Introduction

Alopecia areata, an autoimmune-mediated disorder characterized by the disruption of hair follicle immune privilege, manifests as localized patches of no scarring hair loss. However, in its most severe manifestations, the condition can involve to alopecia totalis (AT), characterized by complete alopecia of the scalp, or alopecia universalis (AU), entailing the absence of hair across the entirety of the body [1].

Characterized by complete hair loss across the entire body, AU represents a severe manifestation of alopecia areata (AA), a T-cell-mediated autoimmune disorder that targets hair follicles [2]. AA exhibits a well-established association with various viral infections and diseases. Numerous investigations have looked into the complex connection between AA and viral pathogens, revealing that coronavirus disease 2019 (COVID-19) can trigger the onset, exacerbation, or recurrence of AA in individuals with a history of COVID-19 infection [3].

This study presents the case of a 44-year-old female with a medical history of well-controlled hypothyroidism (20 years on levothyroxine) who presented with rapidly progressive AU within 2 weeks of the COVID-19 vaccine.

This study investigated severe-onset AU and AA as potential side effects of COVID-19 vaccines with a focus on the timeline of these conditions and their clinical presentation through a literature review.

Case Presentation

We encountered a 44-year-old female with a medical history of well-controlled hypothyroidism (20 years on levothyroxine). Otherwise, she had no past medical or family history of AA or other autoimmune or dermatologic diseases. Upon initial exposure to the COVID-19 vaccine (AstraZeneca) in March 2021, the patient exhibited minimal adverse reactions. Subsequent administration of the COVID-19 vaccine in July 2021 utilized the Pfizer formulation, which was also tolerated without significant sequelae. She was doing well until 3-4 days later, when she started to have sudden, rapidly progressive hair loss resulting in complete alopecia within 2 weeks, as shown in (Figure 1-3).

Figure 2: Occipital view of scalp.

Figure 3: Alopecia.

She sought medical affinition at our institute in March 2022. Physical examination showed a 44year-old fair and overweight lady with complete alopecia over the scalp, face (including eyebrows and eyelashes), and the rest of the body. Nails were normal with no paging. She was diagnosed clinically with AU. She scored 100% on the Severity of Alopecia Tool (SALT), which is very severe.

We discussed treatment options with her and decided to start methotrexate and mini-pulse dexamethasone, stating that if no improvement were seen in 3 months, we would consider switching to to facitinib. A comprehensive medical evaluation was conducted, encompassing a thorough hematological assessment via complete blood count, an evaluation of hepatic function through liver function tests, a renal profile to assess kidney function, a lipid profile to evaluate blood fat levels, fasting blood sugar determination to assess glycemic control, HbA1c testing to gauge long-term glycemic control, QuantiFERON-TB Gold testing for latent tuberculosis infection, a chest X-ray, and serological testing

We started with 0.1 mg/kg dexamethasone (11 mg) on two consecutive days weekly and 7.5 mg methotrexate weekly. Her scalp hair started to regrow within 1 month, and she was tolerating the medication with minimal gastritis that improved with lifestyle modifications. One year later, the patient was very satisfied, as there was complete regrowth of the scalp, eyebrows, eyelashes, and body hair, as shown in (Figure 4).

Figure 4: Complete hair growth of scalp, eyebrows, eyelashes and body hair.

Since starting therapy, we managed to taper dexamethasone and increase the dose of methotrexate gradually to maintain efficacy and minimize side effects.

Currently, she is on 0.04 mg/kg dexamethasone, 12.5 mg methotrexate, and folic acid 5 mg weekly with complete hair growth. We plan to taper off dexamethasone completely and continue on methotrexate and folic acid. If the patient maintains an optimal response for 2 months, we plan to taper off methotrexate gradually and monitor her response. If the patient starts losing efficacy with tapering, we will consider showing the patient to JAK inhibitors (Table 1).

Table 1: Demographics, medical history, SARS-CoV-2 vaccine administra8on, approximate 8meframe between receiving vaccine and experiencing hair loss treatment.