5%) |
| Anagen effluvium (n = 4) | 0 | 100 | 10 | NR | (1/1, 100%) | Dyspnea (3/4, 75%), Cutaneous Manifestations (3/4, 75%), Headache (1/4, 25%), Cough (1/4, 25%), Myalgia/Arthralgia (1/4, 25%), GI symptoms (1/4, 25%), Chest pain (1/4, 25%) | Steroid (1/1, 100%) | NR |
NR, not reported.
Our analysis revealed that most forms of hair loss, with the exception of FA, presented more frequently in women. However, women tend to find hair loss more troubling than men, and therefore are more likely to seek treatment. 2 Our study also found that the most common form of COVID‐induced hair loss was TE. Although not entirely understood, a variety of mechanisms have been proposed for COVID‐19‐induced TE including increased release of proinflammatory cytokines or direct damage to hair follicles by the COVID‐19 virus. 3 Treatment outcomes were rarely reported because of the lack of follow‐up data. One study demonstrated three sessions of intradermal injections containing minoxidil, dutasteride, and biotin were likely to improve symptoms in TE patients who showed no initial signs of improvement. 4 However, more studies are required to better determine optimal hair regrowth regimens for COVID‐19‐induced hair loss. Perhaps more importantly, patients with different forms of COVID‐induced hair loss experienced hair shedding and recovery at different points in time following infection. Recognition of this phenomenon may facilitate realistic expectations for both patients and physicians regarding the timelines for hair loss and recovery.
Limitations include a small sample size, lack of control groups and follow‐up, publication bias, potential of misdiagnoses, potential for COVID‐19 treatment‐induced hair loss, and heterogeneity of data among the studies. Despite these limitations, our study provides patient‐level data on hair loss onset and clinical characteristics which will allow clinicians to better manage expectations and diagnose COVID‐induced hair loss. In conclusion, COVID‐19 infection has been associated with alopecia, 1 with telogen effluvium representing an overwhelming majority of cases.
Conflict of interest: None.
Funding source: None.
Data availability statement
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.
References
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Associated Data
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Data Availability Statement
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.