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The Association Between Hair Loss and COVID-19: The Impact of Hair Loss After COVID-19 Infection on the Quality of Life Among Residents in Saudi Arabia

Background

Coronavirus illness 2019 (COVID-19) is an infectious illness that’s related to many well being situations, together with, however not restricted to, dermatological illnesses. Some sufferers endure from hair loss after changing into contaminated with extreme acute respiratory syndrome coronavirus 2. Acute telogen effluvium (TE) is a non-scarring hair loss that often happens three months after a aggravating occasion and might last as long as six months, and it may be related to post-COVID-19 infections. This examine goals to discover the prevalence of hair loss amongst recovered COVID-19 sufferers in Saudi Arabia and decide the contributing elements. Furthermore, we aimed to measure the influence of hair loss after COVID-19 on their high quality of life.

Methodology

An observational, cross-sectional examine was carried out from September to December 2021 in Saudi Arabia. A questionnaire was used to evaluate hair loss after being contaminated with COVID-19. Furthermore, high quality of life was assessed utilizing the Dermatology Life Quality Index (DLQI) questionnaire. Participants have been recruited by sharing the questionnaire on social media platforms (Twitter, Telegram, and WhatsApp). The information have been analyzed utilizing SPSS model 23 (IBM Corp., Armonk, NY, USA). Frequency and percentages have been used to show categorical variables, whereas minimal, most, imply, and commonplace deviation have been used to current steady variables. The categorical variables have been in contrast utilizing a chi-square check, and the statistical significance cut-off was set at p < 0.05.

Results

A complete of 806 members have been included within the examine, of whom 52.7% skilled hair loss after COVID-19 an infection. Age, gender, excessive temperature throughout, and the presence of hair loss previous to an infection have been considerably related to the incidence of TE. The severity of life affection based mostly on DLQI confirmed that 91.4% of the members didn’t have extreme life affection, whereas 8.6% had their lives severely affected.

Conclusions

This examine revealed subjective hair loss that was considerably related to excessive temperature, being feminine, and having a historical past of earlier hair loss. Further research utilizing goal assessments are prompt for reaching extra exact conclusions.

Introduction

The novel coronavirus illness 2019 (COVID-19) outbreak was declared a world pandemic by the World Health Organization (WHO) on March 11, 2020 [1]. COVID-19 has contaminated greater than 76 million individuals over the past yr and brought on greater than 3.8 million deaths worldwide [2].

Quite a lot of pores and skin manifestations in COVID-19 sufferers have been reported. According to a case sequence from a global registry from the American Academy of Dermatology and the International League of Dermatological Societies, a morbilliform rash was essentially the most generally reported dermatological discovering in laboratory-confirmed COVID-19 sufferers [3]. In addition, varied research have proven that some sufferers developed hair loss after extreme acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections [4]. A associated potential examine carried out at Istanbul Medeniyet University revealed that out of 75 (36.8%) telogen effluvium (TE) instances, 57 (27.9%) have been thought of COVID-19-associated TE [5].

TE is the most typical reason behind non-scarring alopecia. It is characterised by non-scarring, diffuse hair loss from the scalp. It happens as a response to numerous insults that may be bodily, psychological, or chemical, leading to a untimely follicular transition from the anagen (lively progress section) to the telogen (resting section). Acute TE is a self-limiting dysfunction that often lasts for about six months, after which it often goes into remission [6].

A big longitudinal examine on 538 COVID-19 survivors and 184 controls was carried out in Wuhan, China, to analyze the prevalence and predictors of COVID-19 medical sequelae [4]. Alopecia was among the many most prevalent grievance in convalescent COVID-19 sufferers, occurring after three to 4 months and being reported extra generally by girls [4]. Multiple research have been carried out to grasp the affiliation between COVID-19 infections and the event of TE; nevertheless, proof regarding the prevalence of TE amongst recovered COVID-19 sufferers in Saudi Arabia is at present restricted. Hence, our examine goals to discover the prevalence of hair loss amongst recovered COVID-19 sufferers and measure the influence of hair loss after COVID-19 on the standard of life amongst residents of Saudi Arabia.

