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Alopecia in patients with COVID-19: A systematic review and meta-analysis

  • Betty Nguyen
    Affiliations
    Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida

    University of California Riverside School of Medicine, Riverside, California
    Search for articles by this author
  • Antonella Tosti
    Correspondence
    Correspondence to: Antonella Tosti, MD, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1295 NW 14th St, Suite L, Miami, FL 33125.
    Affiliations
    Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
    Search for articles by this author
Open AccessPublished:February 21, 2022DOI:https://doi.org/10.1016/j.jdin.2022.02.006

      Background

      COVID-19 is associated with androgenetic alopecia (AGA), telogen effluvium (TE), and alopecia areata (AA). No studies have analyzed the aggregate data to date.

      Objective

      We conducted a systematic review to characterize the types, incidence, timing, and clinical outcomes of COVID-19–associated alopecia.

      Methods

      We searched PubMed/MEDLINE, Scopus, and Embase for articles published between November 2019 and August 2021 using the key words “alopecia” or “hair” and COVID-19–related search terms, identifying 41 original articles describing patients with alopecia and COVID-19.

      Results

      The current review included 1826 patients with alopecia and COVID-19 (mean age, 54.5 years; 54.3% male). The most common types of alopecia identified were AGA (30.7%, 86.4% male), TE (19.8%, 19.3% male), and AA (7.8%, 40.0% male). AGA preceded COVID-19 symptoms. TE was usually newly triggered by COVID-19 (93.6%). AA usually occurred in patients with preexisting disease (95.1%).

      Limitations

      Definitions of COVID-19 onset varied. Studies differed in methodology and were susceptible to reporting and sampling bias. Studies with large sample sizes may exert a disproportionate influence on data.

      Conclusion

      AGA may be a risk factor for severe COVID-19, whereas TE presents as a sequela of COVID-19. AA generally occurs as a relapse in patients with preexisting alopecia.

      Key words

      Abbreviations used:

      AA (alopecia areata), ADT (androgen-deprivation therapy), AE (anagen effluvium), AGA (androgenetic alopecia), PA (pressure-induced alopecia), TE (telogen effluvium)
      • Telogen effluvium and alopecia areata may be associated with COVID-19, while adrogenetic alopecia may be associated with severe infection.
      • Patients with COVID-19 and androgenetic alopecia may benefit from antiandrogen therapy, though further research is needed.

      Introduction

      SARS-CoV-2, the causative agent of the COVID-19 pandemic, has given rise to a global health emergency. Although dermatologic signs
      • Fahmy D.H.
      • El-Amawy H.S.
      • El-Samongy M.A.
      • et al.
      COVID-19 and dermatology: a comprehensive guide for dermatologists.
      of COVID-19 have been described, considerably more attention has been directed toward skin-related, rather than hair-related, manifestations.
      • Wollina U.
      • Karadag A.S.
      • Rowland-Payne C.
      • Chiriac A.
      • Lotti T.
      Cutaneous signs in COVID-19 patients: a review.
      ,
      • Seirafianpour F.
      • Sodagar S.
      • Pour Mohammad A.
      • et al.
      Cutaneous manifestations and considerations in COVID-19 pandemic: a systematic review.
      Recent observational reports have documented associations between COVID-19 and various types of alopecia, including androgenetic alopecia (AGA), alopecia areata (AA), telogen effluvium (TE), anagen effluvium (AE), and pressure-induced alopecia (PA). Mechanisms of these associations are not entirely clear but are believed to be multifactorial; hair loss, like other cutaneous manifestations of COVID-19, may be related to various virus-induced or delayed immunologic responses to infection.
      • Wollina U.
      • Karadag A.S.
      • Rowland-Payne C.
      • Chiriac A.
      • Lotti T.
      Cutaneous signs in COVID-19 patients: a review.
      ,
      • Seirafianpour F.
      • Sodagar S.
      • Pour Mohammad A.
      • et al.
      Cutaneous manifestations and considerations in COVID-19 pandemic: a systematic review.
      Given the growing number of reports documenting associations between COVID-19 and certain types of alopecia, we sought to summarize these findings in a systematic review and meta-analysis. Recently published review articles have summarized findings from reports documenting associations between COVID-19 and AGA; however, no reviews have pooled data from all types of COVID-19–associated alopecia.
      • Moravvej H.
      • Pourani M.R.
      • Baghani M.
      • Abdollahimajd F.
      Androgenetic alopecia and COVID-19: a review of the hypothetical role of androgens.
      • Mohamed M.S.
      • Moulin T.C.
      • Schioth H.B.
      Sex differences in COVID-19: the role of androgens in disease severity and progression.
      • Moradi F.
      • Enjezab B.
      • Ghadiri-Anari A.
      The role of androgens in COVID-19.
      To our knowledge, this article is the first comprehensive review to include all published studies describing hair-related manifestations of COVID-19. In this report, we have summarized the demographic information of affected patients and the types, incidence, timing, and clinical outcomes of types of alopecia associated with COVID-19.

      Methods

      A flowchart summarizing the steps for study identification according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines is shown in Figure 1. We searched PubMed/MEDLINE, Scopus, and Embase for articles available in English from November 1, 2019, through August 31, 2021, using the key words “alopecia” or “hair” and COVID-19–related search terms adapted from the Medical Library Association Clinical Librarians Caucus’ COVID-19 hedge (search terms will be available upon request), yielding 525 articles. Broad search terms were intentionally used to minimize the chance of excluding relevant studies. A reviewer (BN) screened the articles on the basis of titles and abstracts to remove the duplicate, abstract-only, non-English, and review articles, yielding 262 articles. Articles were further excluded if they had no full text available, did not specify individual patient details, or lacked direct relevance to alopecia and COVID-19. After these exclusions, 41 reports (19 case series, 11 case reports, 5 cross-sectional studies, 4 cohort studies, and 2 case-control studies) were included in this review. When available, information collected from each article included the country of the patient population, type of study, the incidence of alopecia, mean age of patients, sex of patients, and survival rate. Data were further characterized on the basis of whether patients had new-onset alopecia or exacerbation of a preexisting alopecia diagnosis.
      Figure thumbnail gr1
      Fig 1Flowchart of study identification via PubMed/MEDLINE, Scopus, and Embase according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

