Androgenetic alopecia in COVID-19: Compared to age-matched epidemiologic studies and hospital outcomes with or without the Gabrin sign

The clinical and immunological features of alopecia areata following SARS-CoV-2 infection or COVID-19 vaccines

INTRODUCTION

Alopecia areata (AA) is an autoimmune disease induced by viral infection or vaccination. With the increased incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the incidence of AA has also increased. Recently the incidence was found to be 7.8% from a previously reported rate of 2.1%. The physical and psychological damage caused by AA could seriously affect patients' lives, while AA is a challenging dermatological disease owing to its complex pathogenesis.

AREAS COVERED

This paper presents a comprehensive review of the prevalence, pathogenesis and potential therapeutic targets for AA after infection with SARS-CoV-2 or SARS-CoV-2 vaccine.

EXPERT OPINION

The treatment of AA remains challenging because of the complexity of its pathogenesis. For patients with AA after SARS-CoV-2 infection or vaccination, the use of sex hormones and alternative regenerative therapies may be actively considered in addition to conventional treatments. For preexisting disease, therapeutic agents should be adjusted to the patient's specific condition.

Efficacy and safety of proxalutamide (GT0918) in severe or critically ill patients with COVID-19: study protocol for a prospective, open-label, single-arm, single-center exploratory trial

BACKGROUND

The rapid worldwide spread of COVID-19 has caused a global health challenge with high mortality of severe or critically ill patients with COVID-19. To date, there is no specific efficient therapeutics for severe or critically ill patients with COVID-19. It has been reported that androgen is related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Proxalutamide as an androgen receptor antagonist has shown potential treatment effects on COVID-19 patients. Thus, this trial is designed to investigate the efficacy and safety of proxalutamide in severe or critically ill patients with COVID-19.

METHODS

This single-arm, open-label, single-center prospective exploratory trial is planned to recruit 64 severe or critically ill patients with COVID-19 in China. Recruitment started on 16 May 2022 and is foreseen to end on 16 May 2023. Patients will be followed-up until 60 days or death, whichever comes first. The primary outcome is the 30-day all-cause mortality. Secondary endpoints included 60-day all-cause mortality, rate of clinical deterioration within 30 days after administration, time to sustain clinical recovery (determined using an 8-point ordinal scale), mean change in the Acute Physiology and Chronic Health Evaluation II scores, change in oxygenation index, changes in chest CT scan, percentage of patients confirmed negative for SARS-CoV-2 by nasopharyngeal swab, change in Ct values of SARS-CoV-2 and safety. Visits will be performed on days 1 (baseline), 15 or 30, 22, and 60.

DISCUSSION

The trial is the first to investigate the efficacy and safety of proxalutamide in severe or critically ill patients with COVID-19. The findings of this study might lead to the development of better treatment for COVID-19 and provide convincing evidence regarding the efficacy and safety of proxalutamide.

TRIAL REGISTRATION

This study was registered on 18 June 2022 at the Chinese Clinical Trial Registry (ChiCTR2200061250).

Androgen receptor, a possible anti-infective therapy target and a potent immune respondent in SARS-CoV-2 spike binding: a computational approach

BACKGROUND

Although androgen in gender disparity of COVID-19 has been implied, no direct link has been provided.

RESEARCH DESIGN AND METHODS

Here, we applied AlphaFold multimer, network and single cells database analyses to highlight specificity of Androgen receptor (AR) against spike receptor binding protein (RBD) of SARS-CoV-2.

RESULTS

LXXL motifs in spike RBD are essential for AR binding. RBD LXXA mutation complex with the AR depicting slightly reduced binding energy, as LXXLL motif usually mediates nuclear receptor binding to coregulators. Moreover, AR preferred to bind a LYRL motif in specificity and interaction interface, and showed reduced affinity against Omicron compared to other variants (alpha, beta, gamma, and delta). Importantly, RBD LYRL motif is a conserved antigenic epitope (9 residues) for T-cell response. Network analysis of AR-related genes against COVID-19 database showed T-cell signaling regulation, and CD8+ T-cell spatial location in AR+ single cells, which is consistent with the AR binding motif LYRL in epitope function.

