key: cord-0691993-5qevgqbj authors: Koç Yıldırım, Sema; Erbağcı, Ece; Demirel Öğüt, Neslihan title: Evaluation of patients with telogen effluvium during the pandemic: May the monocytes be responsible for post COVID‐19 telogen effluvium? date: 2022-02-28 journal: J Cosmet Dermatol DOI: 10.1111/jocd.14883 sha: 049d20bff4be1f26c132965d3a42032ad02b895b doc_id: 691993 cord_uid: 5qevgqbj INTRODUCTION: Telogen effluvium (TE) is one of the causes of non‐scarring hair loss that occurred commonly 2–3 months after a triggering factor. It was reported that the incidence of TE increased during the COVID‐19 (coronavirus disease 2019) pandemic. However, to date, there is no study evaluating the status of COVID‐19 before the onset of hair loss in patients with TE. The aim of this study is to evaluate the patients with TE whether they had COVID‐19 or not before the onset of their hair loss and to compare the demographic and clinical characteristics and laboratory parameters of those with and without a history of COVID‐19. METHOD: We conducted an observational cohort study of TE patients. The diagnosis of TE depended on anamnesis and physical examination of the patients. Also, hair pull test was performed. Demographic data and the results of COVID‐19 real‐time polymerase chain reaction (RT‐PCR) were recorded from the electronic medical records. RESULTS: Totally, 181 patients with TE were included in the study. Sixty‐four of patients (35.4%) had been diagnosed with COVID‐19 before the hair loss started. The median duration of development of hair loss was 2 months (range 1–11 months, IQR 3) after COVID‐19 diagnosis. In this group, 87.5% of patients (n = 56) had acute TE and 12.5% of patients (n = 8) had chronic TE. The rate of acute TE and the use of vitamin supplements were ignificantly higher (p < 0.001 and p = 0.027, respectively) and the monocyte count in peripheral blood was lower (p = 0.041) in the group diagnosed with COVID‐19. DISCUSSION AND CONCLUSION: It was stated that monocytes and macrophages infected by SARS‐CoV‐2 can produce pro‐inflammatory cytokines that play a crucial role in the development of COVID‐19‐related complications. Also, it was suggested that the number of monocytes tends to be lower in the late recovery stage. The lower monocyte count in patients with a history of COVID‐19 in our study may be related to evaluating the patients in the late period of recovery and the migration of circulating monocytes to hair follicles. The history of COVID‐19 must be questioned in patients with TE. It should be kept in mind that hair loss that develops after COVID‐19 may be presented as chronic TE form too. The exact mechanisms of hair loss induced by COVID‐19 are not fully explained; the roles of monocytes on the hair follicles may be one of the responsible mechanisms. Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), the cause of COVID-19 infection, has been associated with variable cutaneous findings including maculopapular, vesicular, urticarial rashes, and vascular lesions such as acro-ischemia, purpura, and livedo 1 At the same time, COVID-19 has previously been linked to telogen effluvium (TE). There are some reports in the literature stating that the incidence of TE increased during the pandemic period compared to the pre-pandemic period. [2] [3] [4] In several reports, it has been stated that the average onset time of the hair shedding was 1-3 months after the diagnosis of COVID-19. [5] [6] [7] [8] [9] [10] Telogen effluvium is one of the most common causes of nonscarring hair loss that is characterized by diffuse hair shedding and manifests commonly 2-3 months after the triggering factor such as metabolic or nutritional alterations, febrile diseases, and physiological or emotional stress or medications. 11 The possible pathogenetic mechanisms of the development of TE after COVID- 19 have been tried to be explained with damaged hair matrix cells by cytokine storm and psychosocial and physical stress resulting from the "stay at home" orders, drugs such as heparinoids and direct viral damage to the hair follicle. 6, 7, 9, 10 To the best of our knowledge, to date, there was no study comparing the characteristics of the patients with TE depending on their previous COVID-19 status. The aim of this study was to evaluate the status of COVID-19 before the onset of hair loss in patients with TE and to evaluate clinical and laboratory differences between these two patient groups (patients with and without previous COVID-19 infection). The secondary objective was to investigate the possible pathogenetic mechanisms of post COVID-19 hair loss. A total of 181 patients with TE were included in the study. One hundred seventy-two (95%) of the cases were female and 9 (5%) were Table 2 . Hair pull test positivity was 64.1% in patients with previous COVID-19 infection. Eight of the patients (12.5%) required hospitalization for COVID-19 (Three of them required intensive care unit hospitalization). About 25% (n = 16) of the patients in this group did not use any medication for COVID-19. Favipiravir was the most common drug used for infection during the disease (n = 45, 70.3%). The other medications were hydroxychloroquine (n = 2, 3.1%), enoxaparin (n = 9, 14.1%), and plasmapheresis (n = 2, 3.1%). Also, RT-PCR tests were negative in 12 of 15 patients who had a history of close contact with a confirmed COVID-19 person and 3 of them had no PCR test. When we compared the groups that were diagnosed with COVID-19 before hair loss started and the group not diagnosed, in terms of demographic and clinical characteristics, there were no statistical differences between the groups about the gender, age, hair pull test positivity, hair pull test positive areas, having surgery, delivery, and/or comorbid disease history. The rate of acute telogen effluvium and the use of vitamin supplements were significantly higher in the group diagnosed with COVID-19 (p < 0.001 and p = 