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      Alopecia areata in a COVID‐19 patient: A case report


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          Dear Editor, In recent months, there have been reported several dermatologic manifestations in COVID‐19 patients such as erythematous rash, widespread urticarial, chickenpox‐like vesicles, acroischemia, chilblain‐like eruptions and petechial rash mimicking dengue. 1 , 2 In this study, we present a case of alopecia areata (AA) in a patient who tested positive for COVID‐19. Our purpose is to further characterize dermatologic manifestations of this disease. At the end of September, a 38‐year‐old healthy male patient presented to the dermatologic department because of sudden appearance of bald spots affecting the beard. The patient had been diagnosed with SARS‐CoV‐2 infection in August, a month before the appearance of the bald spots. He referred no other underlying diseases and denied taking any drugs during the last year, except for the paracetamol used as a symptomatic treatment for SARS‐CoV‐2 infection. No family history for AA and other autoimmune diseases was present. Physical examination revealed sharply demarcated bald patches on the beard. The patches were round, variously distributed on the beard area. The underlying skin was unscarred and looks superficially normal (Figure 1). FIGURE 1 Pictures showing round bold patches variously distributed on the beard area Our diagnosis was confirmed by trichoscopy showing yellow dots, black dots, broken hairs and short vellus hairs (Figure 2). FIGURE 2  Pictures showing trichoscopic findings of Alopecia Areata of the beard: black dots, yellow dots, broken hairs, vellus hairs Further examination including liver, kidney and thyroid functionality were within normal limits. Serologic tests were negative for HIV, HBV, HCV and parvovirus B19. Nasopharyngeal swab was negative for SARS‐CoV‐2 as well. After 2 weeks of treatment with a trichological lotion with nicotinic acid, resorcinol and hyaluronic acid , the patient presented with an important improvement of the old lesions and the appearance of new ones (Figure 3). FIGURE 3 Pictures showing an improvement of the old lesions and the appearance of new ones, after two weeks of treatment with a trichological lotion with nicotinic acid, resorcinol and hyaluronic acid Only few cases of AA in SARS‐CoV‐2‐infected patients have been reported in the literature. 3 The interplay among genetic factors (ie, HLA‐DR, CTLA4 and ULBP3) and environmental factors (ie, emotional/physical stress, hormones and infections) has been shown to play a key role in the AA etiology and progression. 4 , 5 Although the exact pathophysiology remains unknown, it seems to be related to an autoimmune reaction against the hair follicles. Supporting the autoimmune genesis of AA, several studies refer its association with other autoimmune diseases, such as type I diabetes and vitiligo. 4 We assume that SARS‐CoV‐2 could be an additional risk factor in the pathogenesis of AA. Referring to this, viral infection seems to be involved in autoimmune pathogenesis by two mechanisms: According to bystander theory, the presence of pathogens increases the release of costimulatory signals allowing the dendritic cells to present antigens more effectively, both pathogen and self‐antigens. If this occurs in genetically predisposed individuals, the activation of self‐reactive T lymphocytes could develop and progress (Figure 4). FIGURE 4 Possible role of SARS‐CoV‐2 in the pathogenesis of Alopecia Areata As stated in the molecular mimicry theory, the virus could have antigens which cross‐react with self‐antigens, so that the immune response turns against host tissues. 6 Moreover, considering the significant impact of COVID‐19 pandemic on mental health, psychological stress appears to be another possible risk factor of AA. 5 , 7 SARS‐CoV‐2 could act as a trigger in different autoimmune pathways, by creating an inflammatory environment which allows the nonspecific activation of the immune system or by a cross‐reaction between its antigens and host antigens. In both cases, antigens expressed at the level of the follicles are recognized and attacked by the immune system. Apart from the psychological effect, we believe that SARS‐CoV‐2 has an important role in the onset of AA. As we do not know the long‐term effects of SARS‐CoV‐2 infection, we will make periodical follow‐ups on our patient. These observations represent a further confirmation of AA as a multifactorial disease, but further studies are needed to confirm the relation between AA and COVID‐19. CONFLICT OF INTEREST The authors declare no potential conflict of interest. AUTHOR CONTRIBUTIONS Severino Persechino conceived the research idea. Alessandro Capalbo, Charalampos Georgios Balampanos and Federica Orrù wrote the paper. Domenico Giordano, Nazareno Gagliostro and Flavia Persechino collected the data.