CONCLUSIONS

We provided the potent mechanisms of AR binding to RBD linking to immune response and vaccination shift. AR could be an anti-infective therapy target for anti-Omicron new lineages.

Associations between sampling characteristics, nutritional supplemental taking and the SARS-CoV-2 infection onset in a cohort of Italian nurses

Background: The aim of the present study was to analyze any relations existed between sampling characteristics and the onset of the SARS-CoV-2 infection, also by considering the number of times that it occurred in a cohort of Italian nurses interviewed. Additionally, by considering the nutritional supplemental taking, this research wanted to assess any differences both in the onset and in the number of times which the infection occurred among participants. Method: An observational cohort study was carried out thorough all Italian nurses by advertising the questionnaire through some professional internet pages. Results: Work typology (p=0.021), ward Covid-19 (p=0.002) and regular meal assumption (p=0.019) significantly associated to the onset of the SARS-CoV-2 infection. Most of nurses who contracted the SARS-CoV-2 infection worked during the night shift (53.7%), 44.3% worked in a no-Covid-19 ward and 53% declared to have a regular meals’ assumption. Ward typology significantly associated to the times of the SARS-CoV-2 onset (p=0.003), as most of nurses who contracted almost one time the SARS-CoV-2 infection were employed in a no-Covid-19 ward (55.5%) and 54.1% of them declared to have a regular meals’ assumption. The onset of the Sars-CoV-2 infection seemed to be more present in the most part of the sample collect. Conclusion: The present study could be considered as pilot in this sense and also more studies will be performed in order to better relate the function of supplemental food intakes with a better functioning of the immune system.

Association of androgenetic alopecia with a more severe form of COVID-19 infection

BACKGROUND

Individual susceptibility to develop acute respiratory distress syndrome is related to age and most frequent comorbidities. So far, it is known that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily infects the type II pneumocytes in humans, with the help of transmembrane serine protease type 2 (TMPRSS2). Up to now, the only known transcriptional promoters of genes coding TMPRSS2 are androgenic. Theoretically, the elevated level of androgens or androgen receptors would lead to a higher expression of TMPRSS2 and a higher level of viremia as a consequence.

AIM

The aim of our research was to indirectly investigate if the severity of SARS-CoV-2 infection is dependent on the expression of androgen receptors.

METHODS

This observational study analysed male patients hospitalized for SARS-CoV-2 infection with respect to the length of hospitalisation, the outcome of the disease, the type of necessary oxygen support and the presence of comorbidities and hairiness. In hairiness estimation, we used an adapted version of the Hamilton-Norwood scale and the presence of the Gabrin sign.

RESULTS

In total, 208 patients were enrolled in the study. There were statistically significant differences comparing the average age of patients with the different types of alopecia when groups were divided according to the presence of the Gabrin sign (t = 4.958, p > 0.01). The outcomes and the type of needed minimal oxygen support, compared with the type of alopecia in the case of Gabrin + / - classification showed a statistically significant difference in the outcome of the disease (p = 0.027). There were no statistically significant differences in the distribution of comorbidities among alopecia groups, but hypertension was related to poor COVID-19 prognosis.

CONCLUSION

Our findings suggest that the Gabrin sign and hypertension are related to a poor COVID-19 prognosis.

The prognostic value of androgenetic alopecia and benign prostatic hyperplasia in men with COVID-19: a prospective multidisciplinaryobservational study of 766 patients from Turkey