Materials & Methods

This observational, cross-sectional examine was carried out from September to December 2021 in Saudi Arabia. An on-line questionnaire was created utilizing Google Forms and distributed on social media platforms (Twitter, Telegram, and WhatsApp). All grownup sufferers residing in Saudi Arabia who have been beforehand recognized with COVID-19 utilizing both polymerase both chain response (PCR) or antibody testing, had skilled hair loss, and consented to take part within the examine have been included. Respondents with a household historical past of alopecia have been additionally included on this examine to show whether or not COVID-19 prompts alopecia in people who find themselves genetically liable to androgenic alopecia. Subjects and not using a historical past of COVID-19 or with a historical past of COVID-19 however and not using a nasopharyngeal swab or hematological evaluation have been excluded. Participants who had skilled aggravating occasions; had any of the next illnesses: anemia, polycystic ovary syndrome, autoimmune illnesses, thyroid dysfunction, and different endocrine problems; and/or had lately used one of many following medicines: anti-dihydrotestosterone, oral contraceptives, testosterone, anticoagulants, chemotherapeutic brokers, and pimples, cholesterol-lowering, anti-hypertensive, melancholy, bipolar, and gout medicines weren’t included within the evaluation, as these elements may trigger hair loss. The examine was authorized by the Institutional Review Board at King Saud University (E-21-6483).

The influence of hair loss on the standard of life was assessed utilizing the Arabic model of the Dermatology Life Quality Index (DLQI) questionnaire. This questionnaire is self-explanatory and may be merely crammed out by the respondents in a single or two minutes. There are 10 questions within the DLQI designed to asses signs, emotions, private relationships, leisure, work, faculty, day by day actions, and therapy. Each query has 4 attainable solutions “very much” (rating 3), “a lot” (rating 2), “a little” (rating 1), and “not at all” (rating 0). “Not relevant” can also be scored as 0. The DLQI rating is then calculated by summing the rating of every query leading to a most rating of 30 and a minimal rating of 0. The greater the rating, the extra high quality of life is impaired. According to the rating of the DLQI, the influence of hair loss on the standard of life is then graded as no impact in any respect (0-1), small impact (2-5), average impact (6-10), very massive impact (11-20), and intensely massive impact (21-30) on the affected person’s life.

The examine was carried out utilizing a comfort random sampling method. The calculated pattern measurement was 385 utilizing the formulation n = z2pqd2 (n = pattern measurement, z = z-score for 95% confidence interval, p = estimated proportion, q = p-1, d = margin of error) with a confidence degree of 95%, an estimated proportion of fifty%, and a 5% degree of precision. A complete of two,500 COVID-19 laboratory-confirmed or suspected volunteers from all areas of Saudi Arabia crammed out the questionnaire. However, 1,694 have been excluded as a result of a scarcity of recognized an infection by nasopharyngeal swab or hematological evaluation. In whole, 806 members enrolled on this examine, which was greater than the calculated minimal pattern measurement and will thus improve the reliability of the examine’s findings and make sure the sufficiency and accuracy of the findings.

The following elements have been used within the prediction mannequin: age, gender, marital standing, place of residence, experiencing an increase in temperature related to COVID-19, being hospitalized as a result of COVID-19, being admitted to the intensive care unit (ICU) as a result of COVID-19, having a historical past of hair loss earlier than having COVID-19, and having a optimistic household historical past of alopecia. The information have been analyzed utilizing SPSS model 23 (IBM Corp., Armonk, NY, USA). Frequency and percentages have been used to show categorical variables, whereas minimal, most, imply, and commonplace deviation have been used to current steady variables. The categorical variables have been in contrast utilizing a chi-square check, and the statistical significance cut-off was set at p < 0.05. Multivariate logistic regression was utilized to foretell the danger elements for hair loss post-COVID-19 an infection.

Results

Among the 806 topics recognized with COVID-19, 490 (60.8%) have been females, and 491 (60.9%) have been single. The majority (212 (26.3%)) have been from the western area, Overall, 400 (49.6%) have been 15-25 years outdated, adopted by 209 (25.9%) who have been 26-35 years outdated (Table 1). COVID-19 was recognized by way of PCR swabs within the mouth or nostril in 99.55% of the sufferers, with solely 0.5% being recognized by a blood check (antibodies) (Table 2).

