Male balding is a major risk factor for severe COVID-19
Authors: Justin Lee, Ahmed Yousaf, Wei Fang, Michael S. Kolodney
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: Recent observations by Wambier et al1Wambier C.G. Vaño-Galván S. McCoy J. et al.Androgenetic alopecia present in the majority of hospitalized COVID-19 patients—the "Gabrin sign".J Am Acad Dermatol. 2020; 83: 680-682Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar suggest that men with pattern baldness are at high risk for severe symptomatic COVID-19 infection. Two preliminary studies1Wambier C.G. Vaño-Galván S. McCoy J. et al.Androgenetic alopecia present in the majority of hospitalized COVID-19 patients—the "Gabrin sign".J Am Acad Dermatol. 2020; 83: 680-682Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar,2Goren A. Vaño-Galván S. Wambier C.G. et al.A preliminary observation: male pattern hair loss among hospitalized COVID-19 patients in Spain—a potential clue to the role of androgens in COVID-19 severity.J Cosmet Dermatol. 2020; 19: 1545-1547Crossref PubMed Scopus (149) Google Scholar noted high rates of androgenic alopecia in men hospitalized for severe COVID-19. Both of these uncontrolled observational studies were limited by small sample size. To further evaluate this intriguing observation, we examined severity of hair loss in 1941 hospitalized male patients tested for COVID-19 using data from the UK Biobank. We conducted multivariable logistic regression analysis, where the outcome was a positive COVID-19 test result, and the main variable of interest was severity of balding. Other variables accounted for were age, body mass index (BMI), hypertension, dyslipidemia, and diabetes. From 2006 to 2010, the UK Biobank recruited approximately 500,000 individuals from the United Kingdom and collected detailed information about their medical history. Informed consent was obtained from all participants registered with the UK Biobank. Data were regularly updated, and the most recent data from 2019 were used for all covariates analyzed in our study. During the original intake, 226,938 men chose from 1 of 4 options that best characterized their hair loss using images adapted from the Hamilton-Norwood scale.3Norwood O.T. Male pattern baldness: classification and incidence.South Med J. 1975; 68: 1359-1365Crossref PubMed Scopus (673) Google Scholar Options included the following text: pattern 1, no hair loss; pattern 2, slight hair loss; pattern 3, moderate hair loss; and pattern 4, severe hair loss.4UK BiobankResource 100423: screenshot from touchscreen questionnaire used to capture field 2395. UK Biobank, 2007http://biobank.ndph.ox.ac.uk/showcase/refer.cgi?id=100423Date accessed: April 20, 2020Google Scholar COVID-19 testing was carried out on symptomatic patients per National Health Service guidelines.5National Health ServiceCoronavirus staff guidance: inpatient testing protocol.2020https://www.uhb.nhs.uk/coronavirus-staff/inpatient-testing-protocol.htmDate accessed: June 22, 2020Google Scholar Descriptive frequencies for COVID-19 results, balding patterns, age, and BMI are reported in Table I. The cohort included 1605 patients who tested negative for COVID-19 and 336 patients who tested positive. Mean age and BMI were similar between the 2 groups. As shown in Table I, COVID-19 positivity trended higher with increasing baldness. Of the 592 patients reporting pattern 1, 15.03% tested positive. Of the 404 patients reporting pattern 2, 16.83% tested positive. Of the 551 patients reporting pattern 3, 18.15% tested positive. Of the 394 patients reporting pattern 4, 20.05% tested positive.Table IDescriptive frequencies for COVID-19 testing results, balding patterns, age, and BMIVariableCOVID-19 (−) test resultCOVID-19 (+) test resultTotal, n1605336Pattern 1, n (%)503 (84.97)89 (15.03)Pattern 2, n (%)336 (83.17)68 (16.83)Pattern 3, n (%)451 (81.85)100 (18.15)Pattern 4, n (%)315 (79.95)79 (20.05)Age, y, mean59.1359.03BMI, kg/m2, mean28.6729.11BMI, Body mass index. Open table in a new tab BMI, Body mass index. Odds ratios and corresponding confidence intervals for balding patterns are shown in Table II. When compared to pattern 1, patients who reported pattern 4 were significantly more likely to test positive for COVID-19 in the hospital (adjusted odds ratio, 1.408; 95% confidence interval, 1.004-1.972; P = .0468). Neither patterns 2 nor 3 reached significance from pattern 1 in rates of positive COVID-19 test results. None of the covariates were associated with a positive COVID-19 test result.Table IIOdds ratios and confidence intervals for balding patterns and covariates from a multivariable logistic regression analysis where the outcome is a positive COVID-19 test result∗All statistical analyses were performed with SAS 9.4 (SAS Institute, Cary NC).EffectOdds Ratio (95% CI)P valuePattern 2 vs 11.144 (0.808-1.613).4454Pattern 3 vs 11.271 (0.928-1.744).1362Pattern 4 vs 11.408 (1.004-1.972).0468Age0.995 (0.979-1.011).5179BMI1.014 (0.987-1.041).3062Hypertension vs no hypertension0.941 (0.714-1.246).6679Dyslipidemia vs no dyslipidemia1.240 (0.960-1.602).0993Diabetes vs no diabetes1.041 (0.721-1.482).8273BMI, Body mass index; CI, confidence interval.∗ All statistical analyses were performed with SAS 9.4 (SAS Institute, Cary NC). Open table in a new tab BMI, Body mass index; CI, confidence interval. Our study compared a large sample of hospitalized COVID-19–positive patients to a control group of hospitalized COVID-19–negative patients and thus builds on and supports the observations of Wambier et al.1Wambier C.G. Vaño-Galván S. McCoy J. et al.Androgenetic alopecia present in the majority of hospitalized COVID-19 patients—the "Gabrin sign".J Am Acad Dermatol. 2020; 83: 680-682Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar A notable limitation of our work is that balding data were self-reported. Although the exact mechanism remains unknown, severe androgenic alopecia seems to be associated with hospitalization for COVID-19. The large effect of baldness on the risk of COVID-19 suggests that the presence of severe baldness may help clinicians and public health authorities identify and protect those at greatest risk. Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: The "Gabrin sign"Journal of the American Academy of DermatologyVol. 83Issue 2PreviewTo the Editor: Dr Frank Gabrin was the first American physician to die of severe acute respiratory syndrome coronavirus (SARS-CoV)-2 infection. Dr Gabrin suffered from androgenetic alopecia and was a long-term survivor of bilateral testicular cancer.1 The association between SARS-CoV-2 infectiveness and the androgen pathway has been previously described.2 Androgen-mediated SARS-CoV-2 vulnerability may help explain the disproportioned mortality rate among men.3 We present further epidemiologic evidence that androgen sensitivity might be associated with severe symptoms leading to hospitalization due to COVID-19. Full-Text PDF CorrectionJournal of the American Academy of DermatologyVol. 85Issue 3PreviewLee J, Yousaf A, Fang W, Kolodney MS. Male balding is a major risk factor for severe COVID-19. J Am Acad Dermatol. 2020;83(5):e353-e354. Full-Text PDF A response to "Male balding is a major risk factor for severe COVID-19"Journal of the American Academy of DermatologyVol. 84Issue 2PreviewTo the Editor: We read with great interest Male Balding is a Major Risk Factor for Severe COVID-19 by Lee et al1 regarding androgenic alopecia as a risk factor for COVID-19 severe symptomatology. A recent study by Wambier et al2 observed similar findings regarding androgenic alopecia and COVID-19. Yet, the relationship between scalp health, androgenic alopecia, and COVID-19 has not been explored. We examined the current, yet limited, literature regarding the role of the scalp in preventing transmission of COVID-19. Full-Text PDF Male balding as a major risk factor for severe COVID-19: A possible role for targeting androgens and transmembrane protease serine 2 to protect vulnerable individualsJournal of the American Academy of DermatologyVol. 83Issue 6PreviewTo the Editor: We would like to praise Lee et al1 for extra data to support the role of androgens in the COVID-19 pandemic. Lee et al showed increased positivity for COVID-19 among individuals previously self-identified as having pattern 4 baldness. Pattern 4 (frontal plus vertex) baldness could be interpreted as very severe baldness or Hamilton-Norwood scale score of 4 to 7.2 They further showed in multivariate logistic regression that very severe baldness had a higher odds ratio for COVID-19 positivity than hypertension, dyslipidemia, diabetes, obesity per body mass index, or age. Full-Text PDF