Objectives: We aimed to investigate the prognostic value of androgenetic alopecia (AGA) and benign prostatic hyperplasia (BPH) in COVID-19. Material and Method: This prospective study was conducted only on men with COVID-19. All patients were recruited consecutively from the COVID-19 emergency service. 766 patients were evaluated in three independent groups between the ages of 30-49 (young), 50-64 (middle-aged), and 65-75 (elderly) to avoid Simson’s paradox. Age, body mass index, smoking, comorbidities, vital signs, oxygen saturation (SpO2%), laboratory (CRP, lymphocyte count, ferritin, d-dimer) and computed tomography (CT) results, hospitalization (primary endpoint), transfer to intensive care unit (ICU), AGA stage (Hamilton-Norwood scale, 3-7=moderate-severe AGA, Gabrin sign) and BPH were recorded. Results: There was no relationship with AGA in any prognostic parameter in the young age group. There was a significant difference in the poor prognostic direction in patients with Gabrin sign, in SpO2 and lymphocyte count for middle-aged, and CRP for the elderly (p=0.141, p=0.013, p=0.029; respectively). The frequencies of transfer to the ICU were higher with no statistical significance in patients with the Gabrin sign. The mortality was more common with no statistical significance in elderly patients with the Gabrin sign. Hospitalization frequencies were significantly higher in patients with BPH in middle-aged and elderly patients (p=0.041, p=0.026; respectively). No relationship was found between transfer to ICU, mortality, and BPH. Conclusions: AGA was not a prognostic indicator, though the increase in hospitalization frequency, particularly in elderly patients with BPH, may be associated with the androgen-mediated COVID-19 severity hypothesis.

Preliminary Investigation on Micro-Needling with Low-Level LED Therapy and Growth Factors in Hair Loss Related to COVID-19

The incidence of hair loss (HL) and telogen effluvium (TE) has increased due to the spread of the coronavirus disease (COVID-19) induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). New biotechnologies based on micro-needling (MND) with Low-Level LED Therapy (LLLT) and Growth Factors (GFs) used for hair re-growth (HR-G) in Androgenetic Alopecia (AGA) need to be standardized also in HL and TE related to COVID-19. This article aims to describe the preliminary clinical results obtained from an open-label case-series observational study. MND with LLLT and GFs was used in patients affected by HL and TE-related to COVID-19. In total, 10 patients (6 men were identified in stage I–III vertex according to the Norwood–Hamilton scale, and 4 women were identified in stage I–II according to the Ludwig scale) were enrolled and analyzed after screening (exclusion and inclusion criteria evaluation). HR-G assessment was analyzed through photography, physician’s and patient’s global assessment scale, and standardized phototrichograms during a short follow-up: T0—baseline; T1—20 weeks (wks). In the targeted area computerized trichograms showed encouraging results with a hair density increase of 11 ± 2 hairs/cm2 at T1 after 20 wks (20 wks vs. 0 wks) compared with baseline (58 ± 2 hairs/cm2 at T1 versus 47 ± 2 hairs/cm2 at baseline) with a not quite statistically significant difference in HR-G (p = 0.0690). The preliminary effectiveness of MND with LLLT and GFs use has been demonstrated in mild-to-moderate HL and TE related to COVID-19. Further controlled trials are required to confirm these preliminary results.

Hair Loss and Telogen Effluvium Related to COVID-19: The Potential Implication of Adipose-Derived Mesenchymal Stem Cells and Platelet-Rich Plasma as Regenerative Strategies

The diffusion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) inducing coronavirus disease 2019 (COVID-19) has increased the incidence of several dermatological disorders, including hair loss (HL). This article aims to review the literature regarding the incidence of HL and telogen effluvium (TE) in COVID-19 patients and critically appraise the available evidence regarding the role of regenerative strategies like Platelet-Rich Plasma (PRP) and Human Follicle Stem Cells (HFSCs). A literature review regarding the correlation of HL and TE in COVID-19 patients analyzing the biomolecular pathway involved and the role of regenerative strategies was performed using PubMed, MEDLINE, Embase, PreMEDLINE, Scopus, and the Cochrane databases. Observational studies revealed an escalated incidence of pattern HL and TE in COVID-19 patients. Psychological stress, systemic inflammation, and oxidative stress are potential culprits. Proinflammatory cytokines and stress hormones negatively affect the normal metabolism of proteoglycans. Reduced anagenic expression of proteoglycans is a potential mediating mechanism that connects HL to COVID-19. Currently, only one study has been published on PRP against HL in COVID-19 patients. Further controlled trials are required to confirm PRP and HFSCs efficacy in COVID-19 patients.

