Clinical Challenge: Hair Loss After COVID-19

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A 53-year-old woman presents to the clinic complaining of hair thinning. She states that the condition was first noted several weeks ago and is of cosmetic concern. She has hypertension, for which she is taking hydrochlorthiazide; treatment was started over 2 years ago. Recent thyroid assays, ordered by her family physician, are within normal limits. She was diagnosed with COVID-19 approximately 3 months ago; she received both vaccinations and a booster prior to infection. Physical examination revealed diffuse hair thinning, a positive hair pull, and no visible abnormalities of her scalp other than decreased hair density.

Telogen effluvium is characterized by the sudden onset of hair thinning. The resulting alopecia does not leave scars, is noninflammatory, and most commonly occurs in women. Several underlying mechanisms have been identified for telogen effluvium. These include an accelerated premature...

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Telogen effluvium is characterized by the sudden onset of hair thinning. The resulting alopecia does not leave scars, is noninflammatory, and most commonly occurs in women. Several underlying mechanisms have been identified for telogen effluvium. These include an accelerated premature shift from the growth phase (anagen) to the involution phase (catagen) and resting phase (telogen), as well as prolongation of the anagen phase resulting in heavy telogen shedding.1 

Patients with telogen effluvium experience abrupt onset of diffuse generalized shedding and may lose hundreds of hairs per day. Moderate tugging on scalp hairs (pull test) is positive with greater than 10% or more of hairs readily extracted during the active phase.2 The condition is often precipitated by identifiable stressors including pregnancy, nutritional deficiency, medications including beta blockers and oral contraceptives, rapid weight loss, and febrile illnesses. About one-third of cases are idiopathic.1

Telogen effluvium is the most common hair disorder associated with COVID-19, with highest prevalence occurring in those experiencing severe disease.3 In an international study, the majority (62.5%) of the patients with telogen effluvium, hair signs and symptoms started within the first month after COVID-19 diagnosis; in 47.8% of patients hair loss started 3 to 4 months after infection.3

In a recent analysis of 10 patients presenting with hair thinning post COVID-19 infection, all were women and 4 had required prior hospitalization.4 A study by Aksoy et al found that some degree of hair loss developed in 27.9% of people who have had COVID.5 Telogen effluvium associated with COVID-19 is a self-limited disorder and patients should be reassured that hair normalization over a period of several months is to be anticipated.

Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.

References

1. Asghar F, Shamim N, Farooque U, Sheikh H, Aqeel R. Telogen effluvium: a review of the literature. Cureus. 2020;12(5):e8320. doi:10.7759/cureus.8320

2. Shrivastava SB. Diffuse hair loss in adult female: approach to diagnosis and managementIndian J Dermatol Verereol Leprol. 2009;75(1):20-28. doi:10.4103/0378-6323.45215

3. Starace M, Iorizzo M, Sechi A, et al. Trichodynia and telogen effluvium in COVID-19 patients: results of an international expert opinion survey on diagnosis and managementJAAD Int. 2021;5:11-18. doi:10.1016/j.jdin.2021.07.006.

4. Mieczkowska K, Deutsch A, Borok J, et al. Telogen effluvium: a sequela of COVID-19Int J Dermatol. 2021;60(1):122-124. doi:10.1111/ijd.15313

5. Aksoy H, Yıldırım UM, Ergen P, Gürel MS. COVID-19 induced telogen effluviumDermatol Ther. 2021;34(6):e15175. doi:10.1111/dth.15175