      Results

      From the 41 articles included in this review, we identified 1826 patients with alopecia and COVID-19.
      • Abrantes T.F.
      • Artounian K.A.
      • Falsey R.
      • et al.
      Time of onset and duration of post-COVID-19 acute telogen effluvium.
      • Berbert Ferreira S.
      • Gavazzoni Dias M.F.R.
      • Berbert Ferreira R.
      • Neves Neto A.C.
      • Trueb R.M.
      • Lupi O.
      Rapidly progressive alopecia areata totalis in a COVID-19 patient, unresponsive to tofacitinib.
      • Capalbo A.
      • Giordano D.
      • Gagliostro N.
      • et al.
      Alopecia areata in a COVID-19 patient: a case report.
      • Cheng D.
      • Calderwood C.
      • Skyllberg E.
      • Ainley A.
      Clinical characteristics and outcomes of adult patients admitted with COVID-19 in East London: a retrospective cohort analysis.
      • Di Landro A.
      • Naldi L.
      • Glaser E.
      • Paus R.
      • Tosti A.
      Pathobiology questions raised by telogen effluvium and trichodynia in COVID-19 patients.
      • FIvenson D.
      COVID-19: association with rapidly progressive forms of alopecia areata.
      • Gao C.
      • Zhao Z.
      • Li F.
      • et al.
      The impact of individual lifestyle and status on the acquisition of COVID-19: a case-control study.
      • Goren A.
      • Vano-Galvan S.
      • Wambier C.G.
      • et al.
      A preliminary observation: male pattern hair loss among hospitalized COVID-19 patients in Spain—a potential clue to the role of androgens in COVID-19 severity.
      • Hayran Y.
      • Yorulmaz A.
      • Gur G.
      • Aktas A.
      Different hair loss patterns in two pediatric patients with COVID-19-associated multisystem inflammatory syndrome in children.
      • Lee J.
      • Yousaf A.
      • Fang W.
      • Kolodney M.S.
      Male balding is a major risk factor for severe COVID-19.
      • Lv S.
      • Wang L.
      • Zou X.
      • et al.
      A case of acute telogen effluvium after SARS-CoV-2 infection.
      • Mazzotta F.
      • Troccoli T.
      • Caselli D.
      • Bonifazi E.
      Acral rash in a child with COVID-19.
      • Mieczkowska K.
      • Deutsch A.
      • Borok J.
      • et al.
      Telogen effluvium: a sequela of COVID-19.
      • Miyazato Y.
      • Morioka S.
      • Tsuzuki S.
      • et al.
      Prolonged and late-onset symptoms of coronavirus disease 2019.
      • Moreno-Arrones O.M.
      • Lobato-Berezo A.
      • Gomez-Zubiaur A.
      • et al.
      SARS-CoV-2-induced telogen effluvium: a multicentric study.
      • Muller Ramos P.
      • Ianhez M.
      • Amante Miot H.
      Alopecia and grey hair are associated with COVID-19 severity.
      • Olds H.
      • Liu J.
      • Luk K.
      • Lim H.W.
      • Ozog D.
      • Rambhatla P.V.
      Telogen effluvium associated with COVID-19 infection.
      • Patel G.
      • Dadey E.
      • Gosal E.
      • et al.
      Clinical characteristics, mortality and short term follow up of patients admitted with COVID-19 in a North East London NHS Trust: a retrospective analysis.
      • Perry II, T.
      • Rosen H.
      • Pettit C.
      • Trinidad J.C.
      Pressure-induced alopecia due to proning in COVID-19.
      • Rahmani H.
      • Davoudi-Monfared E.
      • Nourian A.
      • et al.
      Comparing outcomes of hospitalized patients with moderate and severe COVID-19 following treatment with hydroxychloroquine plus atazanavir/ritonavir.
      • Rinaldi F.
      • Trink A.
      • Giuliani G.
      • Pinto D.
      Italian survey for the evaluation of the effects of coronavirus disease 2019 (COVID-19) pandemic on alopecia areata recurrence.
      • Rizzetto G.
      • Diotallevi F.
      • Campanati A.
      • et al.
      Telogen effluvium related to post severe SARS-CoV-2 infection: clinical aspects and our management experience.
      • Rossi A.
      • Magri F.
      • Sernicola A.
      • et al.
      Telogen effluvium after SARS-CoV-2 infection: a series of cases and possible pathogenetic mechanisms.
      • Rossi A.
      • Magri F.
      • Michelini S.
      • et al.
      New onset of alopecia areata in a patient with SARS-CoV-2 infection: possible pathogenetic correlations?.
      • Rudnicka L.
      • Rakowska A.
      • Waskiel-Burnat A.
      • Kurzeja M.
      • Olszewska M.
      Mild-to-moderate COVID-19 is not associated with worsening of alopecia areata: a retrospective analysis of 32 patients.
      • Saeed W.
      • Hussain I.
      • Altaf F.
      Telogen effluvium: long term Covid-19 symptom.
      • Salazar Arenas M.A.
      • Munoz Del Carpio-Toia A.
      • Aybar Galdos J.
      • Rodriguez-Morales A.J.
      Alopecia and severity of COVID-19: a cross-sectional study in Peru.
      • Savas Sen Z.
      • Polat M.
      • Oz F.N.
      • Tanir G.
      Hair loss as a late complication of multisystem inflammatory syndrome in children.
      • Sgubbi P.
      • Savoia F.
      • Calderoni O.
      • Longo R.
      • Stinchi C.
      • Tabanelli M.
      Alopecia areata in a patient with SARS-CoV-2 infection.
      • Shanshal M.
      COVID-19 related anagen effluvium.
      • Sharquie K.E.
      • Jabbar R.I.
      COVID-19 infection is a major cause of acute telogen effluvium.
      • Suarez-Diaz S.
      • Moran-Castano C.
      • Coto-Hernandez R.
      • Mozo-Avellaneda L.
      • Suarez-Cuervo C.
      • Caminal-Montero L.
      Mild COVID-19 in ANCA-associated vasculitis treated with rituximab.
      • Suzuki T.
      • Kutsuna S.
      • Saito S.
      • et al.
      Clinical course of alopecia after COVID-19.
      • Temiz S.A.
      • Kutlu O.
      The development of dermatologic diseases in patients recovered from COVID-19.
      • Thuangtong R.
      • Angkasekwinai N.
      • Leeyaphan C.
      • et al.
      Patient recovery from COVID-19 infections: follow-up of hair, nail, and cutaneous manifestations.
      • Torabi S.
      • Mozdourian M.
      • Rezazadeh R.
      • Payandeh A.
      • Badiee S.
      • Darchini-Maragheh E.
      Androgenetic alopecia in women and men is not related to COVID-19 infection severity: a prospective cohort study of hospitalized COVID-19 patients.
      • Tosti G.
      • Barisani A.
      • Queirolo P.
      • et al.
      Skin signs resembling vascular acrosyndromes during the COVID-19 outbreak in Italy.
      • Trueb R.M.
      • Dutra Rezende H.
      • Gavazzoni Dias M.F.R.
      What can the hair tell us about COVID-19?.
      • Wambier C.G.
      • Vano-Galvan S.
      • McCoy J.
      • et al.
      Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: the “Gabrin sign”.
      • Welsh E.C.
      • Alfaro Sanchez A.B.
      • Ortega Gutierrez G.L.
      • et al.
      COVID-19 dermatological manifestations: results from the Mexican Academy of Dermatology COVID-19 registry.
      • Xiong Q.
      • Xu M.
      • Li J.
      • et al.
      Clinical sequelae of COVID-19 survivors in Wuhan, China: a single-centre longitudinal study.
      Identifying information of each study (article title, author, country, and study type) and patient information (age, sex, alopecia incidence, alopecia type, and survival rate) are shown in Table I. When reported, the mean age of patients was 54.5 years (range, 7-100 years), with a slight male predominance (54.3%). Of the 1826 patients, age and sex were not reported in 1056 (57.8%) and 709 (38.8%) patients, respectively. A total of 17 distinct countries were represented in the patient populations of the included studies, with no clear geographic patterns apparent.
      Table ICharacteristics and findings of 41 original articles reporting alopecia in 1826 patients with COVID-19
      TitleAuthor; country of patient populationType of study, number of alopecia cases (n)/number of COVID-19–positive patients, age (y), (sex, male:female)Type of alopeciaClinical outcomes
      Time of onset and duration of post-COVID-19 acute telogen effluviumAbrantes; United States, Brazil, Spain
      • Abrantes T.F.
      • Artounian K.A.
      • Falsey R.
      • et al.
      Time of onset and duration of post-COVID-19 acute telogen effluvium.
      Case series: n = 30/30