Demographical traits n %
Age
   15–25 years 400 49.60
   26–35 years 209 25.90
   36–45 years 126 15.60
   46 years and older 71 8.80
Gender
   Male 316 39.20
   Female 490 60.80
Marital standing
   Single 491 60.90
   Married 294 36.50
   Divorced 15 1.90
   Widowed 6 0.70
Place of residency
   Eastern area 179 22.20
   Central area 172 21.30
   Western area 212 26.30
   Southern area 147 18.20
   Northern area 96 11.90
Question n %
Q1: How was it confirmed that you simply had COVID-19?
Test by swab within the mouth or nostril 802 99.5
Blood check (antibodies) 4 0.5
Q2: Did your temperature rise whilst you have been contaminated with COVID-19?
Yes 554 68.7
No 252 31.3
Q3: While you have been contaminated with COVID-19, have you ever been hospitalized?
Yes 84 10.4
No 722 89.6
This fall: During your COVID-19 an infection, have you ever been admitted to the intensive care unit?
Yes 6 0.7
No 800 99.3

After being contaminated with COVID-19, 425 (52.7%) members had skilled hair loss, 243 (30.1%) had not, and 138 (17.1%) weren’t certain if they’d. Scalp signs related to alopecia in sufferers with COVID-19 have been dandruff (19%), itching (17.5%), ache (8.4%), and a burning sensation (3.5%); 64.4% of the examine’s members didn’t expertise any scalp signs.

Of the members, 196 (46.12%) observed hair loss one to 3 months after having COVID-19, adopted by 119 (28%) who observed it one week or much less after contracting COVID-19. A complete of 140 (32.94%) members suffered hair loss for greater than six months after being contaminated with COVID-19, whereas in 111 (26.12%) members, hair loss lasted one to 3 months. In response to questions on hair loss complaints pre-pandemic and a household historical past of alopecia, 426 (52.9%) and 539 (66.9%) members reported not having earlier hair loss or a household historical past of alopecia, respectively. The majority (86%) of the members who skilled alopecia had not consulted a dermatologist for this downside (Table 3).

Question n %
Q1: If your reply was sure, how lengthy did your hair loss final? (n = 425)
1 week or much less 35 8.24
1–3 months 111 26.12
4–6 months 55 12.94
More than 6 months 140 32.94
I’m unsure 84 19.76
Q2: When did you discover your hair loss after contracting COVID-19? (n = 425)
1 week or much less 119 28.00
1–3 months 196 46.12
4–6 months 24 5.65
More than 6 months 12 2.82
I’m unsure 74 17.41
Q3: Have you consulted a dermatologist/physician about your hair loss? (n = 425)
Yes 57 13.41
No 368 86.59
This fall: Had you ever suffered from hair loss earlier than contracting COVID-19? (n = 806)
Yes 380 47.1
No 426 52.9
Q5: Do you will have a household historical past of alopecia? (n = 806)
Yes 178 22.1
No 539 66.9
I’m unsure 89 11

There was a major affiliation of age (p = 0.003), gender (p < 0.001), excessive temperature throughout COVID-19 an infection (p = 0.002) ,and having a earlier historical past of hair loss earlier than COVID-19 (p = 0.002) with the incidence of hair loss post-COVID-19 (p < 0.001). Those who have been 46 years and older had a notably decrease charge of hair loss in comparison with the opposite age teams, whereas females had a notably greater charge of hair loss in comparison with males (75.6% vs 45%) (Table 4). To predict the danger elements for the incidence of hair loss post-COVID-19, multivariate logistic regression was used, and the next elements have been attributed to the next incidence of hair shedding after COVID-19: dwelling within the western area (p = 0.002, odds ratio = 2.32), dwelling within the southern area (p = 0.019, odds ratio = 2.06), and having a excessive temperature when contaminated with COVID-19 (p = 0.001, odds ratio = 1.96) (Table 5).

