key: cord-1012136-2yc9pk4h
authors: Rivetti, Nicolò; Barruscotti, Stefania
title: Management of Telogen Effluvium During The Covid‐19 Emergency: Psychological Implications
date: 2020-05-22
journal: Dermatol Ther
DOI: 10.1111/dth.13648
sha: dcceb86688832caea847e793259219d2a2269fb6
doc_id: 1012136
cord_uid: 2yc9pk4h

nan

During the Coronavirus 2019 disease (COVID-19) emergency, the Italian Government imposed a national quarantine from March 9th to May 4 th (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) (Garcovich, Bersani, Chiricozzi, & De Simone, 2020; Sani et al., 2020) . Increased psychosocial stress may have an impact on the course of many common "stress-responsive" skin conditions, leading to a real or This article is protected by copyright. All rights reserved.

perceived exacerbation of the disease (Garcovich, Bersani, Chiricozzi, & De Simone, 2020; Jafferany & Franca, 2016) . This is true especially for TE, a disease often induced by stressful events (Rebora, 2019; Alexopoulos & Chrousos, 2016) . The importance of the brain-skin axis has been consistently underlined (Garcovich, Bersani, Chiricozzi, & De Simone, 2020; Alexopoulos & Chrousos, 2016) . 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 (Jafferany & Patel, 2020) .

According to the latest literature (Deepak, Subuhi, & Ishmeet, 2020) , 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 realtime video consultation (one per patient) using a webcam (Deepak, Subuhi, & Ishmeet, 2020) . 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 (Guarrera, Cardo, & Rebora, 2011) . 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 (Rebora, 2019; Guarrera, Cardo, & Rebora, 2011) .

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 This article is protected by copyright. All rights reserved. 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 counselling 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.

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