0.027, respectively) ( Table 3) . When we compared the laboratory parameters between the two groups, there was no statistically significant difference in the thyroid function tests, total iron-binding capacity, saturated/unsaturated iron-binding capacity, ferritin level, folate level, and Vitamin B12 level, and these parameters were in normal limits. In terms of complete blood count parameters, there was no statistical difference in hemoglobin, hematocrit, white blood cell and platelet counts, MCV, RDW, MPV, and PCT values between the groups. However, the median monocyte count was 0.41 (×10 3 /µl) (IQR 0.18) in the group of patients with previous COVID-19 infection and 0.43(×10 3 / µl) (IQR 0.16) in other group and this difference was statistically significant (p = 0.041). NLR, dNLR, and MLR were lower and PLR was higher in the group of patients with previous COVID-19 infection, but these differences were not statistically different (Table 4 ). Telogen effluvium is a non-scarring alopecic condition that often occurs 2-3 months after the triggering event including infections, emotional stress, and medications. COVID-19 is an infectious febrile disease that is related to physiological and psychosocial stress and using some medications and all of them may be a potential causative reason for TE following COVID-19. In a study, it was reported that the incidence of TE increased from 0.5% to 2.3% 3 months after the COVID-19 pandemic was declared. 2 In another study, it was stated that the incidence of TE increased from 0.4% to 2.7% approximately 2 months after the declaration of a pandemic when compared to the corresponding month of the previous year. 3 On the other hand, the frequency of TE in individuals with diagnosed COVID-19 and recovered was also evaluated. In a study, TE was found to be 36.7% in post COVID-19 individuals. 10 In another study, it was reported that 24% of patients recovered from COVID-19 had alopecia as a late-onset symptom without specifying the subtype 12 As well, the frequency of TE was found to be higher with 66.3% in patients with a history of COVID-19 who were evaluated in specialized hair clinics. 13 To the best of our knowledge, there is no study in the literature evaluating the status of having COVID-19 prior to their complaints in patients diagnosed with TE. In our study, we found that more than a third of the TE patients (35.4%) were diagnosed with COVID-19 before the hair loss onset. Therefore, we would like to emphasize that it is important to question the history of COVID-19 in patients who present with hair loss and are evaluated as TE. In the reports evaluating the hair loss after the diagnosis of COVID-19, the average onset time was stated as 1-3 months. [5] [6] [7] [8] [9] [10] The median onset time of TE was 2 months after the COVID-19 diagnosis in our study consistent with the literature. When we grouped the patients according to the duration of the disease, acute TE was 87.5% in patients diagnosed with COVID-19, and the rate of acute TE was significantly higher than those without a history of COVID-19. Although postinfectious TE is traditionally categorized as acute TE, similar to our study. [5] [6] [7] 9, 10, 13, 15 This might be explained by the fact that female patients notice hair shedding more easily due to their hair length and need to consult a physician more frequently because of taking hair loss more seriously than men. 11 The use of vitamin supplements was significantly higher in the group with a history of COVID-19 in our study. This is an expected result because of a few reasons. First of all, these products are available over-the-counter medication in our country. The other explanation is that the vitamin or mineral supplementation may have a theoretical role in the prevention or treatment of COVID-19. Because of their potential to influence immune response and antioxidant capacity, they have been hypothesized to be useful for the prevention or treatment of COVID-19. 16, 17 Several pathogenetic mechanisms have been suggested to explain the development of TE after COVID-19. The cytokine storm is the most likely explanation that pro-inflammatory cytokines such as IL-6 (interleukin-6), IL-1β, TNFα (tumor necrosis factor-alpha), and IFNγ (interferon-gamma) may be responsible for inducing the catagen phase and damaging the hair matrix cells. 5, 18 The inhibition of the hair growth by metalloproteinases 1 and 3 and IL-1β that showed high levels in COVID-19 may be another possible explanation. 6, 19 It was hypothesized that SARS-Cov-2 may cause direct viral damage to the hair follicle via antibody-dependent enhancement phenomenon that an entry mechanism has been documented in coronaviruses. 6, 20 In addition to these, the micro- an effect on the psychosocial condition of patients and we did not evaluate whether there was a difference between the two groups in terms of anxiety and depression levels of the patients. 28 As a conclusion, in our study, we found a history of COVID-19 in 34% of patients diagnosed with TE in our outpatient clinic. For this reason, the history of COVID-19 must be questioned in patients who have the complaint of hair loss and been diagnosed with TE. Hair loss that develops after COVID-19 may not be only in acute TE form; therefore, it is necessary to follow up the patients. Although the exact mechanisms of hair loss induced by COVID-19 are not well known, the effects of monocytes on the hair follicle may be one of the responsible mechanisms in addition to the data in the literature. The authors declare no conflict of interest. Data available on request from the authors. 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A review of the literature Clinical sequelae of COVID-19 survivors in Wuhan, China: a single-centre longitudinal study How to cite this article Evaluation of patients with telogen effluvium during the pandemic: May the monocytes be responsible for post COVID-19 telogen effluvium?