COVOID-19 IMPACT

You're Not Imagining It: The Pandemic Is Triggering Stress-Induced Hair Loss

In the closing months of a year unlike any other, many dermatologists report an uptick in patients suffering from hair loss — a symptom they attribute to an unprecedented level of anxiety caused by the COVID-19 pandemic.
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She first noticed it back in June — about three months after her earliest COVID-19 symptoms set in. "I started seeing a lot of hair coming off in my hairbrush," says Courtney Dunlop, a long-time beauty editor and cofounder of Good Clean Wine in Springfield, Missouri. "Then it was like a dam had broken: I was pulling out handfuls in the shower. After, when I combed my hair, I felt like I was removing hair extensions. I could've put clips on the end and stuck the hair back in. These long strands were everywhere. I was vacuuming three times a day."

While Dunlop developed the classic signs of COVID-19 in March — the telltale cough, the lost sense of smell — and endured fever, fatigue, shortness of breath, and body aches in the subsequent weeks, she didn't get tested for the virus until early May. Her positive result was followed by a negative swab a few weeks later. But even now, nearly eight months post-infection, she continues to suffer the lingering effects of COVID-19 — hair loss among them.

Her story is hardly unique. Our DMs and social feeds are studded with eerily similar accounts (and more than a few hairball pics) from friends, colleagues, and even dermatologists — reminding us they aren’t immune to the very issues they're tasked with treating.

We recently watched as Anna Karp, a clinical assistant professor of dermatology at NYU School of Medicine, took to IGTV to talk about her own COVID-19 diagnosis and "scary" shedding. "I had a very mild case — only loss of smell and partial taste and some fatigue," she tells us. "The hair loss started in June and slowed down in August."

Another dermatologist pal, Nazanin Saedi, an associate professor of dermatology at Thomas Jefferson University in Philadelphia, messaged me in August about the unsettling amount of hair she's been losing. She didn't have COVID-19, however. It was the "stress and uncertainty" of the pandemic that triggered her shedding, she says, roughly three months after the world essentially stopped. "My pillow was covered in hair, my clothes, my bathroom — and it has not yet slowed."

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Board-certified New York City dermatologist Shereene Idriss (aka #pillowtalkderm) reliably updates her Instagram followers on the status of her own shedding, which was instigated by the birth of her second child and propelled by the turmoil of the pandemic. "It was kind of like a perfect storm," she says.

Given all the upheaval and injustice lobbed our way this year, mass hair loss seems utterly apropos of 2020. But what exactly is going on here?

Why Everyone Seems to Be Losing Their Hair Right Now

Over the summer, as dermatologists across the country were reopening their clinics, many began reporting a curious surge in patients seeking treatment for this sudden and dramatic thinning called telogen effluvium. "I didn't go an hour without seeing a hair loss patient," says Papri Sarkar, a board-certified dermatologist in Brookline, Massachusetts. "Everyone whom I've had any contact with throughout the pandemic has seen a huge, huge increase in hair loss" — including the many primary care physicians, allergists, and pediatricians who’ve reached out to her for consults on their telogen effluvium cases.

"This is a temporary hair loss from excessive shedding due to a shock to the system," Saedi explains. (Emphasis on temporary; telogen effluvium will not render you forever bald.) The jolt of postpartum or menopause — and the hormonal swings associated with these conditions — will commonly trigger telogen effluvium in women, according to Saedi. 

But the condition "does not discriminate," says Corey L. Hartman, an assistant clinical professor of dermatology at the University of Alabama School of Medicine. "It can be seen across races, ethnicities, skin types, and hair textures."

For some, the physical wallop of contracting an immune-rocking coronavirus is uprooting their strands; for others, it's the psychological trauma of the pandemic — be it the "social isolation and depression or the anxiety the comes from trying to balance work-from-home with home-schooling three kids," says Amelia Hausauer, a board-certified dermatologist in Campbell, California. "Those are two separate precipitants that can lead to the same pathway."

Indeed, Karp says her practice similarly "saw a huge uptick in the telogen effluvium type of hair loss like I had due to COVID-19 and/or the stress related to it."