      Mean age: 40.5 (9 M: 21 F)
      PA: 1

      TE: 29
      30 (100%) survival
      Rapidly progressive alopecia areata totalis in a COVID-19 patient, unresponsive to tofacitinibBerbert; Brazil
      • Berbert Ferreira S.
      • Gavazzoni Dias M.F.R.
      • Berbert Ferreira R.
      • Neves Neto A.C.
      • Trueb R.M.
      • Lupi O.
      Rapidly progressive alopecia areata totalis in a COVID-19 patient, unresponsive to tofacitinib.
      Case report: n = 1/1

      Age: 24 (0 M: 1 F)
      AE: 11 (100%) survival
      Alopecia areata in a COVID-19 patient: a case reportCapalbo; Italy
      • Capalbo A.
      • Giordano D.
      • Gagliostro N.
      • et al.
      Alopecia areata in a COVID-19 patient: a case report.
      Case report: n = 1/1

      Age: 38 (1 M: 0 F)
      AA: 11 (100%) survival
      Clinical characteristics and outcomes of adult patients admitted with COVID-19 in East London: a retrospective cohort analysisCheng; United Kingdom
      • Cheng D.
      • Calderwood C.
      • Skyllberg E.
      • Ainley A.
      Clinical characteristics and outcomes of adult patients admitted with COVID-19 in East London: a retrospective cohort analysis.
      Cohort study: n = 9/139

      Age: NR (Sex NR)
      Unclassified: 99 (100%) survival
      COVID-19: association with rapidly progressive forms of alopecia areataDi Landro; Italy
      • Di Landro A.
      • Naldi L.
      • Glaser E.
      • Paus R.
      • Tosti A.
      Pathobiology questions raised by telogen effluvium and trichodynia in COVID-19 patients.
      Case series: n = 39/39

      Mean age: 64.6 (9 M: 30 F)
      TE: 3939 (100%) survival
      The impact of individual lifestyle and status on the acquisition of COVID-19: a case-control studyFlvenson; United States
      • FIvenson D.
      COVID-19: association with rapidly progressive forms of alopecia areata.
      Case series, n = 1/1

      Age: 56 (0 M: 1 F)
      AA (universalis): 11 (100%) survival
      A preliminary observation: male pattern hair loss among hospitalized COVID-19 patients in Spain—a potential clue to the role of androgens in COVID-19 severityGao; China
      • Gao C.
      • Zhao Z.
      • Li F.
      • et al.
      The impact of individual lifestyle and status on the acquisition of COVID-19: a case-control study.
      Case-control study, n = 30/105

      Mean age: 55 (Sex NR)
      Unclassified: 3030 (100%) survival
      Different hair loss patterns in two pediatric patients with COVID-19-associated multisystem inflammatory syndrome in childrenGoren; Spain
      • Goren A.
      • Vano-Galvan S.
      • Wambier C.G.
      • et al.
      A preliminary observation: male pattern hair loss among hospitalized COVID-19 patients in Spain—a potential clue to the role of androgens in COVID-19 severity.
      Case series, n = 41/41

      Mean age: 58 (41 M: 0 F)
      AGA: 41NR
      Pathobiology questions raised by telogen effluvium and trichodynia in COVID-19 patientsHayran; Turkey
      • Hayran Y.
      • Yorulmaz A.
      • Gur G.
      • Aktas A.
      Different hair loss patterns in two pediatric patients with COVID-19-associated multisystem inflammatory syndrome in children.
      Case series: n = 2/2

      Mean age: 11.5 (2 M: 0 F)
      AA: 1

      TE: 1
      2 (100%) survival
      Male balding is a major risk factor for severe COVID-19Lee; United Kingdom
      • Lee J.
      • Yousaf A.
      • Fang W.
      • Kolodney M.S.
      Male balding is a major risk factor for severe COVID-19.
      Case-control study, n = 274/336

      Mean age: 59.0 (274 M: 0 F)
      AGA: 274NR
      A case of acute telogen effluvium after SARS-CoV-2 infectionLv; China
      • Lv S.
      • Wang L.
      • Zou X.
      • et al.
      A case of acute telogen effluvium after SARS-CoV-2 infection.
      Case report: n = 1/1

      Age: 38 (0 M: 1 F)
      TE: 11 (100%) survival
      Acral rash in a child with COVID-19Mazzotta; Italy
      • Mazzotta F.
      • Troccoli T.
      • Caselli D.
      • Bonifazi E.
      Acral rash in a child with COVID-19.
      Case report: n = 1/1

      Age: 9 (1 M: 0 F)
      AA (universalis): 11 (100%) survival
      Telogen effluvium: a sequela of COVID-19Mieczkowska; United States
      • Mieczkowska K.
      • Deutsch A.
      • Borok J.
      • et al.
      Telogen effluvium: a sequela of COVID-19.
      Case series, n = 10/10

      Mean age: 52.4 (0 M: 10 F)
      TE: 10NR
      Prolonged and late-onset symptoms of coronavirus disease 2019Miyazato; Japan
      • Miyazato Y.
      • Morioka S.
      • Tsuzuki S.
      • et al.
      Prolonged and late-onset symptoms of coronavirus disease 2019.
      Case series, n = 14/58

      Mean age: NR (9 M: 5 F)
      Unclassified: 14NR
      SARS-CoV-2-induced telogen effluvium: a multicentric studyMoreno-Arrones; Spain
      • Moreno-Arrones O.M.
      • Lobato-Berezo A.
      • Gomez-Zubiaur A.
      • et al.
      SARS-CoV-2-induced telogen effluvium: a multicentric study.
      Case series, n = 191/191