Association of androgenetic alopecia and severity of coronavirus disease 2019

OBJECTIVE

To establish the association of androgenetic alopecia (AGA) and the severity of coronavirus disease 2019 (COVID-19).

DESIGN

Observational study.

METHODOLOGY

A total of 300 hospitalized patients of COVID-19 were included. Scoring of AGA was done, and severity of COVID-19 was measured as better and worse hospital outcomes. Correlation between severity of AGA and severity of COVID-19 was noted.

RESULTS

Out of 300 patients, 220 (73.33%) were male and 80 (26.67%) were female. In males, mild-to-moderate Hamilton-Norwood scale (HNS<3) and severe alopecia (HNS3-7) were noted among 43(20%) and 177(80.55%) patients, respectively. In females, 43(54%) had no AGA while 37(46%) had AGA. In 37 females with AGA, mild-to-moderate (Ludwig scale <2) and severe alopecia (Ludwig scale 2-3) were seen in 9(24.32%) and 28(75.68%) patients, respectively. We report a significant increase in frequency (95%) and severity of AGA and worse outcomes in males (p-value 0.000, chi-square: 18.90) compared with females (46%) (p-value 0.273, chi-square: 7.544), with notable adverse COVID-19 disease outcomes in the younger age group of men and also in few women of younger age group suffering from AGA without any comorbidities.

CONCLUSION

Our study shows a significant increase in frequency and severity of AGA and worse outcomes in men compared with women. There was a significant association between AGA severity and hospital disease outcome in men compared with women. Younger age group patients with severe AGA particularly men also faced adverse outcomes while having no known comorbidities, supporting the hypothesis that anti-androgen drugs might be valuable in patients of COVID-19.

Roles of steroid receptors in the lung and COVID-19

COVID-19 symptoms and mortality are largely due to its devastating effects in the lungs. The disease is caused by the SARS (Severe Acute Respiratory Syndrome)-CoV-2 coronavirus, which requires host cell proteins such as ACE2 (angiotensin-converting enzyme 2) and TMPRSS2 (transmembrane serine protease 2) for infection of lung epithelia. The expression and function of the steroid hormone receptor family is important in many aspects that impact on COVID-19 effects in the lung - notably lung development and function, the immune system, and expression of TMPRSS2 and ACE2. This review provides a brief summary of current knowledge on the roles of the steroid hormone receptors [androgen receptor (AR), glucocorticoid receptor (GR), progesterone receptor (PR), mineralocorticoid receptor (MR) and oestrogen receptor (ER)] in the lung, their effects on host cell proteins that facilitate SARS-CoV-2 uptake, and provides a snapshot of current clinical trials investigating the use of steroid receptor (SR) ligands to treat COVID-19.

Androgenetic alopecia and COVID-19: Is there a clinical connection?

BACKGROUND

During the coronavirus disease 2019 (COVID-19) outbreak, multiple studies showed higher rates of severe infection in adults and specifically in male patients, which may be related to differences in androgen receptor (AR) expression. Androgenetic alopecia (AGA) is one of the AR expression manifestations.

AIM

To explore AGA severity as a possible risk factor for COVID-19 severity in hospitalized patients.

METHODS

A total of 164 subjects (116 men and 48 females) with confirmed COVID-19 in need of hospitalization were included in this study. An experienced dermatologist examined the correlation of clinical signs of COVID-19 severity with AGA types. For evaluation of the association between categorical variables and comparison of the mean age in three groups of COVID-19 patients, the Fisher's exact test and the analysis of variance were used.

RESULTS

Our cross-sectional study included 116 male patients (70.7%) with a median age of 65.5 (age range: 22-97) years. Among them, 13.8% required intubation, 15.5% needed intensive care unit (ICU) care, and 70.7% required inward hospitalization. The Hamilton-Norwood Scale (HNS) was as follows: HNS I 14.7%, HNS II 12.1%, HNS III 20.7%, HNS IV 19.8%, HNS IV 29.8%, HNS V 17.2%, HNS VI 13.8%, and HNS VII 1.7%. Also, 29.3% of the patients were female, possessing a median age of 72 (age range: 23-98) years. In this group, 8.3% required intubation, 6.3% required ICU care, and 85.4% needed inpatient ward admission care. The Ludwig Scale (LS) was as follows: LS I 52.1%, LS II 35.4%, and LS III 12.5%.