Even mindless modifications to our everyday habits, like "dietary changes, [a sudden] lack of exercise, or cessation of enjoyable sources of relaxation, can cause enough stress to trigger telogen effluvium,” notes Hartman, explaining how our lockdown lifestyles may be influencing our follicles.

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Hair loss after illness among COVID-19 "long-haulers" — those who battle symptoms for months rather than the average two- to three-week span — "can be misinterpreted as an extension of the disease, because it typically manifests two to three months after the initial insult," he adds. 

But shedding is not so much a symptom of COVID-19 as it is a consequence of the viral attack and the overwhelming stress it puts on the body. "We don't have a lot of good evidence to suggest that COVID-19 has a specific mechanistic reason to cause hair loss other than through [physical] stress, as is the case with other diseases," Sarkar says.

The Stress-Shedding Connection

Precisely how does something like an unexpected furlough, a knockdown fever, or an abrupt upending of our routines translate to hundreds of hairs leaving our head every day?

When confronted with a major physical or emotional stressor, the body eventually responds by pushing more hairs than usual into the telogen, or resting, phase of the hair cycle, explains Joshua Zeichner, director of cosmetic and clinical research in dermatology at Mount Sinai Hospital in New York City. Over time, this signals them to stop growing and then, months later, fall out simultaneously.

To his point, Dunlop describes her virus-related shedding as "quick and disastrous, like a tornado," lasting only a few weeks, but leaving behind a thin mess — "sea hag hair," she calls it.

Still, she might consider herself lucky. "Once the stressor is mitigated, shedding can last three to six months based on a person’s hair cycle," notes Hausauer. The typical progression of telogen effluvium goes something like this: “You’ll have the onset of shedding weeks to months after the stressor. You’ll shed for three months or so. You'll notice the shedding slow, and then you'll start to get regrowth at that point — the hairs are now transitioning back into the anagen [or active growing] phase." Since hair growth is a very slow process, it can take up to a year for hair to get back to baseline.

"We don't understand why this shift [in the hair cycle] occurs, but it's likely because stress interferes with the follicles' ability to function optimally," adds Zeichner, "and the resting state doesn’t require the same amount of energy [as the growing phase]."

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Which makes sense when you recall the basics of the human fight-or-flight response. As Sarkar explains, in times of stress, the hormones cortisol and adrenaline activate our primal survival mechanism, sparking a chain of physiological reactions designed to help us deal with the impending threat. Blood flow to the skin and distal body parts is reduced and shunted more centrally to our muscles, brain, lungs, and heart. "Basically, your body is trying to preserve resources for vital organs and essential functions — and hair is considered an appendage, not a priority," says Hausauer.

Normally, she explains, "about 90 percent of our scalp is in the growth [anagen] phase and 10 percent is in the telogen phase, but when you get telogen effluvium, greater than 20 percent of hairs go into telogen, all at the same time." For many folks, it can be more like 50 percent swiftly switching to telogen and idling for a spell before absconding, in unison, weeks to months later.

According to Hartman, "research has established a direct correlation between cortisol and our hair follicles, with increased levels of cortisol causing degradation of integral skin substances, like hyaluronan and proteoglycan, that are essential for effective hair growth." In other words, cortisol not only contributes to the hair-cycle shift that spurs shedding, it also robs follicles of key sources of fuel.

While dermatologists say the bulk of what they've been seeing during the pandemic has been telogen effluvium, other types of hair loss are also rising. Alopecia areata.) is an autoimmune disease — whereby the cells in your immune system attack the hair follicles — that can be brought on or exacerbated by extreme anxiety. In those who are predisposed, notes Sarkar, initial bouts of hair loss and "sudden stark increases" in shedding tend to occur after periods of stress. "That's why we're seeing more of it right now," she adds.

Androgenetic alopecia, also known as male or female pattern hair loss, is also cropping up alongside telogen effluvium in certain patients. The genetic condition is "not influenced by stress and not thought to be affected by the pandemic," clarifies Hartman. "However, a person may exhibit signs of more than one type of alopecia, and telogen effluvium may uncover concomitant androgenetic alopecia that had previously gone unnoticed."