      Mean age: 47.4 (41 M: 150 F)
      TE: 191NR
      Alopecia and grey hair are associated with COVID-19 severityMüller Ramos; Brazil
      • Muller Ramos P.
      • Ianhez M.
      • Amante Miot H.
      Alopecia and grey hair are associated with COVID-19 severity.
      Cross-sectional survey, n = 513/43,595

      Mean age: NR (Sex NR)
      Unclassified: 513NR
      Telogen effluvium associated with COVID-19 infectionOlds; United States
      • Olds H.
      • Liu J.
      • Luk K.
      • Lim H.W.
      • Ozog D.
      • Rambhatla P.V.
      Telogen effluvium associated with COVID-19 infection.
      Case series, n = 10/10

      Mean age: 48.5 (1 M: 9 F)
      TE: 1010 (100%) survival
      Clinical characteristics, mortality and short term follow up of patients admitted with COVID-19 in a North East London NHS Trust: a retrospective analysisPatel; United Kingdom
      • Patel G.
      • Dadey E.
      • Gosal E.
      • et al.
      Clinical characteristics, mortality and short term follow up of patients admitted with COVID-19 in a North East London NHS Trust: a retrospective analysis.
      Cohort study: n = 5/109

      Mean age: NR (Sex NR)
      Unclassified: 5NR
      Pressure-induced alopecia due to proning in COVID-19Perry; United States
      • Perry II, T.
      • Rosen H.
      • Pettit C.
      • Trinidad J.C.
      Pressure-induced alopecia due to proning in COVID-19.
      Case report: n = 1/1

      Age: 49 (1 M: 0 F)
      PA: 11 (100%) survival
      Comparing outcomes of hospitalized patients with moderate and severe COVID-19 following treatment with hydroxychloroquine plus atazanavir/ritonavirRahmani; Iran
      • Rahmani H.
      • Davoudi-Monfared E.
      • Nourian A.
      • et al.
      Comparing outcomes of hospitalized patients with moderate and severe COVID-19 following treatment with hydroxychloroquine plus atazanavir/ritonavir.
      Cohort study, n = 3/213

      Mean age: 60 (Sex NR)
      Unclassified: 3NR
      Italian survey for the evaluation of the effects of coronavirus disease 2019 (COVID-19) pandemic on alopecia areata recurrenceRinaldi; Italy
      • Rinaldi F.
      • Trink A.
      • Giuliani G.
      • Pinto D.
      Italian survey for the evaluation of the effects of coronavirus disease 2019 (COVID-19) pandemic on alopecia areata recurrence.
      Cross-sectional study: n = 133/133

      Mean age: 36.1 (Sex NR)
      AA: 133NR
      Telogen effluvium related to post severe Sars-Cov-2 infection: clinical aspects and our management experienceRizzetto; Italy
      • Rizzetto G.
      • Diotallevi F.
      • Campanati A.
      • et al.
      Telogen effluvium related to post severe SARS-CoV-2 infection: clinical aspects and our management experience.
      Case series, n = 3/3

      Mean age: 64.6 (0 M: 3 F)
      TE: 33 (100%) survival
      Telogen effluvium after SARS-CoV-2 Infection: a series of cases and possible pathogenetic mechanismsRossi; Italy
      • Rossi A.
      • Magri F.
      • Sernicola A.
      • et al.
      Telogen effluvium after SARS-CoV-2 infection: a series of cases and possible pathogenetic mechanisms.
      Case series: n = 14/14

      Mean age: 47.6 (3 M: 11 F)
      TE: 1414 (100%) survival
      New onset of alopecia areata in a patient with SARS-CoV-2 infection: possible pathogenetic correlations?Rossi; Italy
      • Rossi A.
      • Magri F.
      • Michelini S.
      • et al.
      New onset of alopecia areata in a patient with SARS-CoV-2 infection: possible pathogenetic correlations?.
      Case report: n = 1/1

      Age: 29 (0 M: 1 F)
      AA (totalis): 11 (100%) survival
      Mild-to-moderate COVID-19 is not associated with worsening of alopecia areata: a retrospective analysis of 32 patientsRudnicka; Poland
      • Rudnicka L.
      • Rakowska A.
      • Waskiel-Burnat A.
      • Kurzeja M.
      • Olszewska M.
      Mild-to-moderate COVID-19 is not associated with worsening of alopecia areata: a retrospective analysis of 32 patients.
      Case series: n = 10/32

      Mean age: 33.6 (Sex NR)
      TE: 1010 (100%) survival
      Telogen effluvium: long term COVID-19 symptomSaeed; Pakistan
      • Saeed W.
      • Hussain I.
      • Altaf F.
      Telogen effluvium: long term Covid-19 symptom.
      Case series: n = 3/3

      Mean age: NR (0 M: 3 F)
      TE: 33 (100%) survival
      Alopecia and severity of COVID-19: a cross-sectional study in PeruSalazar Arenas; Peru
      • Salazar Arenas M.A.
      • Munoz Del Carpio-Toia A.
      • Aybar Galdos J.
      • Rodriguez-Morales A.J.
      Alopecia and severity of COVID-19: a cross-sectional study in Peru.
      Cross-sectional study: n = 45/98

      Mean age: 62 (45 M: 0 F)
      AGA: 4535 (77.8%) survival
      Hair loss as a late complication of multisystem inflammatory syndrome in childrenSavaş Şen; Turkey
      • Savas Sen Z.
      • Polat M.
      • Oz F.N.
      • Tanir G.
      Hair loss as a late complication of multisystem inflammatory syndrome in children.
      Case report: n = 1/1

      Age: 7 (0 M: 1 F)
      TE: 11 (100%) survival
      Alopecia areata in a patient with SARS-Cov-2 infectionSgubbi; Italy
      • Sgubbi P.
      • Savoia F.
      • Calderoni O.
      • Longo R.
      • Stinchi C.
      • Tabanelli M.
      Alopecia areata in a patient with SARS-CoV-2 infection.
      Case report: n = 1/1

      Age: 54 (0 M: 1 F)
      AA: 11 (100%) survival
      COVID-19 related anagen effluviumShanshai; Iraq
      • Shanshal M.
      COVID-19 related anagen effluvium.
      Case report, n = 1/1

      Age: 35 (0 M: 1 F)
      AE: 11 (100%) survival
      COVID-19 infection is a major cause of acute telogen effluviumSharquie; Iraq
      • Sharquie K.E.
      • Jabbar R.I.
      COVID-19 infection is a major cause of acute telogen effluvium.
      Cross-sectional study: n = 39/39

      Mean age: 41.3 (3 M: 36 F)
      TE: 3939 (100%) survival
      Mild COVID-19 in ANCA-associated vasculitis treated with rituximabSuárez-Diáz; Netherlands
      • Suarez-Diaz S.
      • Moran-Castano C.
      • Coto-Hernandez R.
      • Mozo-Avellaneda L.
      • Suarez-Cuervo C.
      • Caminal-Montero L.
      Mild COVID-19 in ANCA-associated vasculitis treated with rituximab.
      Case report: n = 1/1

