Reply to comment on: The Gabrin sign.

To the Editor: We thank Trüeb et al for their compassion for Dr Gabrin. We share their thoughts about the COVID-19 androgen theory. Because of the COVID-19 worldwide crisis, it is imperative to identify COVID-19 patients at increased risk for mortality and disease severity. Although several risk factors such as obesity, cardiovascular disease, and diabetes have been initially associated with increased COVID-19 disease burden, with the exception of obesity and aging, no other visual marker existed. Over the last 6 months, it has become evident that males and individuals with baldness are more vulnerable.

Goren et al were the first to hypothesize that androgens and androgenetic alopecia (AGA) could be associated with COVID-19 disease severity; however, other independent groups have arrived at similar conclusions. The frequency of men taking 5-α reductase inhibitors (5ARi) among hospitalized COVID-19 patients was significantly lower than the frequency of men taking 5ARi in the age-matched population, which is in agreement with the previous observation that the use of androgen depravation therapy was associated with reduced infectivity among prostate cancer patients. In fact, uro-oncologists worldwide are conducting studies on the use of androgen deprivation therapy for COVID-19. For example, the United States Department of Veterans Affairs is conducting a multicenter study on the use of degarelix in hospitalized COVID-19 patients (NCT04397718), and Umean University in Sweden is evaluating enzalutamide as a treatment for hospitalized COVID-19 patients (NCT04475601). We expect results of a randomized, placebo-controlled clinical trial to evaluate the effects of dutasteride or proxalutamide as Early Antiandrogen Therapy (EAT) for COVID-19 soon (NCT04446429).

Pertaining to AGA, Lee et al examined hair loss severity in 1,941 hospitalized COVID-19 patients. And Ramos et al conducted a controlled cross-sectional survey with 43,595 valid questionnaires (39,789 controls, 2,332 suspected COVID-19 cases, and 1,474 confirmed COVID-19 cases). Their findings supported the association between severe AGA and vulnerability to COVID-19.

The protective role of antiandrogens is supported by the results of a prospective cohort of 77 hospitalized men that showed that antiandrogens, particularly dutasteride, may protect against COVID-19–associated intensive care unit admissions, as well as significant reduction in COVID-19 symptoms among men with AGA undergoing long-term 5aRi therapy compared with age-matched controls. Undoubtably results of randomized clinical trials of EAT for COVID-19 are needed; however, as many medical professionals are oblivious to AGA in medical emergency settings, it is essential to share that hyperandrogenic individuals exhibit visual markers for significant COVID-19 disease burden.

Finally, we honored Dr Gabrin with the medical eponym to remind the medical community of the vulnerability imposed by androgens. Many merits include his extreme humanistic approach to care, which he communicated in online videos and the article Discovering the Heart of Care. He will be remembered as the first physician to fall in this fight against the COVID-19 pandemic in the United States. He is a martyr for his tragic death caused by providing care and for his will to help others in the front-line of the heart of the world's pandemic.

Conflicts of interest

None disclosed.