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          Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis

          Background The COVID-19 pandemic has had a significant impact on public mental health. Therefore, monitoring and oversight of the population mental health during crises such as a panedmic is an immediate priority. The aim of this study is to analyze the existing research works and findings in relation to the prevalence of stress, anxiety and depression in the general population during the COVID-19 pandemic. Method In this systematic review and meta-analysis, articles that have focused on stress and anxiety prevalence among the general population during the COVID-19 pandemic were searched in the Science Direct, Embase, Scopus, PubMed, Web of Science (ISI) and Google Scholar databases, without a lower time limit and until May 2020. In order to perform a meta-analysis of the collected studies, the random effects model was used, and the heterogeneity of studies was investigated using the I2 index. Moreover. data analysis was conducted using the Comprehensive Meta-Analysis (CMA) software. Results The prevalence of stress in 5 studies with a total sample size of 9074 is obtained as 29.6% (95% confidence limit: 24.3–35.4), the prevalence of anxiety in 17 studies with a sample size of 63,439 as 31.9% (95% confidence interval: 27.5–36.7), and the prevalence of depression in 14 studies with a sample size of 44,531 people as 33.7% (95% confidence interval: 27.5–40.6). Conclusion COVID-19 not only causes physical health concerns but also results in a number of psychological disorders. The spread of the new coronavirus can impact the mental health of people in different communities. Thus, it is essential to preserve the mental health of individuals and to develop psychological interventions that can improve the mental health of vulnerable groups during the COVID-19 pandemic.
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            Cutaneous manifestations in COVID-19: a first perspective

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              Cutaneous signs in COVID ‐19 patients: A review

              Abstract Coronavirus disease (COVID‐19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) primarily affects the epithelium of the airways. With the increasing involvement of dermatologist in management of this crisis, cutaneous symptoms gained more and more attention. In this review, we will describe cutaneous symptoms of patients of all ages in association with COVID‐19. We will focus on such disorders that are caused by direct action of SARS‐CoV‐2 on tissues, complement, and coagulation system and on nonspecific eruption of the systemic viral infection. Drug‐induced reactions are only mentioned in the differential diagnoses. Although more systematic investigations are warranted, it becomes clear that some symptoms are clinical signs of a milder COVID‐19 course, while others are a red flag for a more severe course. Knowledge of the cutaneous manifestations of COVID‐19 may help in early diagnosis, triage of patients, and risk stratification.

                Author and article information

                Dermatol Ther
                Dermatol Ther
                Dermatologic Therapy
                John Wiley & Sons, Inc. (Hoboken, USA )
                12 January 2021
                [ 1 ] NESMOS Department, Dermatology Unit, Sant' Andrea Hospital Faculty of Medicine and Psychology Roma Sapienza University of Rome Rome Italy
                [ 2 ] Department of Clinical and Molecular Medicine Sapienza University of Rome Rome Italy
                [ 3 ] Sant' Andrea Hospital Faculty of Medicine and Psychology Roma Sapienza University of Rome Rome Italy
                Author notes
                [*] [* ] Correspondence

                Prof. Severino Persechino, NESMOS Department, Dermatology Unit, Sant' Andrea Hospital Faculty of Medicine and Psychology Roma, Sapienza University of Rome, Rome, Italy.

                Email: severino.persechino@ 123456uniroma1.it

                © 2020 Wiley Periodicals LLC.

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

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                Figures: 4, Tables: 0, Pages: 2, Words: 1078
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