      Age: 64 (0 M: 1 F)
      AA: 11 (100%) survival
      Clinical course of alopecia after COVID-19Suzuki; Japan
      • Suzuki T.
      • Kutsuna S.
      • Saito S.
      • et al.
      Clinical course of alopecia after COVID-19.
      Case report: n = 1/1

      Age: 49 (1 M: 0 F)
      TE (unconfirmed): 11 (100%) survival
      The development of dermatologic diseases in patients recovered from COVID-19Temiz; Turkey
      • Temiz S.A.
      • Kutlu O.
      The development of dermatologic diseases in patients recovered from COVID-19.
      Case series: n = 8/33

      Mean age: 37.2 (2 M: 6 F)
      AA: 2

      TE: 6
      8 (100%) survival
      Patient recovery from COVID-19 infections: follow-up of hair, nail, and cutaneous manifestationsThuangtong; Thailand
      • Thuangtong R.
      • Angkasekwinai N.
      • Leeyaphan C.
      • et al.
      Patient recovery from COVID-19 infections: follow-up of hair, nail, and cutaneous manifestations.
      Case series, n = 22/93

      Mean age: 43.5 (8 M: 14 F)
      Unclassified: 22NR
      Androgenetic alopecia in women and men is not related to COVID-19 infection severity: a prospective cohort study of hospitalized COVID-19 patientsTorabi; Iran
      • Torabi S.
      • Mozdourian M.
      • Rezazadeh R.
      • Payandeh A.
      • Badiee S.
      • Darchini-Maragheh E.
      Androgenetic alopecia in women and men is not related to COVID-19 infection severity: a prospective cohort study of hospitalized COVID-19 patients.
      Cohort study: n = 77/116

      Mean age of cohort: 60.4 (45 M: 32 F)
      AGA: 77NR
      Skin signs resembling vascular acrosyndromes during the COVID-19 outbreak in ItalyTosti; Italy
      • Tosti G.
      • Barisani A.
      • Queirolo P.
      • et al.
      Skin signs resembling vascular acrosyndromes during the COVID-19 outbreak in Italy.
      Case series: n = 1/4

      Age: 16 (0 M: 1 F)
      AA (universalis): 11 (100%) survival
      What can the hair tell us about COVID-19?Trüeb; Brazil, Switzerland
      • Trueb R.M.
      • Dutra Rezende H.
      • Gavazzoni Dias M.F.R.
      What can the hair tell us about COVID-19?.
      Case series, n = 10/10

      Mean age: 55.5 (3 M: 7 F)
      AGA: 6

      TE: 4
      10 (100%) survival
      Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: the "Gabrin sign"Wambier; Spain
      • Wambier C.G.
      • Vano-Galvan S.
      • McCoy J.
      • et al.
      Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: the “Gabrin sign”.
      Case series, n = 118/175

      Mean age: 66.7 (96 M: 22 F)
      AGA: 118NR
      COVID-19 dermatological manifestations: results from the Mexican Academy of Dermatology COVID-19 registryWelsh; Mexico
      • Welsh E.C.
      • Alfaro Sanchez A.B.
      • Ortega Gutierrez G.L.
      • et al.
      COVID-19 dermatological manifestations: results from the Mexican Academy of Dermatology COVID-19 registry.
      Cross-sectional study: n = 6/164

      Mean age: NR (Sex NR)
      Unclassified: 6NR
      Clinical sequelae of COVID-19 survivors in Wuhan, China: a single-centre longitudinal studyXiong; China
      • Xiong Q.
      • Xu M.
      • Li J.
      • et al.
      Clinical sequelae of COVID-19 survivors in Wuhan, China: a single-centre longitudinal study.
      Case series, n = 154/538

      Mean age: 52 (12 M: 142 F)
      Unclassified: 154154 (100%) survival
      AA, Alopecia areata; AE, anagen effluvium; AGA, androgenic alopecia; F, female; M, male; NR, not reported; PA, pressure-induced alopecia; TE, telogen effluvium.
      Table II summarizes the patient demographic and survival data stratified by type of alopecia. When classified, the 3 most common types of alopecia identified were AGA (n = 561/1826, 30.7%), TE (n = 362/1826, 19.8%), and AA (n = 143/1826, 7.8%). The 2 less common types of alopecia identified were AE (n = 2/1826, 0.1%) and PA (n = 2/1826, 0.1%). The type of alopecia in the remaining patients (n = 756/1826, 41.4%) was not specified. The mean age of patients with AGA was the highest (mean, 61.1 years; range, 18-100 years), followed by TE (mean, 48.0 years; range, 15-88 years) and PA (mean, 43.0 years; range, 37-49 years). The mean age of patients with AE was the lowest (mean, 29.5 years; range, 24-35 years), followed by AA (mean, 36.1 years; range, 7-64 years). Male predominance was observed in AGA (n = 504/561, 89.8%), whereas female predominance was observed in TE (n = 284/352, 80.7%) and AA (n = 6/10, 60%). The sample size of patients with AE (n = 2) and PA (n = 2) was too small to draw any meaningful conclusions about sexual preference. When reported, the survival rates for all types of alopecia were 100%, except AGA, which had a 79.2% (n = 38/48) survival rate; survival outcomes were not reported for most patients (n = 1402/1826, 76.8%).
      Table IISummary of types of alopecia associated with COVID-19 in 1826 patients and survival data
      CharacteristicsAAAEAGAPATEUnclassified
      Number of patients (n = 1826)143 (7.8%)2 (0.1%)561 (30.7%)2 (0.1%)362 (19.8%)756 (41.4%)
      Mean age (y), number of patients with reported age, age range36.1 (n = 10)29.5 (n = 2)61.1 (n = 484)43.0 (n = 2)48.0 (n = 352)51.5 (n = 206)
      Range: 7-64Range: 24-35Range: 18-100Range: 37-49Range: 15-88Range: NR
      Sex4 M, 6 F

      133 NR
      0 M, 2 F504 M, 57 F2 M, 0 F68 M, 284 F

      10 NR
      29 M, 161 F

      566 NR
      Country of patientItaly

      Netherlands

      Turkey

      United States
      Brazil

      Iraq
      Brazil

      Iran

      Peru

      Spain

      Switzerland

      United Kingdom
      Brazil

      United States
      Brazil

      China

      Iraq

      Italy

      Pakistan

      Poland

      Spain

      Switzerland

      Turkey

      United States
      Brazil

      China

      Iran

      Japan

      Mexico

      Thailand

      United Kingdom
      Survival10/10 (100%)

