Treatment of post-Covid alopecia: analysis of clinical cases

Anna Prilipko , dermatovenerologist, cosmetologist, member of the European Association of Dermatovenerologists

In multiple studies, the predominant amount of alopecia occurs in the telogen phase. Since the number of patients with this symptomatology is increasing, it is assumed that it is possible to make the diagnosis “Post-Covid acute diffuse telogen effluvium” in ICD-10. But is the introduction of this diagnosis appropriate? After all, the pathogenesis of acute diffuse telogen effluvium completely justifies hair loss after COVID-19, as well as after other diseases that are accompanied by acute intoxication syndrome. In this article we will analyze two clinical cases. Both patients suffered from COVID-19 in a fairly mild form. Treatment was carried out on an outpatient basis. Both are somatically healthy, no chronic diseases, no complaints of hair loss.

Clinical case No. 1

Patient born in 1976 (45 years old)

07/12/2021 Complained of excessive hair loss. Visible thickening of the parting on the central part of the head. The problem is associated with COVID-19 in March 2021. Denies previous tuberculosis and hepatitis. There are no chronic diseases. Somatically healthy.

St. Localis: Skin is clean and free from rashes. On the scalp, hair thinning is observed in the fronto-parietal and temporo-parietal zones. When performing a traction test (Hair Pull Test), up to 30 hair shafts are freely separated. There are no rashes or damage to the scalp. During instrumental examination using a dermatoscope: epidermal and perifollicular peeling is not visualized, excessive sebum is not noted, there is no inflammatory process, there are no empty hair follicles, hair shafts are within normal limits. There is no damage to the cortex.

Diagnosis: Acute diffuse telogen effluvium?

Recommended: additional examination (BAC, BAM, biochemical blood test (direct, indirect, total bilirubin, ALT, AST, creatinine), TSH, T3, T4 free, ATPO, coagulogram, vitamin D 25-OH, ferritin)

Diagnostic criteria that I rely on when making a diagnosis:

1. Anamnesis collection.
2. Visual inspection, PULL test.
3. Instrumental examination using a dermatoscope, trichoscope (phototrichogram).
4. Additional examination using laboratory data.

A minor deviation was found in the general blood test :

• Red blood cells – 4.71 (reference interval – 3.7-4.7 cells/l)

• Monocytes – 10.9% (reference interval – 3.0-10.0% per 100 leukocytes)

• Basophils – 1.4% (reference interval – 0.0-1.0% per 100 leukocytes)

• 25-hydroxyvitamin D 25-(OH)-D- 20.16 mg/ml (reference interval – 30.0-100.0 mg/ml)

Conclusion: immature forms of leukocytes predominate, which may indicate a previous viral infection. From the anamnesis it is known that 10 days before the delivery of biological material, vaccination was carried out to prevent influenza, which could provoke a specific immune response).

Treatment algorithm:

1. Conducting a conversation with the patient, explaining that all processes are physiological and correctable. Recommendations regarding a balanced diet, dosed and regular physical activity, minimizing the stress factor.
2. Replenishment of vitamin D deficiency.
3. Use of shampoo with aminexil in hygiene procedures.
4. Intradermal administration of the drug (a combination of B vitamins and iron) into the scalp. Course – 8 procedures with an interval of 10 days.

Dynamics of treatment:

1. 1 month has passed since the start of treatment.
2. I assess the dynamics using a dermoscopic picture and a PULL test.

Results 3 months after the start of therapy:

• no complaints;
• according to the patient, hair loss per day is moderate (up to 50 hair shafts per day);
• during the PULL test, up to three units of hair shafts separated freely;
• a sufficient amount of hair is visualized in the anagen phase during dermatoscopy;
• notes improvement in hair quality.

Clinical case No. 2

Patient born in 1996 (25 years old)

10/29/2021 Complained of excessive hair loss. The problem is associated with COVID-19 at the end of September 2021. Denies previous tuberculosis and hepatitis. There are no chronic diseases. Somatically healthy.

St. Localis: Skin is clean and free from rashes. On the scalp, hair thinning is observed in the frontoparietal and temporoparietal zones. When performing a traction test (Hair Pull Test), up to 20 hair shafts are freely separated. There are no rashes or damage to the scalp.

During instrumental examination using a dermatoscope: epidermal and perifollicular peeling is not visualized, excessive sebum is not noted, there is no inflammatory process, there are no empty hair follicles, hair shafts are within normal limits, there is no damage to the cortex.

Diagnosis: Acute diffuse telogen effluvium?

Recommended: additional examination (BAC, BAM, biochemical blood test (direct, indirect, total bilirubin, ALT, AST, creatinine), TSH, T3, T4 free, ATPO, coagulogram, vitamin D 25-OH, ferritin).

Diagnostic criteria:

1. Anamnesis collection.
2. Visual inspection, PULL test.
3. Instrumental examination using a dermatoscope, trichoscope (phototrichogram).
4. Additional examination using laboratory data (in this case, no deviations were detected).

Treatment algorithm:

1. Conducting a conversation with the patient, explaining that all processes are physiological and correctable. Recommendations regarding a balanced diet, dosed and regular physical activity, minimizing the stress factor.
2. Consultation with a psychiatrist.
3. Use of shampoo with aminexil in hygiene procedures.
4. Administration of the drug intradermally (PDRN 2%) into the scalp. Course – 4 procedures with an interval of 14 days.

Results 1 month after the start of therapy (2 procedures were performed):

• no complaints;
• according to the patient, hair loss per day is moderate (up to 20 hair shafts per day);
• during the PULL test, 1 unit of hair shaft separated freely;
• a sufficient amount of hair is visualized in the anagen phase during dermatoscopy;
• notes improvement in hair quality.

At the end of this article I would like to summarize:

• After the proposed treatment regimen, positive dynamics were noted in both clinical cases.
• Introducing the diagnosis “Post-Covid alopecia” as a separate nosology in ICD-10 is not appropriate, since the etiology and pathogenesis of acute diffuse alopecia is comparable to the cause of hair loss after COVID-19.
• By injecting the drug intradermally, we accelerate the restoration of physiological processes in the hair life cycle.

Analysis of mistakes made:

• a more detailed instrumental study (phototrichogram) was not carried out;
• There is no laboratory IgG test to estimate the amount of antibodies to COVID-19. It is possible that the immune response has a connection with hair loss after infection.

Taking into account this analysis, it would be possible to conduct a more thorough diagnosis, which in the future could positively influence the treatment tactics of patients.