Androgenetic alopecia in COVID-19: Compared to age-matched epidemiologic studies and hospital outcomes with or without the Gabrin sign
Authors: Carlos Gustavo Wambier, Sergio Vaño-Galván, John McCoy, Suraj Pai, Rachita Dhurat, Andy Goren
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: We greatly appreciate the various comments to our original article.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 We also would like to thank dermatologists worldwide who have contributed to the knowledge of COVID-19 and androgenetic alopecia (AGA). Attempts to compare data with other epidemiologic studies are interesting, but caution must be used and attention to detail is required. For example, Nanes2Nanes B. Androgenetic alopecia in COVID-19: compared to what?.J Am Acad Dermatol. 2020; https://doi.org/10.1016/j.jaad.2020.06.1031Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar attempted comparisons using the remote Hamilton scale without converting scores to the current Hamilton-Norwood scale (HNS). Nanes also attempted to compare studies that used scores from dermatologist examination with studies that used self-administered surveys as their methodology.2Nanes B. Androgenetic alopecia in COVID-19: compared to what?.J Am Acad Dermatol. 2020; https://doi.org/10.1016/j.jaad.2020.06.1031Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Refined comparative analyses were available in the Supplementary Materials of our original article (available via Mendeley at https://dx.doi.org/10.17632/jk63cthxbr.2), which included a disclaimer.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 We would like to motivate other groups to evaluate AGA in their populations, specifically comparing outcomes in COVID-19–positive individuals. For example, our Indian colleagues, in a pilot observational prospective study (raw data available via Mendeley at https://dx.doi.org/10.17632/jdkx76y8fz.1), examined outcomes in admitted patients with COVID-19 by AGA severity. In their cohort of 44 men admitted for severe COVID-19, all patients had clinically significant AGA. However, the most severe outcomes (respiratory failure requiring ventilators or fatal outcomes) happened when HNS was greater than 2. One patient was 45 years old and had no previous comorbidities; he required prolonged intensive care unit stay due to ventilator use and had an HNS score of 3v. Thus, in general terms, we prefer to classify patients with severe AGA (HNS score, 3-7) as having the Gabrin sign (Fig 1). This definition of the Gabrin sign is currently being used as an inclusion criterion in a randomized controlled clinical trial for early COVID-19 therapy (NCT04446429). A comparison of proportions by age range (50-69 y) and severity of HNS with the Norwood study3Norwood O.T. Male pattern baldness: classification and incidence.South Med J. 1975; 68: 1359-1365Crossref PubMed Scopus (673) Google Scholar shows an increase of relative proportions for an HNS score of 2 to 7 of 7%, HNS score of 3 to 7 of 26%, and HNS score of 4 to 7 of 33%. This gap becomes particularly obvious when comparing the frequencies of HNS scores of 4 to 7 in the age range of 55 to 69 years (Fig 2),4Severi G. Sinclair R. Hopper J.L. English D.R. Mccredie M.R.E. Androgenetic alopecia in men aged 40–69 years: prevalence and risk factors.Br J Dermatol. 2003; 149: 1207-1213Crossref PubMed Scopus (168) Google Scholar which is the age group that contains the median age of the 122 men hospitalized with COVID-19.1Wambier 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 Severe AGA in young men also confers increased vulnerability. To further exemplify this, we present in this reply letter one of our unpublished patients from Brazil: a previously healthy 37-year-old physician (HNS score of 5) (depicted in Fig 1) with no previous comorbidities; he required hospitalization for 21 days, which included 16 days in the intensive care unit (ventilator for 10 days and hemodialysis for 5 days). Because vaccines are still not available and the epidemic is affecting men disproportionately, particularly bald individuals, more emphasis could be given to investigations directed at antiandrogen therapies, which are routinely prescribed both for hair loss and benign prostatic hyperplasia as the standard of care (such as dutasteride and finasteride). Finally, severe AGA, (HNS score, 3-7)—the Gabrin sign—is an objective phenotype that reflects individual androgen sensitivity throughout decades of life. AGA is associated with individual vulnerability to severe acute respiratory syndrome coronavirus 2 infection through the androgen gateway.5Wambier C.G. Goren A. Vaño-Galván S. et al.Androgen sensitivity gateway to COVID-19 disease severity.Drug Dev Res. 2020; https://doi.org/10.1002/ddr.21688Crossref PubMed Scopus (116) Google Scholar It is remarkable that severe outcomes such as the requirement for a ventilator and/or fatalities have occurred in men with this phenotype without other known comorbidities at younger age groups, such as 35 to 45 years. Androgenetic alopecia in COVID-19: Compared to what?Journal of the American Academy of DermatologyVol. 83Issue 6PreviewTo the Editor: In a timely study certain to attract considerable attention, Wambier et al1 propose an association between androgenetic alopecia (AGA) and severe manifestations of coronavirus disease 2019 (COVID-19). In a cohort of patients hospitalized with COVID-19, they find AGA prevalence of 79% in men and 42% in women, citing other literature to argue these rates exceed expectation. Unfortunately, in the absence of additional clarification, the literature cited does not appear to support this claim. Full-Text PDF