      133 NR
      2/2 (100%)

      0 NR
      38/48 (79.2%)

      513 NR
      Unknown

      2 NR
      171/171 (100%)

      191 NR
      193/193 (100%)

      563 NR
      AA, Alopecia areata; AE, anagen effluvium; AGA, androgenic alopecia; F, female; M, male; NR, not reported; PA, pressure-induced alopecia; TE, telogen effluvium.
      Table III summarizes composite data, stratified by alopecia type, to show whether alopecia symptoms in patients with COVID-19 represented worsening of a preexisting alopecia diagnosis or a newly triggered event. When reported, all patients with COVID-19 who experienced symptoms of AGA had a preexisting diagnosis of AGA (n = 287/287, 100%). Similarly, most patients with COVID-19 who experienced symptoms of AA also had a preexisting diagnosis of AA (n = 136/143, 95.1%); of these 136 patients, 58 (42.6%) patients experienced a new AA flareup worsened by COVID-19, whereas 78 (57.4%) patients had no new AA symptoms. In contrast, patients with COVID-19 presenting with TE generally had no preexisting diagnoses of alopecia (n = 339/362, 93.6%), although a small percentage of these patients had a preexisting diagnosis of AA (n = 10/362, 2.8%) or AGA (n = 13/362, 3.6%). Thus, unlike AGA and AA, TE symptoms in patients with COVID-19 all represented the first-time occurrences of disease rather than worsening of a previous alopecia diagnosis. Notably, the onset of TE symptoms generally lagged that of COVID-19 symptoms, with a mean duration to symptom onset of 56.5 days. When reported, TE resolved in 100% (86/86) of the patients within approximately 1 to 6 months of hair loss onset. Treatment was not required in most cases, although minoxidil, finasteride, and topical clobetasol were used in some cases.
      Table IIIPrevalence of the types of classified alopecia in 1070 patients with COVID-19 and the number of patients with preexisting alopecia versus new-onset alopecia
      Types of classified alopeciaPreexisting alopecia diagnosisNo preexisting alopecia diagnosisNot reported
      No new symptoms triggered by COVID-19New alopecia flareup worsened by COVID-19New-onset alopecia triggered by COVID-19
      AA (n = 143, 13.4%)78 (54.5%)58 (40.6%)7 (4.9%)0
      AE (n = 2, 0.2%)01 (50%)1 (50%)0
      AGA (n = 561, 52.4%)287 (51.2%)
      Not reported whether alopecia symptoms worsened (or were stable) after COVID-19.
      0274 (48.8%)
      PA (n = 2, 0.2%)01 (50%)1 (50%)0
      TE (n = 362, 33.8%)023 (6.4%)

      (n = 10 had prior AA)

      (n = 13 had prior AGA)
      339 (93.6%)0
      AA, Alopecia areata; AE, anagen effluvium; AGA, androgenic alopecia; PA, pressure-induced alopecia; TE, telogen effluvium.
      Not reported whether alopecia symptoms worsened (or were stable) after COVID-19.
      Table IV summarizes data from studies that report the prevalence of AGA in patients with severe COVID-19 requiring hospitalization. Among the studies that specify this information, the prevalence of AGA in these patients ranged from 70.7% to 91.4% (mean, 75.5%; n = 449/595) in men and from 41.5% to 56.1% (mean, 49.1%; n = 54/110) in women.
      Table IVPrevalence of androgenetic alopecia among men and women with severe COVID-19
      StudyPrevalence of AGA in patients with severe COVID-19
      Men
       Goren et al,
      • Goren A.
      • Vano-Galvan S.
      • Wambier C.G.
      • et al.
      A preliminary observation: male pattern hair loss among hospitalized COVID-19 patients in Spain—a potential clue to the role of androgens in COVID-19 severity.
      2020
      70.7% (29/41)
       Lee et al,
      • Lee J.
      • Yousaf A.
      • Fang W.
      • Kolodney M.S.
      Male balding is a major risk factor for severe COVID-19.
      2020
      73.5% (247/336)
       Salazar et al,
      • Salazar Arenas M.A.
      • Munoz Del Carpio-Toia A.
      • Aybar Galdos J.
      • Rodriguez-Morales A.J.
      Alopecia and severity of COVID-19: a cross-sectional study in Peru.
      2021
      91.4% (32/35)
       Torabi et al,
      • Torabi S.
      • Mozdourian M.
      • Rezazadeh R.
      • Payandeh A.
      • Badiee S.
      • Darchini-Maragheh E.
      Androgenetic alopecia in women and men is not related to COVID-19 infection severity: a prospective cohort study of hospitalized COVID-19 patients.
      2021
      73.8% (45/61)
       Wambier et al,
      • Wambier C.G.
      • Vano-Galvan S.
      • McCoy J.
      • et al.
      Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: the “Gabrin sign”.
      2020
      78.7% (96/122)
       Total75.5% (449/595)
      Women
       Torabi et al,
      • Torabi S.
      • Mozdourian M.
      • Rezazadeh R.
      • Payandeh A.
      • Badiee S.
      • Darchini-Maragheh E.
      Androgenetic alopecia in women and men is not related to COVID-19 infection severity: a prospective cohort study of hospitalized COVID-19 patients.
      2021
      56.1% (32/57)
       Wambier et al,
      • Wambier C.G.
      • Vano-Galvan S.
      • McCoy J.
      • et al.
      Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: the “Gabrin sign”.
      2020
      41.5% (22/53)
       Total49.1% (54/110)
      AGA, Androgenic alopecia.

      Discussion

      Overview

      Understanding the hair-related manifestations of COVID-19 is clinically important for both patients and providers. Many distinct types of alopecia appear to be associated with COVID-19, although the mechanisms for these associations likely differ among these types. Findings from our review strengthen the current understanding of the relationship between the types of alopecia associated with COVID-19. Although we identified 5 distinct types of alopecia associated with COVID-19, we lacked a sufficient sample size of patients with PA (n = 2, 0.1%) and AE (n = 2, 0.1%) to draw any meaningful conclusions. Thus, we discuss implications for only the 3 most common types of alopecia identified: AGA, TE, and AA.

