Alopecia and grey hair are associated with COVID‐19 Severity

Abstract

Individual vulnerability to severe acute respiratory syndrome due to COVID-19 has been associated with age and some comorbidities, such as hypertension, diabetes and cardiovascular disease.1 Men have an increased risk for severe disease; conversely, prepubescent males appear to be protected.1 Wambier et al reported a higher prevalence of androgenetic alopecia (AGA) in 175 hospitalized patients with COVID-19 compared with the expected prevalence for an age-matched population.2 Nevertheless, the authors did not include a control group, and they evaluated only hospitalized patients. With the aim of exploring this hypothesis, we performed a population survey in Brazil. A total of 66,667 individuals from a countrywide institutional database were invited (through SMS phone messages) to complete an electronic questionnaire and were solicited to share it with their contacts (snowball sampling). The survey was performed through May to September/2020 and comprised demographics (sex, age, skin colour, body composition), amount of hair (head full of hair, mild alopecia, baldness), hair colour (same colour as always, some grey hairs and totally grey hair), systemic comorbidities (hypertension, heart disease, smoking, diabetes), COVID-19 status (never, suspected or confirmed) and severity outcomes (if treated at home, at hospital or at intensive care unit). Some known population prevalence diseases (psoriasis, atopic dermatitis and HIV) were assessed for quality control of the survey (extensive supplement). The project was approved by institutional review board (Unesp Medical School). The standard cut-off for severity in COVID is 60 years old. To provide a rational symmetric division based on this, the age parameters were divided into three categories: 0-30; 31-60 and over 60 years old. The severity of COVID-19 outcomes was assessed according to the main covariates using an ordinal logistic model. A total of 43,595 valid questionnaires (39,789 controls, 2332 suspected COVID-19 cases and 1474 confirmed COVID-19 cases) were analysed. The prevalence of alopecia and grey hair in participants with COVID-19 and controls according to sex and age is presented in Figure 1. The prevalence of both extensive grey hair and baldness was associated with age group (P < .01) in both sexes. Table 1 presents the main clinical and demographic data from the confirmed COVID-19 patients for each gender, according to the severity of the disease. We endorsed older age, hypertension, obesity, diabetes and heart disease as risk factors for more severe outcomes; in addition, both extensive grey hair and alopecia were independently associated with COVID-19 severity (P ≤ .05). The sensitivity analysis, which included the suspected cases, resulted in comparable results (extensive supplement—Table S1). The androgen receptor regulates the transcription of the transmembrane protease, serine 2 (TMPRSS2), which is required for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infectivity.3 In a population-based study, prostate cancer patients receiving androgen-deprivation therapies were partially protected from COVID-19.3 Thus, the dermatological signs of the hyperactivation of androgen receptors, such as AGA, could identify patients at a higher risk of worse outcomes. Actually, AGA is the leading cause of alopecia in adults, and must likely to account for most of cases that reported moderate and severe alopecia, in this survey.4 Grey hair and AGA were previously associated with an increased risk of cardiovascular disease, a known risk factor for worse prognosis for COVID-19.5, 6 Conversely, acute stress could lead to hair greying through the quick depletion of melanocyte stem cells.7 Furthermore, diffuse hair greying and telogen effluvium should be investigated as a consequence of COVID-19. The limitations of this study lie in the fact that participants were not examined by a dermatologist, the alopecia phenotypes were not discriminated (to facilitate the questionnaire completion) and the presence of telogen effluvium was not evaluated. However, the effect size of the associations, the confirmation of the same results through the analysis of COVID-19 participants awaiting confirmation, and the identification of other well-known risk factors for disease severity strengthen the reliability of these conclusions. Finally, the pandemic reinforced the need for international collaboration groups using harmonized data sets to facilitate the generation of results.8 In addition to reinforcing the association between alopecia and COVID-19 severity in a larger controlled study, we also identified grey hair as an independent risk factor. The authors have declared no conflicting interests. PMR: designed the research study, performed the research and wrote the paper. M.I: designed the research study, performed the research and wrote the paper. HAM: designed the research study, performed the research, analysed the data and wrote the paper. Data available on request from the authors. 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