CONCLUSION

The severity of AGA type did not correlate with the severity of COVID-19 among hospitalized patients. Our results were in contrast with other research that suggested AGA severity as a marker of unfavorable outcomes of COVID-19.

Systematic investigation of a potential epidemiological and genetic association between male androgenetic alopecia and COVID-19

Background

Male androgenetic alopecia (AGA) has been implicated as a putative risk factor in severe COVID‐19 based on high incidences of advanced AGA in male hospitalized COVID‐19 patients. Research further suggests that androgen signalling, which plays a central role in AGA aetiology, promotes SARS‐CoV‐2 infection and is associated with severe COVID‐19 symptoms in men.

Objectives

We aimed to systematically investigate a potential association between AGA and COVID‐19 both on an epidemiological and a genetic level in a large single‐population cohort.

Methods

We performed regression, genetic correlation and polygenic risk score (PRS) analyses using data from the UK Biobank and published GWAS data on AGA and COVID‐19.

Results

Our analyses did not reveal any significant epidemiological or genome‐wide genetic association between AGA and severe COVID‐19. Pathway‐based PRS analyses however revealed a significant association in specific pathways, namely vitamin metabolism, natural killer cell‐mediated cytotoxicity, WNT signalling and aryl hydrocarbon receptor signalling.

Limitations

We restricted our analyses to the white British population and used self‐reported AGA status. Sample size may be a limitation in our regression and PRS analyses.

Conclusions

Our data yield no evidence for an epidemiological association between AGA and COVID‐19 but suggest that a shared genetic basis for both traits exists in specific pathways.

Treatment options for androgenetic alopecia: Efficacy, side effects, compliance, financial considerations, and ethics

Background

Androgenetic alopecia (AGA) is the most common form of hair loss consisting of a characteristic receding frontal hairline in men and diffuse hair thinning in women, with frontal hairline retention, and can impact an individual's quality of life. The condition is primarily mediated by 5‐alpha‐reductase and dihydrotestosterone (DHT) which causes hair follicles to undergo miniaturization and shortening of successive anagen cycles. Although a variety of medical, surgical, light‐based and nutraceutical treatment options are available to slow or reverse the progression of AGA, it can be challenging to select appropriate therapies for this chronic condition.

Aims

To highlight treatment options for androgenetic alopecia taking into consideration the efficacy, side effect profiles, practicality of treatment (compliance), and costs to help clinicians offer ethically appropriate treatment regimens to their patients.

Materials and Methods

A literature search was conducted using electronic databases (Medline, PubMed, Embase, CINAHL, EBSCO) and textbooks, in addition to the authors' and other practitioners' clinical experiences in treating androgenetic alopecia, and the findings are presented here.

Results

Although topical minoxidil, oral finasteride, and low‐level light therapy are the only FDA‐approved therapies to treat AGA, they are just a fraction of the treatment options available, including other oral and topical modalities, hormonal therapies, nutraceuticals, PRP and exosome treatments, and hair transplantation.

Discussion

Androgenetic alopecia therapy remains challenging as treatment selection involves ethical, evidence‐based decision‐making and consideration of each individual patient's needs, compliance, budget, extent of hair loss, and aesthetic goals, independent of potential financial benefits to the practitioners.

Safety and efficacy of ALRV5XR in men with androgenetic alopecia: A randomised, double-blinded, placebo-controlled clinical trial

BACKGROUND

Androgenetic alopecia (AGA) is the most common hair loss disorder seen in men. It can have an early onset but has also been associated with ageing and senescence. It often induces pronounced psychological impact. ALRV5XR, a new hair loss treatment herein evaluated, was designed to target multiple molecular pathways involved in hair growth and hair follicle stem cell biology. The main objectives of the study were the assessment of safety and efficacy profiles of ALRV5XR in men.