      AGA: Risk factor for COVID-19

      AGA is reported as a risk factor for, rather than sequela of, COVID-19. In our study, patients with COVID-19 with symptoms of AGA all had a preexisting diagnosis of AGA, although it was not reported whether AGA had worsened or remained stable after COVID-19. An increased prevalence of AGA in patients with severe COVID-19 has been reported by 5 of 6 studies.
      • Goren A.
      • Vano-Galvan S.
      • Wambier C.G.
      • et al.
      A preliminary observation: male pattern hair loss among hospitalized COVID-19 patients in Spain—a potential clue to the role of androgens in COVID-19 severity.
      ,
      • Lee J.
      • Yousaf A.
      • Fang W.
      • Kolodney M.S.
      Male balding is a major risk factor for severe COVID-19.
      ,
      • Salazar Arenas M.A.
      • Munoz Del Carpio-Toia A.
      • Aybar Galdos J.
      • Rodriguez-Morales A.J.
      Alopecia and severity of COVID-19: a cross-sectional study in Peru.
      ,
      • Torabi S.
      • Mozdourian M.
      • Rezazadeh R.
      • Payandeh A.
      • Badiee S.
      • Darchini-Maragheh E.
      Androgenetic alopecia in women and men is not related to COVID-19 infection severity: a prospective cohort study of hospitalized COVID-19 patients.
      ,
      • Wambier C.G.
      • Vano-Galvan S.
      • McCoy J.
      • et al.
      Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: the “Gabrin sign”.
      A report found that 71% of patients (n = 41) hospitalized with COVID-19–related pneumonia in Spain had AGA,
      • Goren A.
      • Vano-Galvan S.
      • Wambier C.G.
      • et al.
      A preliminary observation: male pattern hair loss among hospitalized COVID-19 patients in Spain—a potential clue to the role of androgens in COVID-19 severity.
      compared with an expected prevalence of 31% to 53% in otherwise healthy Spanish Caucasian men.
      • Severi G.
      • Sinclair R.
      • Hopper J.L.
      • et al.
      Androgenetic alopecia in men aged 40-69 years: prevalence and risk factors.
      ,
      • Guan W.J.
      • Ni Z.Y.
      • Hu Y.
      • et al.
      Clinical characteristics of coronavirus disease 2019 in China.
      A follow-up study by the same authors expanded on this data set to include an additional 175 patients who were hospitalized with COVID-19 and reported a similar prevalence of AGA of 67% (72% in men and 49% in women).
      • Wambier C.G.
      • Vano-Galvan S.
      • McCoy J.
      • et al.
      Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: the “Gabrin sign”.
      A separate report by Torabi et al
      • Torabi S.
      • Mozdourian M.
      • Rezazadeh R.
      • Payandeh A.
      • Badiee S.
      • Darchini-Maragheh E.
      Androgenetic alopecia in women and men is not related to COVID-19 infection severity: a prospective cohort study of hospitalized COVID-19 patients.
      on patients hospitalized with severe COVID-19 in Iran also found a comparable 73.7% prevalence of AGA in men and 56.1% in women; interestingly, the authors of this study found no association between AGA and COVID-19 severity,
      • Torabi S.
      • Mozdourian M.
      • Rezazadeh R.
      • Payandeh A.
      • Badiee S.
      • Darchini-Maragheh E.
      Androgenetic alopecia in women and men is not related to COVID-19 infection severity: a prospective cohort study of hospitalized COVID-19 patients.
      whereas 3 separate reports found that AGA was associated with increased COVID-19 severity.
      • Lee J.
      • Yousaf A.
      • Fang W.
      • Kolodney M.S.
      Male balding is a major risk factor for severe COVID-19.
      ,
      • Salazar Arenas M.A.
      • Munoz Del Carpio-Toia A.
      • Aybar Galdos J.
      • Rodriguez-Morales A.J.
      Alopecia and severity of COVID-19: a cross-sectional study in Peru.
      ,
      • Wambier C.G.
      • Vano-Galvan S.
      • McCoy J.
      • et al.
      Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: the “Gabrin sign”.
      After pooling data from these reports, we found that the prevalence of AGA among men with severe COVID-19 requiring hospitalization (n = 449/595, 75.5%) exceeded the expected AGA prevalence of approximately 31% to 53% in men without COVID-19.
      • Severi G.
      • Sinclair R.
      • Hopper J.L.
      • et al.
      Androgenetic alopecia in men aged 40-69 years: prevalence and risk factors.
      ,
      • Hamilton J.B.
      Patterned loss of hair in man; types and incidence.
      In women, the prevalence of AGA among patients with severe COVID-19 (n = 54/110, 49.1%) also exceeded the expected AGA prevalence of approximately 6% to 38% in women without COVID-19.
      • Birch M.P.
      • Messenger J.F.
      • Messenger A.G.
      Hair density, hair diameter and the prevalence of female pattern hair loss.
      Although a causal relationship cannot be established from these studies, these composite data suggest that AGA may be a risk factor for severe COVID-19.
      The mechanism of this association is believed to be related to androgen-mediated upregulation of the transmembrane serine protease 2, facilitating entry of SARS-CoV-2 into cells through the angiotensin-converting enzyme 2 receptor.
      • Cattrini C.
      • Bersanelli M.
      • Latocca M.M.
      • Conte B.
      • Vallome G.
      • Boccardo F.
      Sex hormones and hormone therapy during COVID-19 pandemic: implications for patients with cancer.
      ,
      • Hoffmann M.
      • Kleine-Weber H.
      • Schroeder S.
      • et al.
      SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor.
      We identified 2 studies that reported that androgen-deprivation therapies (ADTs) could be protective against COVID-19. One prospective cohort study of 77 men hospitalized with COVID-19 found that patients who had received ADT for at least 6 months prior to hospitalization were less likely to be admitted to the intensive care unit (n = 1/12, 8%) compared with those who had not received ADT (n = 38/65, 58%) (P = .0015).
      • Goren A.
      • Wambier C.G.
      • Herrera S.
      • et al.
      Anti-androgens may protect against severe COVID-19 outcomes: results from a prospective cohort study of 77 hospitalized men.
      In a large population-based study (n = 4532) of patients with prostate cancer diagnosed with COVID-19 in Italy, patients who received ADT had a significantly lower risk of COVID-19 than those who did not receive ADT (odds ratio, 4.05; 95% confidence interval, 1.55-10.59).
      • Montopoli M.
      • Zumerle S.
      • Vettor R.
      • et al.
      Androgen-deprivation therapies for prostate cancer and risk of infection by SARS-CoV-2: a population-based study (N = 4532).
      Two additional studies found that treatment with an androgen receptor antagonist, proxalutamide, decreases both time to clinical remission and hospitalization from COVID-19. In a double-blinded, randomized controlled trial of 236 patients with COVID-19, proxalutamide treatment significantly reduced the time of clinical infection (4.2 ± 5.4 days vs placebo of 21.8 ± 13.0 days) (P < .001) by accelerating viral clearance of COVID-19.
      • Cadegiani F.A.
      • McCoy J.
      • Gustavo Wambier C.
      • et al.
      Proxalutamide significantly accelerates viral clearance and reduces time to clinical remission in patients with mild to moderate COVID-19: results from a randomized, double-blinded, placebo-controlled trial.
      In a similar double-blinded, randomized controlled trial of 268 men with COVID-19, patients treated with proxalutamide had a 91% reduction in 30-day hospitalization rate compared with those receiving placebo (2.2% vs 26%; risk ratio = 0.09; 95% confidence interval, 0.03-0.27).
      • McCoy J.
      • Goren A.
      • Cadegiani F.A.
      • et al.
      Proxalutamide reduces the rate of hospitalization for COVID-19 male outpatients: a randomized double-blinded placebo-controlled trial.
      Collectively, findings from these studies suggest that the association between AGA and COVID-19 may be mediated by androgens, and antiandrogen therapy may be beneficial for patients with AGA and COVID-19.