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Such was the case with Idriss: "I have a little bit of both — there's definitely an androgenetic component, as well; for me, it is familial."

Since these conditions are treated somewhat differently, it's important for dermatologists to look for unique symptoms of each in addition to running labs and taking a thorough patient history. Patterns of hair loss also provide clues. With telogen effluvium, there's a diffuse shedding, notes Hausauer, "with hair coming from all over." Thinning takes different shapes with other forms of hair loss — a widening center part in women hints at androgenetic alopecia; circular bald patches scream alopecia areata.

In any case, the "rapid shedding [of telogen effluvium] is alarming and can lead to temporary but significant hair thinning," says Zeichner. While it's totally normal to lose up to 150 strands a day, in cases of telogen effluvium, he notes, it can be double, even triple, the number of hairs you'd normally lose. "I deliberately tell my patients, Don't count [the hairs] that fall out. Don't bring in bags of hair," says Hausauer. 

That merely heightens anxiety, because there is no benefit to fixating on hair loss. Besides, to an untrained eye, it can be hard to distinguish a normal-size hairball from a more troublesome one. "If you see a big clump in the shower or in your hairbrush, I'm a little less worried about that than if you’re seeing hairs on your pillow [when you wake up], or on the counter and in your food when you're cooking," she adds. Anytime you apply tension to your hair — while shampooing or styling, say — some strands will naturally give way. Unprovoked shedding, however, may warrant a call to your dermatologist.

When and Why to See a Dermatologist for Hair Loss

Since telogen effluvium is a self-limiting condition — resolving on its own once the instigating event passes — doctors can usually reassure patients that their hair loss is normal and reversible, and send them on their way. "The hairs will grow back," says Caroline Chang, a board-certified dermatologist in East Greenwich, Rhode Island. Think about it: "If patients were losing 300 hairs a day, and the hairs weren’t growing back, they would essentially develop bald spots, which doesn’t happen [with this particular type of hair loss]."

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Zeichner co-signs: "Even with no treatment, the condition will correct itself over several months.” Which is why, under normal circumstances, telogen effluvium sufferers will often ride it out rather than spending time and money on regrowth solutions. But when the source of one's stress is an enduring global pandemic, the resultant shedding can feel equally neverending. 

For many patients, "the hair loss is not going away; it's not getting better," says Sarkar. In light of this fact, she adds, "I offer therapy earlier and they usually take it earlier. [There's] a much higher proportion of people jumping on doing something now versus waiting."

The Diagnosis

Treatment typically starts with what's known as a pull test. The doctor will firmly grasp a section of hair near the scalp and tug all the way down, repeating this around the head. "In the true telogen phase, the connection of the hair shaft to the scalp is very loose, and I'll get a bunch of hairs out — not just one or two but like six [per pull]," says Hausauer. 

When the strands dislodge, they have tiny bulbs attached to the roots. A preponderance of hairs with club-shaped bulbs — follicles shaped like the end of a golf club — indicates an abnormal number of hairs in the telogen phase, explains Sarkar. "Most hairs should be in the anagen phase and have plump, beautiful bulbs," she adds.

Your dermatologist will likely send you for bloodwork next. "We always check thyroid function when someone has hair loss," Sarkar says. "Abnormalities in thyroid hormone levels — in either direction, meaning too high or too low — can cause hair loss on their own. So, checking thyroid in hair loss is imperative — we won't solve hair loss without normalizing the thyroid hormone."

Moreover, thyroid disease can cause its own hair changes, making strands brittle or very fine and downy, so the combination of hypo- or hyperthyroidism along with telogen effluvium "can be a double whammy," Hausauer says. If she notices someone's levels are off, she'll refer them to an endocrinologist for further investigation and thyroid-specific treatment.