Factor Incidence of hair loss after contracting COVID-19 P-value
Yes No
Age 0.003*
   15–25 years 213 (64.7%) 116 (35.3%)
   26–35 years 117 (69.2%) 52 (30.8%)
   36–45 years 69 (63.3%) 40 (36.7%)
   46 years and older 26 (42.6%) 35 (57.4%)
Gender <0.001*
   Male 118 (45%) 144 (55%)
   Female 307 (75.6%) 99 (24.4%)
Marital standing 0.165
   Single 263 (65.9%) 136 (34.1%)
   Married 148 (59.2%) 102 (40.8%)
   Divorced 12 (80%) 3 (20%)
   Widowed 2 (50%) 2 (50%)
Place of residence 0.092
   Eastern area 108 (69.7%) 47 (30.3%)
   Central area 96 (65.3%) 51 (34.7%)
   Western area 103 (58.5%) 73 (41.5%)
   Southern area 65 (57%) 49 (43%)
   Northern area 53 (69.7%) 23 (30.3%)
Q1: Did your temperature rise whilst you have been contaminated with COVID-19? 0.002*
   Yes 309 (67.5%) 149 (32.5%)
   No 116 (55.2%) 94 (44.8%)
While you have been contaminated with COVID-19, have been you hospitalized? 0.633
   Yes 47 (66.2%) 24 (33.8%)
   No 378 (63.3%) 219 (36.7%)
Q2: During your COVID-19 an infection, have been you admitted to the intensive care unit? 0.876
   Yes 4 (66.7%) 2 (33.3%)
   No 421 (63.6%) 241 (36.4%)
Q3: Had you suffered from hair loss earlier than contracting COVID-19? <0.001*
   Yes 225 (74.5%) 77 (25.5%)
   No 200 (54.6%) 166 (45.4%)
This fall: Do you will have a household historical past of alopecia? 0.091
   Yes 87 (58.8%) 61 (41.2%)
   No 299 (66.4%) 151 (33.6%)
Factor P-value Odds ratio Confidence interval
Gender (male vs. feminine) <0.001* 0.24 0.16 0.35
Age (15–25 years is the referent)
   26–35 years 0.028* 0.55 0.33 0.94
   36–45 years 0.340 0.71 0.35 1.44
   46 years and older 0.313 1.55 0.66 3.65
Marital standing (single is the referent)
   Married 0.328 1.33 0.75 2.37
   Divorced 0.408 0.50 0.10 2.61
   Widowed 0.440 2.37 0.27 21.23
Place of Residence (the japanese area is the referent)
   Central area 0.480 1.23 0.70 2.17
   Western area 0.002* 2.32 1.36 3.96
   Southern area 0.019* 2.06 1.13 3.77
   Northern area 0.320 1.43 0.71 2.91
Q1: Did your temperature rise whilst you have been contaminated with COVID-19? (sure vs. no) 0.001* 1.96 1.31 2.93
Q2: While you have been contaminated with COVID-19, have been you hospitalized? (sure vs. no) 0.419 0.77 0.41 1.46
Q3: During your COVID-19 an infection, have been you admitted to the intensive care unit? (sure vs. no) 0.172 5.15 0.49 54.00
This fall: Do you will have a household historical past of alopecia? (sure vs. no) 0.686 0.91 0.59 1.42

Of the members, 423 (52.5%) reported that their high quality of life was not affected in any respect. In distinction, solely three (0.4%) reported that their hair loss had a particularly massive impact on their life (Figure 1).

A major distinction within the imply of the DLQI rating was noticed when evaluating these with hair loss and people with out hair loss (p < 0.001) (4.84 ± 4.73 vs 0.99 ± 2.48) (Table 6).

Factor Dermatology Life Quality Index P-value
Mean Standard deviation
Have you suffered from hair loss after contracting COVID-19? <0.001*
   Yes 4.84 4.73
   No 0.99 2.48

Discussion

Hair shedding is a harrowing sequela of COVID-19. When contaminated with this virus, the rise in proinflammatory cytokines (tumor necrosis issue α, interleukin 1b, interleukin 6, and kinds 1 and a couple of interferons) is believed to play a job within the improvement of hair shedding by damaging the hair follicle stem cell. However, the particular mechanisms of hair shedding following COVID-19 an infection are usually not well-known and additional research to elucidate the precise mechanisms are required [7]. Although hair loss is taken into account a benign situation, it may be devastating to a affected person’s vanity, self-image, and total high quality of life.

Multiple research have been carried out to analyze the event of TE as a consequence of COVID-19. Our examine revealed that out of 806 members, 425 (52.7%) skilled hair loss after contracting COVID-19. Similarly, a big examine that investigated the prevalence and related elements of COVID-19 hair loss amongst 5,891 sufferers discovered that hair loss was essentially the most reported post-COVID-19 manifestation (2,800, 48%) [8]. According to the outcomes of this examine, hair loss after COVID-19 occurred sooner than did traditional TE. A complete of 196 (46.12%) members observed hair loss one to 3 months after having COVID-19. However, this interval is shorter than that noticed with different febrile situations during which hair loss is seen after three to 4 months from publicity to the triggering issue [9].

Our examine additionally revealed that hair shedding was extra widespread in girls than males (75.5% vs. 54.6%). Moreno-Arrones et al. investigated 191 sufferers with TE who had been contaminated with COVID-19, 78.5% of whom have been females [10]. TE is regarded as extra widespread in females as a result of they will endure excessive stress, similar to giving start. Iron deficiency anemia is one other set off of this situation, which is extra prone to happen in girls as a result of menstruation. In addition, girls take hair loss extra critically than males and subsequently usually tend to seek the advice of a doctor with this grievance [7].