      TE: Triggered by COVID-19

      TE is a sequela of COVID-19 that is most likely triggered by cytokine storm. Unlike patients with AGA, who all had a preexisting diagnosis of AGA, no patients with TE had a preexisting diagnosis of TE prior to COVID-19. In our review, the mean duration to the onset of TE symptoms was 56.5 days after COVID-19, which is slightly less than the duration of 2 to 3 months reported for TE caused by other factors.
      • Malkud S.
      Telogen effluvium: a review.
      ,
      • Sinclair R.
      Diffuse hair loss.
      The mechanism of the association between COVID-19 and TE is believed to be related to the upregulation of proinflammatory cytokines, including interleukin 1b, interleukin 6, tumor necrosis factor-α, and interferon gamma, that may induce catagen development and subsequent TE.
      • Di Landro A.
      • Naldi L.
      • Glaser E.
      • Paus R.
      • Tosti A.
      Pathobiology questions raised by telogen effluvium and trichodynia in COVID-19 patients.
      ,
      • Ye Q.
      • Wang B.
      • Mao J.
      The pathogenesis and treatment of the ‘cytokine storm’ in COVID-19.
      • Huang C.
      • Wang Y.
      • Li X.
      • et al.
      Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
      • Ito T.
      • Ito N.
      • Saathoff M.
      • Bettermann A.
      • Takigawa M.
      • Paus R.
      Interferon-gamma is a potent inducer of catagen-like changes in cultured human anagen hair follicles.
      • Webb B.J.
      • Peltan I.D.
      • Jensen P.
      • et al.
      Clinical criteria for COVID-19-associated hyperinflammatory syndrome: a cohort study.
      Although the large sex bias for TE seen in our review (80.7% female) may be due to sex differences in immune responses, females may be more likely to notice hair thinning than males (and, therefore, more likely to seek treatment) or be more susceptible to TE because of postpartum hormonal changes.
      • Sharquie K.E.
      • Jabbar R.I.
      COVID-19 infection is a major cause of acute telogen effluvium.
      ,
      • Malkud S.
      Telogen effluvium: a review.
      ,
      • Hughes E.C.
      • Saleh D.
      Telogen Effluvium.

      AA: Worsened by COVID-19

      AA typically occurred as a relapse of a preexisting diagnosis of AA, rather than new-onset symptoms triggered by COVID-19. A recent cohort study of 7958 COVID-19–positive individuals with no prior history of AA found that only 0.2% (18/7958) of the patients developed a new diagnosis of AA from COVID-19.
      • Kim J.
      • Hong K.
      • Gomez Gomez R.E.
      • Kim S.
      • Chun B.C.
      Lack of evidence of COVID-19 being a risk factor of alopecia areata: results of a national cohort study in South Korea.
      Of the 143 patients with COVID-19 in our review, 95.1% (n = 136/143) had a preexisting diagnosis of AA, compared with only 4.9% (n = 7/143) without a preexisting diagnosis. Most patients with AA and COVID-19 included in our review were derived from a cross-sectional study (n = 133) in Italy that found an AA relapse rate of 42.5% after COVID-19, compared with a relapse rate of 12.5% in patients without COVID-19, suggesting that AA may be worsened by COVID-19.
      • Rinaldi F.
      • Trink A.
      • Giuliani G.
      • Pinto D.
      Italian survey for the evaluation of the effects of coronavirus disease 2019 (COVID-19) pandemic on alopecia areata recurrence.
      Relapses of AA have been associated with several other viruses, including Epstein-Barr virus, cytomegalovirus, and hepatitis B vaccination.
      • Richardson C.T.
      • Hayden M.S.
      • Gilmore E.S.
      • Poligone B.
      Evaluation of the relationship between alopecia areata and viral antigen exposure.
      The mechanism of AA is believed to be an autoimmune reaction related to loss of immune privilege of hair follicles in the anagen stage.
      • Rajabi F.
      • Drake L.A.
      • Senna M.M.
      • Rezaei N.
      Alopecia areata: a review of disease pathogenesis.
      Viral infections can cause buildup of reactive oxygen species; this oxidative stress, in turn, can upregulate the expression of major histocompatibility complex class I ligands in hair root sheaths, leading to increased T-cell activation.
      • Rossi A.
      • Magri F.
      • Michelini S.
      • et al.
      New onset of alopecia areata in a patient with SARS-CoV-2 infection: possible pathogenetic correlations?.
      ,
      • Rajabi F.
      • Drake L.A.
      • Senna M.M.
      • Rezaei N.
      Alopecia areata: a review of disease pathogenesis.
      T cells release interferon gamma and tumor necrosis factor-α around hair follicles, causing autoimmune-induced hair loss.
      • Rajabi F.
      • Drake L.A.
      • Senna M.M.
      • Rezaei N.
      Alopecia areata: a review of disease pathogenesis.

      Limitations

      There are several limitations of our study, including reporting and sampling bias. Findings from our review relied heavily on case reports and series with small sample sizes, from which generalized conclusions may be difficult to draw. Although several articles had significantly larger sample sizes (n > 100), these frequently lacked individual patient details, such as patient age, sex, and/or the type of alopecia. These few studies may also exert a disproportionate influence on our data compared with case reports and series with fewer patients, as approximately 75% of patients included in the review come from only approximately 15% of articles. Moreover, some cross-sectional studies presented patient data from self-reported questionnaires, which may be susceptible to both reporting and sampling bias. Some of our statistics may also be overestimated for various reasons. For example, some studies on AGA were conducted at male-only hospitals, which could overestimate the true proportion of males with AGA. Survival rates may similarly be overestimated in patients with TE, given that the onset of TE symptoms generally only occurs in the weeks to months after COVID-19. Many studies that reported hair outcomes of TE or AA associated with COVID-19 did not describe the severity of the symptoms, and, therefore, comparisons to hair outcomes in TE or AA without COVID-19 could not be made. Definitions of COVID-19 onset also varied across studies. Our meta-analysis is based only on aggregate data from each study and only includes a descriptive analysis. Despite these limitations, our review provides meaningful and clinically relevant information to providers, as it is, to our knowledge, the first to summarize findings from all published articles that describe hair manifestations of COVID-19.

      Conclusion

      AGA appears to be a risk factor for severe COVID-19, whereas TE presents as a new-onset sequela of COVID-19. AA generally occurs as a relapse in patients with preexisting AA, although, rarely, COVID-19 may also trigger new-onset AA. In this review, we have summarized findings from studies published to date describing any type of alopecia in patients with COVID-19. Although we have also included information about the current understanding of the relationships between COVID-19 and these various forms of alopecia, further studies are needed to elucidate mechanisms underlying these associations.

      Conflicts of interest

      Dr Tosti is a consultant for DS Laboratories, Monat Global, Almirall, Thirty Madison, Eli Lilly, Bristol Myers Squibb, P&G, Pfizer, and Myovant. Author Nguyen has no conflicts of interest to declare.

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