Doctors also parse lab results for deficiencies in nutrients "that play a role in building strong hair," says Hausauer, like vitamins D and B12 along with ferritin, "which is a marker of total body iron." Low levels in isolation may not spark telogen effluvium, but they "can leave you more vulnerable, so if hit with a stressor, you'll be more apt to experience shedding," she adds. Filling the nutritional gaps revealed by your bloodwork is vital to treatment — and sometimes supplements alone can be enough to jumpstart hair growth.

Topical Minoxidil

Rogaine (5 percent minoxidil) is another first-line fix for telogen effluvium. It "dilates blood vessels to encourage the optimal delivery of oxygen and nutrients to the hair follicles," Zeichner says. It's not without drawbacks though. Minoxidil can take months to show results. It can be irritating. And sometimes it worsens shedding before improving it.

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The drug "tries to get all of the hairs into the anagen phase — that's part of how it works — so some people, when they start using it for androgenetic alopecia, notice that at six weeks, they start shedding more than they were, because it's pushing out all of the hairs that were going to go into telogen so they can grow more robust anagen hairs," Hausauer explains. "In cases of telogen effluvium, this tends to be less of a concern, because those hairs are already being shed." 

Side effects aside, it is "helping to support the growth of more robust hairs at a faster rate" — and it's fairly easy and inexpensive — which is why she frequently recommends it.

Platelet-Rich Plasma (PRP) Scalp Injections

When people want to take treatment a step further, dermatologists introduce PRP — commonly referred to as "liquid gold" and equated with "fertilizer for follicles." During treatment, they draw blood from your arm and spin it down in a centrifuge to separate out the plasma, which is teeming with follicle-stimulating growth factors. The plasma is then reinjected into areas of thinning on the scalp. 

While there are "no clear studies to suggest it's a slam dunk" for telogen effluvium, says Hausauer, "we know that it decreases inflammation and increases blood flow to the hair follicle to help support a healthier environment in the scalp."

Because PRP costs thousands of dollars, requires several sessions, and isn't a promised panacea, it's not always a go-to for telogen effluvium, especially since hairs lost to the condition will eventually grow back on their own. 

Still, Hausauer says, "I have patients who feel like [PRP has] aborted some of their shedding." And in cases where androgenetic alopecia is also in play, “almost everyone gets some results — many very profound and dramatic.” (There's more data supporting PRP as a beneficial therapy for hormonal hair loss than telogen effluvium.)

With outcomes being iffy, Idriss suggests trying three monthly rounds of PRP and then pausing to see what, if anything, sprouts. She did three treatments throughout June and July and began to see regrowth around her hairline six weeks after her final session. "I didn't even notice a change until I posted a picture of myself in early September," she says.

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Success rates for PRP vary depending on your health and how the procedure is performed, she notes, "but I'd say if you are suffering from telogen effluvium and you do PRP you will more likely than not have a positive outcome, because it does help to speed up the [growth] process and make hair appear thicker, faster.”

Shampoos, Serums, and Synergistic Solutions

Since telogen effluvium is so distressing, doctors often take a multipronged approach to treating it. "I like to stack the deck with as many complementary treatments as possible to encourage new hair growth," Zeichner says. For him, that includes supplements, minoxidil, PRP, red light hair caps (which encourage blood flow to the scalp), and even shampoos and conditioners for thinning hair, such as the peptide-enriched Grande Hair System.

While some experts pooh-pooh the notion of short-contact products for hair growth, Saedi says KeraFactor, which contains a proprietary peptide complex, started regrowing her hair after about a month of use. "I've been very diligent about using the shampoo and the solution every day, and it’s made a difference — I'm shocked. My ponytail feels fuller and is shinier."

While Dunlop hasn't seen a dermatologist for her hair loss, she has tried a variety of supplements and topicals. She's also contemplating a new cut, knowing that her waist-length locks will otherwise take years to fully repopulate, roots to tips.

This sort of change can be beneficial in more ways than one, notes Hausauer. Whether it's getting a fresh chop, honing your coping mechanisms, or investing in scalp injections — "sometimes just doing something and taking control can make you feel better." And with a condition as emotionally charged as hair loss, a mood boost can be the best medicine.

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