In our sequence, we discovered that age was considerably related to the incidence of hair loss post-COVID-19. Overall, 49.6% of these with hair loss have been 15-25 years outdated, adopted by 25.9% who have been 26-35 years outdated, with the remainder being 36-46 years outdated and older. Participants 46 years and older had a considerably decrease charge of hair loss in comparison with different age teams. In distinction, a scientific meta-analysis of cohort research discovered extended results following acute COVID-19 in 80% of the examine inhabitants aged 17-87 years. Because youngsters are much less generally contaminated with SARS-CoV-2 and have much less extreme signs than adults with COVID-19, most hair loss instances seem at older ages [11]. In one examine, 175 individuals have been assessed for COVID-19. Of these with COVID-19 affected by hair loss, the median age of the feminine sufferers was 71, and the median age of the male sufferers was 62.5 [12].

In our studied inhabitants, we discovered that 68.7% of members skilled a excessive temperature throughout COVID-19 an infection, whereas 31.3% didn’t. The incidence of hair loss after COVID-19 an infection in individuals who reported a excessive temperature was 67.5%. Similarly, one other examine on 10 sufferers with COVID-19 reported that post-infection hair loss was related to the severity of the illness and high-grade fever [13].

Only 13.41% of members suffered from hair loss earlier than contracting COVID-19, whereas 86.59% didn’t. A examine accomplished in Turkey revealed that 25.6% of the pattern had TE, 4.4% had scalp alopecia areata (SAA), and 19.5% had seborrheic dermatitis (SD) earlier than the pandemic, whereas 74.4%, 95.6%, and 80.5% didn’t have TE, SAA, or SD, respectively [12]. According to our examine, the incidence of hair loss after COVID-19 in those that had beforehand skilled hair loss previous to COVID-19 was 74.5%, whereas 25.5% didn’t. A small variety of research have investigated the event of TE because of COVID-19. A examine by Kutlu and Metin discovered that the incidence of TE elevated 5.51 occasions in the course of the COVID-19 pandemic in comparison with the identical month the earlier yr, rising from 0.40% to 2.17% [5]. Similarly, roughly three to 4 months after COVID-19 was declared a pandemic, Cline et al. discovered an increase within the incidence of TE from 0.5% to 2.3% [5]. However, in a examine accomplished at Istanbul Medeniyet University Prof. Dr. Suleyman Yalcin City Hospital, TE was present in 36.7% of the sufferers, of whom 27.9% have been decided to have COVID-19-associated TE after excluding instances with different potential causes of TE or those that had skilled hair loss previous to COVID-19 [5].

The COVID-19 pandemic has had psychological results on the overall inhabitants. Increased psychological stress can have a optimistic influence on the development of many pores and skin situations and might probably result in aggravating the underlying illness(s). This is very true for hair loss, for which a wealth of literature reviews may be as a result of psychological stress. Furthermore, hair loss may be aggravating by itself, and that stress can exacerbate hair loss. This could possibly be one other reason behind hair loss in individuals who’ve recovered from COVID-19 [7,9].

Hair loss can have a destructive impact on vanity for each women and men. Low vanity, along with anxiousness and fear about hair shedding, can have an effect on the standard of lifetime of a person. Based on the DLQI, our examine discovered that 69 (8.6%) COVID-19 sufferers had their lives severely affected by hair loss, whereas (91.4%) didn’t, and a major distinction within the imply of the DLQI scores was noticed when evaluating these with hair loss and people with out hair loss (p < 0.001) (4.84 ± 4.73 vs. 0.99 ± 2.48).

The authors of this examine consider that that is the primary examine to report on the prevalence and influence of hair loss on the standard of life amongst COVID-19 survivors from totally different areas of Saudi Arabia. However, varied limitations of the examine must be thought of. First, it’s a cross-sectional examine and thus it isn’t attainable to deduce causality between the examine’s variables. Second, as a result of the info collected was based mostly on an internet survey, it might have some weaknesses, similar to recall bias.

Conclusions

Patients with COVID-19 reported many sequels similar to fatigue, headache, and dyspnea. Dermatological points have been one of many long-term results of COVID-19 similar to TE. This examine revealed subjective proof of hair loss in those that had contracted COVID-19 that was considerably related to excessive physique temperature, being feminine, and having a historical past of hair loss. Hence, physicians ought to concentrate on the connection between this an infection and hair loss to enhance affected person well being outcomes and their medical care. Although hair loss can have a dramatic impact on vanity and high quality of life, nearly all of the respondents reported that hair loss after COVID-19 didn’t have an effect on their high quality of life. Further research utilizing goal assessments of hair loss are prompt for reaching extra exact conclusions.

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