Healthcare e-Compendium
A joint initiative of DPSRU & DRSC
Healthcare e-Compendium
A joint initiative of DPSRU & DRSC
Author: Dr. Chanchal Bhar
M.B.B.S., DVD, PGDM, Ph.D (Dermatology), (Trinity College, Seychelles), Fellow of NIER, Consultant Dermatologist, AMRI Hospital, Kolkata
download ArticleAbstract
Recent cases of COVID-19 are showing excessive hair fall and damage to hair matrix. This has been now identified as a side effect of post-COVID-19 infection. The clinical diagnosis of this sudden hair fall is known as Telogen effluvium. Although it is not so serious and gets cured gradually as the patient recovers, but at some cases it is more severe. A proper treatment and early diagnosis can prevent this hair loss and the socio psychological stress of an individual. This article focuses on the factors leading to post-COVID-19 hair loss and its proposed treatment.
Keywords: Telogen effluvium, Post-COVID-19 hair fall, COVID-19 infection
Introduction
The global pandemic of coronavirus has imposed massive side effects and severe strains on the recovering patients for an extended period of time. From affecting the lungs to the lingering effects and symptoms on the brain, heart, etc., the post-COVID-19 side effects and battling the infection can be very profound [1]. Some of the side effects are very serious, like blood coagulation, brain fog, etc. While other side effects like headache, cough are also observed in post-COVID-19 patients. Among all of the symptoms, one is hair fall; while hair fall is encountered daily, the problem may seem a trivial ordeal faced very commonly. However, severe hair fall can be very stressful and perplexing to experience for post-COVID-19 patients. One of the main reasons can be a high level of inflammation in hair follicles due to the COVID-19 infection. In addition, there are several other factors like stress, dietary complications, and nutritional deficiency post-COVID-19, which add to hair fall as well.
However, the onset of diffuse hair loss post-COVID-19 is a serious issue and is clinically categorized as ‘Telogen effluvium’. Telogen effluvium mainly occurs due to the premature transition of hair follicles to the telogen (resting phase) from the anagen (active growth phase) [2]. The stage of post-COVID-19 telogen effluvium can be for 6 months minimum to a span of 9 months to recover completely [1].
Telogen Effluvium
The commonly known cause of diffuse hair loss is telogen effluvium. It is mainly a temporary hair loss due to traumatic events or shock to the body. It is primarily characterized by a dramatic increase in hair shedding or hair thinning from the scalp diffusely 2-3 months after any triggering event, trauma, and shock [3]. The hair shedding lasting for 6 months is categorized as acute telogen effluvium, an unusual shedding of hair more than 100 strands of hair shed per day due to a sudden shift of phase of the hair follicles from anagen to telogen phase. When the hair fall duration exceeds 6 months, it is categorized as chronic telogen effluvium [4]. Generally, telogen effluvium is mostly seen in women, but the telogen effluvium related to COVID-19 infection has shown occurrence in both men and women. The leading cause of the condition is the disturbance in the hair cycle.
Hair Growth Cycle
The hair growth cycle is a process comprising of 3 phases (Figure-1) [5]:-
Figure 1: Hair Growth Cycle
Factors Leading to Post-COVID-19 Telogen Effluvium
Patients with COVID-19 infection has shown a consistent increase in proinflammatory cytokines (interleukin 1b, interleukin 6, tumor necrosis factor α, and types 1 and 2 interferons) [8], which explains skin manifestations related to infections, like urticaria, COVID toes, and rashes [9]. Development of telogen effluvium can be initiated by this cytokine storm, further damaging the matrix cells [10]. There is evidence and confirmation of the high levels of interferons related and associated with acute telogen effluvium [11]. Currently, the patients are being treated with multi-drug regime for mild and moderate COVID-19 infection according to the National Guidance for Clinical Management. Enoxaparin used in the treatment has the implication in the development of acute telogen effluvium [12]. Watras et al. [12] has discussed and explained the anticoagulants role, including enoxaparin [13] in telogen effluvium. Increase in psychosocial tension also have an effect on the course of many skin conditions, leading to a real exacerbation of the disease [14]. Particularly for telogen effluvium, a disease mostly induced by stressful conditions [15]. Stress and change in hair growth cycle have a relation that results in selecting an axis of brain hair follicle. In particular, the release of specific hormones, neuropeptides and neurotransmitters along the brain hair follicle axis promotes visible remarkable changes in the hair growth cycle by stimulating the shifting of anagen hair into the telogen phase [16].
