Mild to moderate COVID-19 is not associated with worsening of alopecia areata: A retrospective analysis of 32 patients.

To the Editor: COVID-19 is a viral, SARS-CoV-2–induced disease associated with systemic immune activation. Patients with COVID-19 have been reported to have substantially higher plasma concentrations of proinflammatory cytokines such as interferon gamma, tumor necrosis factor, interleukin (IL) 6, IL-1β, IL-2, and IL-17A. This has raised concerns about the possible effect of COVID-19 on the course of alopecia areata. The aim of our study was to determine whether COVID-19 infection is associated with worsening disease in patients with pre-existing alopecia areata.

The study included 32 consecutive patients with alopecia areata. All the patients had confirmed, mild-to-moderate COVID-19. The patients' characteristics are presented in Table I and Supplemental Table I, available via Mendeley at https://doi.org/10.17632/8v3s224grh.1. In all the patients, the severity of alopecia tool (SALT) score was assessed during regular check-up visits 1-6 weeks before COVID-19 and 3 months after disease onset. In 5 patients, an additional evaluation was performed 6 months after the onset of COVID-19. A post-COVID-19 trichoscopy checkup was performed in 17 patients. The study was conducted according to the principles outlined in the Declaration of Helsinki. The patients were receiving the following treatment when COVID-19 developed: intralesional triamcinolone (12 patients), oral glucocorticosteroids (10 patients), cyclosporine (10 patients), methotrexate (6 patients), azathioprine (1 patient), and none (4 patients). Their dermatologic comorbidities were as follows: lichen planopilaris with oral lichen planus, pemphigus, and psoriasis. In 10 (31.3%) of the 32 patients, the treatment was discontinued for 7-28 days because of COVID-19.

Table I

Characteristics of 32 patients with alopecia areata and COVID-19

Characteristic	Data
Women/men, n (%)	20/12 (62.5%/37.5%)
Age in years, mean (range)	33.6 (14-59)
Patchy alopecia/AT and AU, n (%)	29/3 (90.6.5%/9.4.%)
SALT score before COVID-19,mean ± SD	40.8 ± 28.6
SALT score after COVID-19, mean ± SD	36.3 ± 27.3
Patients in whom treatment was discontinued during COVID-19, n (%)	10 (31.3%)
Time of treatment discontinuation during COVID-19 in days, mean (range)	11 (7-28)

AT, Alopecia totalis; AU, alopecia universalis; SALT, severity of alopecia tool.

The SALT scores were as follows: 40.8 ± 28.6 (mean ± SD) before COVID-19 and 36.3 ± 27.3 after COVID-19. The difference was not statistically significant. In trichoscopy, only 3 (17.6%) of 17 patients were found to have the features of disease activity (exclamation-mark hairs and black dots). Patient history reviews revealed that there were no unexpected changes in the extent of alopecia areata from the moment of acquiring the SARS-CoV-2 infection to the first dermatologic appointment after recovery. No deterioration was observed in patients who were evaluated 6 months after the onset of COVID-19. In our patients, COVID-19 was not associated with the worsening of the dermatologic comorbidities. However, mild-to-moderate diffuse hair loss developed in 10 patients, consistent with telogen effluvium (confirmed using a trichogram). Progression from patchy alopecia to alopecia totalis/universalis occurred in none of the patients. A limitation of the study was the small group of patients included in the analysis and the fact that majority of the patients were on active treatment, which might have suppressed an inflammatory response.

The literature presents conflicting data on the statistics regarding new-onset alopecia areata in the context of COVID-19. Cases of new-onset patchy alopecia areata and alopecia universalis developing in association with COVID-19 have been described. An increase in the incidence of alopecia areata during the pandemic was observed and was attributed to increased psychologic stress or the inflammatory storm associated with COVID-19. , The pandemic and the stress related to the pandemic may have caused an increase in the incidence of alopecia areata.

In this study, we evaluated the association between COVID-19 and the severity of pre-existing alopecia areata. Our analysis shows that mild-to-moderate COVID-19 is not associated with the worsening of the disease.

Conflicts of interest

Dr Rudnicka is a member of advisory boards in Eli Lilly, Janssen Pharmaceutical Companies, L'Oreal, Leo Pharma, Pfizer, Sanofi, Novartis, and UCB; a speaker for Abbvie, Eli Lilly, Leo Pharma, L'Oreal, and Pierre Fabre. Dr Olszewska is a speaker for Axxon, Leo Pharma, and medac. Dr Rakowska is a speaker for Pierre Fabre and Axon. Drs Waskiel-Burnat and Kurzeja have no conflicts of interest to declare.