Telogen effluvium (TE) is a transient type of hair loss that can occur after significant physical or emotional stress. There is reason to suspect that patients who have either contracted and recovered from COVID-19 or had severe emotional stress due to the pandemic may be at risk of developing TE in the months and years ahead. Clinically TE manifests as a diffuse hair shedding that occurs 3-6 months after a physical or emotional stressor. The natural course of TE involves about 1-3 months of hair shedding in the active phase and then 6-12 months of regrowth during the resolution phase.
One of the most common causes of TE is childbirth, and up to 20% of new mothers experience hair shedding 2-3 months after delivery of their child. TE can also occur after starting certain medications such as Accutane (isotretinoin) and after discontinuing oral birth control pills. Testosterone supplementation may also contribute to TE. Nutritional or micronutritional deficiency may also contribute to TE. Studies have showed that some patients with TE have a deficiency in zinc, Vitamin D, or ferritin (1). Another recent study showed that low dose Vitamin C and D supplementation may actually help improve TE (2).
Emotional stress may also contribute to the development of TE. In fact, mouse studies have shown that experimental stress may lead to alterations in immune response, contributing to hair cell death (3). A study of 33 medical students showed that the stress related to finals examinations correlated with a change in their immune response and to a temporary decrease in hair growth (4). Given the significant emotional stress that many are going through during the COVID-19 pandemic, it is possible that a cross-section of the population may experience an episode of TE in the next few months and years.
Another population of people who may experience TE are those who contracted and recovered from COVID-19. Severe viral infections have been shown to be a cause of TE. Although we do not have direct data on whether COVID-19 infection leads to TE, we can learn from history by looking back at the medical literature from the last great pandemic, the Spanish Influenza of 1918. Spanish Flu survivors were reported to experience TE 2 to 6 weeks after the onset of a high fever (around 39.5℃ or 103 F) (5). As reports of high fever have also been reported with COVID-19, it may be reasonable to suspect that there may be a post-febrile TE that can occur. There may also be direct effects by viruses on hair follicle growth that lead to TE. Diffuse TE occurs in 7% of HIV-1 infected patients. Apoptosis (death) of the follicular stem cells has been described in HIV-1 alopecia (hair loss) (6). Since there are reports of thrombotic (blood clotting and vascular damage) complications from COVID-19, it may be inferred that infection with COVID-19 may compromise hair follicle vasculature.
Since Dr. Ratushny is both a Harvard-trained, board-certified dermatologist and a hair restoration surgeon, he is able to assess and diagnose many different types of hair loss including TE. Based on his thorough assessment and diagnosis, he can make a specific treatment plan that suits your needs. Not every patient is a surgical patient needing a hair transplant. Having TE is generally a temporary condition and not one for which one would perform hair restoration surgery. If you are concerned that you have a medical hair loss condition like TE, we recommend that you schedule a medical hair loss assessment with Dr. Ratushny before scheduling a hair transplant consultation.
References:
1. Cheung EJ, Sink JR, English JC III. Vitamin and mineral deficiencies in patients with telogen effluvium: a retrospective cross-sectional study. J Drugs Dermatol. 2016;15:1235–1237.
2. Almohanna HM, Ahmed AA, Tsatalis JP, et al. The role of vitamins and minerals in hair loss: a review. Dermatol Ther. 2019;9:51–70.
3. Arck PC, Handjiski B, Peters EM, et al. Stress inhibits hair growth in mice by induction of premature catagen development and deleterious perifollicular inflammatory events via neuropeptide substance P-dependent pathways. Am J Pathol. 2003;162:803–814.
4. Peters EMJ, Müller Y, Snaga W, et al. Hair and stress: a pilot study of hair and cytokine balance alteration in healthy young women under major exam stress. PLoS One. 2017;19:12(4).
5. Savill A. The Hair and Scalp – A Clinical Study. 4th ed. London: Arnold & Co; 1952:p.84.
6. Barcaui CB, Gonçalves da Silva AM, Sotto MN, Genser B. Stem cell apoptosis in HIV-1 alopecia. J Cutan Pathol. 2006 Oct;33(10):667-71.