High level of inflammation can also be the reason of post-COVID-19 infection hair fall, that turns into side effects in future. The acute infection and inflammation in the body can break in the hair follicles growth on the scalp, thus pushing the hair into the telogen phase, resulting in shedding of the hair strand. While recovering the COVID-19 infection, the immunity of the body is weak as the system is more involved in replenishing the body and healing the damage caused by the virus, therefore a severe deficiency of nutrition, most importantly, Vitamin B12 and Vitamin D levels depletion, which are necessary for healthy hair and skin, can be possible reasons for telogen effluvium, which many are currently facing as a post-COVID-19-consequence.
Telogen Effluvium and its Treatment
The reason for hair fall is very important to investigate, and then proper treatment can be started to cure the cause of the hair loss. Clinical examination of scalp like trichoscopy, hair-pull test, and hair combing test are essential tools that can enable a quick diagnosis in patients with hair loss [17].
Investigations
The causes of diffuse telogen hair loss can be identified by laboratory tests [18]. The basic investigation that are done for patients suffering from diffuse hair loss are as follows:
After the above investigations, advanced clinical and diagnostic tests and their implications are:
Minoxidil
Minoxidil is assumed to open channels of potassium, which leads hyperpolarization of cell membranes. It helps hair follicles to get more amount of oxygen, blood and nutrition by widening the blood vessels [19]. It shortens the hair cycle in telogen phase, which further makes the resting hair follicles enter the anagen phase prematurely. The hair follicle size is increased and extends the anagen phase. It has many different effects on growth of hair by keratinocytic senescence delay and inhibiting or stimulating the proliferation of fibroblastic and epithelial cells. It inhibits collagen and prostacyclin production, while stimulating synthesis of prostaglandin E2 and vascular endothelial growth factor (VEGF) [20].
Shampoos
The direct role or benefits of shampoo are not there aligning with telogen effluvium or diffused hair loss treatment. It is recommended to use sodium lauryl sulfate free mild shampoo. Usage of the right shampoo is important. While using shampoo, patients need to be gentle on scalp and rinsing it off thoroughly. Vigorous application should not be done to avoid damage of hair [17].
In-Clinic Treatment
Platelet-rich plasma
Platelet-rich plasma is a novel treatment of modality for excessive hair loss, where concentration of platelets is autologous, contained within a little volume of plasma, which is used to rejuvenate hair follicles, in the presence of different growth factors and cellular adhesion molecules [17].
Nutritional Haircare Guide
Nutrients play an important role in hair growth like zinc, iron, selenium, niacin, Vitamin A, Vitamin D, folic acid, biotin and amino acids. Studies have reported an association between nutritional deficiency and telogen effluvium. Protein supplementation is required when there is occurrence of protein deficiency due to stress or metabolic causes [21].
Therefore, nutritional supplements play a vital role in the treatment of telogen effluvium. There should be balance of all vitamins, minerals and trace elements needed in our daily diet. Omega-3 fatty acids, soya protein and green tea extract are recommended. Protein-rich diet is a must recommended for patients with established protein deficiency. Sulfur-containing amino acids are specifically good for hair growth.
Biotin, known as vitamin B7, is a co-enzyme for carboxylase enzymes, which plays a role in the metabolism of glucose, branched-chain amino acids, and fatty acids. Biotin was useful at recommended dietary allowance (RDA) limits of 30μg. Since it is water-soluble, excess intake is usually excreted [17].
Topical Haircare Guide
With nutritional haircare, one must have a proper hair care regime and should follow the following tips to reduce hair loss:
Conclusion
Telogen effluvium is a diffused hair loss that has increased in recent times due to the COVID-19 pandemic. The release of cytokine storm during the infection has shown to play an important role in telogen effluvium in post-COVID-19 patients. The psychological state of the recovering patient needs to be stable and stress needs to be avoided, as these are some other reasons that contribute to the post-COVID-19 telogen effluvium. The COVID-19 pandemic has an impression on social life of people and people are more susceptible to depression and anxiety, from which telogen effluvium may occur. Patients need to take care of their diet and hair care regime with extra care after the infection as the virus damages and affects the whole body and different systems.
References
