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Diffused Hair-loss And Telogen Effluvium A Cause Of Worry Among Post COVID-19 Recovering Patients

Author: Dr. Chanchal Bhar

M.B.B.S., DVD, PGDM, Ph.D (Dermatology), (Trinity College, Seychelles), Fellow of NIER, Consultant Dermatologist, AMRI Hospital, Kolkata

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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



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]:-

  1. Anagen- Active growing phase
  2. Catagen- Regressing phase
  3. Telogen- Resting phase
  • Anagen- The stage lasts for a long period of time, many years for human scalp hairs. The phase has the formation of a new hair strand in the hair follicle, which lengthens till the point of no growth. The anagen phase is different for body hair, as it is of a shorter period of time [6]. Melanin, the pigment, is produced in the bulb of the hair throughout this phase. However, towards the end of the growth of hair strands in anagen, melanocytes release fewer pigment granules.
  • Catagen- This stage is characterized by the onset of cell division in the matrix and the regression of the root bulb toward the skin surface. The root bulb shrinks and rounds off to produce a club-like structure of loosely organized cells. The catagen phase is fleeting, and this stage of hair is not likely to be recovered as forensic specimens. Catagen is the phase of transition, and the hair growth stops and becomes detached from the follicle's base. The bulb of hair begins to break down, which results in the follicle becoming shorter. On average, 1% of follicles are in the catagen stage [7].
  • Telogen- This stage is considered as the resting period before shedding of a hair. It typically lasts several months for scalp hairs, longer for hairs in other parts of the body. During this phase, the hair halts growth but remains attached to the follicle. Some tissue does anchor the root club in the skin during this stage, but removing hair is comparatively simple by mechanical means (e.g., brushing) or due to the growth of a new anagen hair beneath it. Each day human scalp may shed an estimated 100–150 telogen hairs [6]. Thus, approximately 10–15% of all hair is in this phase at any one time [7]. At the end of the telogen phase, the hair follicle reenters the anagen phase, forming new hair.

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].


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:

  • Serum Vitamin D
  • Complete Blood Count
  • Routine Urine Examination
  • Thyroid Function Tests

After the above investigations, advanced clinical and diagnostic tests and their implications are:

  • Diagnosing hypocalcemia for serum calcium
  • Vitamin B12 (person with atrophic gastritis, malabsorption syndromes, pernicious anemia, or autoimmune disorders)
  • Serum proteins to identify protein energy malnutrition
  • Serum zinc for checking deficiency
  • Distinguishing between Telogen effluvium and Androgenetic Alopecia (AGA) by hormonal assays
  • Anti-dsDNA antibodies when autoimmune diseases are suspected


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].


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:

  • Wide-tooth comb needs to be used for preventing tension in hair strands, which leads to breakage
  • Sulfate free mild shampoo should be used as needed
  • Excessive use of heating tools should be avoided
  • Excessive use of chemicals such as hair colours need to be avoided
  • Tight hairstyles should be avoided
  • Deep conditioning of hair tip with coconut oil can be done frequently



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.



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