METHODS

This 24-week, parallel randomised, placebo-controlled, double-blinded clinical trial was performed in a USA community clinic. Healthy men (age 22-65) with AGA and belonging to the Hamilton-Norwood (HN) classification I-VII and Fitzpatrick skin type (FST) I-VI, were randomly allocated in a 1:1 ratio into ALRV5XR or placebo treatment groups. Dermatologist assessment, phototrichograms, and blood samples were obtained in a blinded fashion at baseline, 12 and 24 weeks. Subjects were given a masked treatment consisting of oral capsules, shampoo, conditioner, and follicle serum, which was intended for daily use. Efficacy was assessed via absolute and per cent changes in terminal hair (TH) density, and response rates. The trial was registered with clinicaltrials.gov (NCT04450589) and is completed.

FINDINGS

Forty-six subjects were enroled in the study, 23 allocated to the ALRV5XR treatment and 23 to the placebo group. Enrolment occurred from April 11 to October 23, 2018. Thirty-six subjects completed the trial (17 ALRV5XR, 19 placebo) and 11 subjects in each group were evaluable for TH outcomes. At 24 weeks, the absolute change in TH density improved by 21·0 THs/cm² (95% CI: 9·2-32·8; p = 0·0014), and the relative density increased by 16·4% (95% CI: 7·4%-25·5%; p = 0·0012). The odds ratio for being a responder (≥ 0 change) was 87·4. TH density increased linearly and was not affected by HN, FST, ethnicity, age, or body mass index. All subjects in the ALRV5XR group responded to treatment while 81·8% of the placebo group decreased TH density. ALRV5XR induced statistically significant changes in both decrease in vellus hair (VH) density as well as in concomitant increase of the TH/VH ratio when compared to placebo. ALRV5XR was well tolerated, and no adverse events were observed.

INTERPRETATION

ALRV5XR treatment resulted in clinically significant TH regrowth in men with AGA. Furthermore, it appeared to reverse the characteristic hair miniaturisation seen in this condition. When compared to results of published trials of standard therapy, ALRV5XR showed a multi-fold increase both in efficacy and in response rates. In addition, the continuance of TH regrowth from 12 to 24 weeks suggests that the normal structure and function of non-productive telogen follicles is restored and that a normal hair phenotype may be attained by extended ALRV5XR treatment.

FUNDING

Arbor Life Labs.

Clinical Patterns and Morphology of COVID-19 Dermatology

Coronavirus disease 2019 (COVID-19), an emergent disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread throughout the globe since its discovery in December 2019. Although first appreciated to cause pneumonia, numerous organ systems are now known to be involved. The objective of this article is to review the broad spectrum of cutaneous manifestations reported in association with SARS-CoV-2 infection. The most commonly reported cutaneous manifestations associated with COVID-19 infection include pernio (chilblain)-like acral lesions, morbilliform (exanthematous) rash, urticaria, vesicular (varicella-like) eruptions, and vaso-occlusive lesions (livedo racemosa, retiform purpura). It is important to consider SARS-CoV-2 infection in the differential diagnosis of a patient presenting with these lesions in the appropriate clinical context, as cutaneous manifestations may be present in otherwise asymptomatic individuals, or present before developing other symptoms of infection. With increased access to diagnostic testing, we are beginning to understand the utility and limitations of currently available assays.

Proxalutamide Reduces the Rate of Hospitalization for COVID-19 Male Outpatients: A Randomized Double-Blinded Placebo-Controlled Trial

Antiandrogens have demonstrated a protective effect for COVOD-19 patients in observational and interventional studies. The goal of this study was to determine if proxalutamide, an androgen receptor antagonist, could be an effective treatment for men with COVID-19 in an outpatient setting. A randomized, double-blinded, placebo-controlled clinical trial was conducted at two outpatient centers (Brasilia, Brazil). Patients were recruited from October 21 to December 24, 2020 (clinicaltrials.gov number, NCT04446429). Male patients with confirmed COVID-19 but not requiring hospitalization (COVID-19 8-point ordinal scale <3) were administered proxalutamide 200 mg/day or placebo for up to 7 days. The primary endpoint was hospitalization rate at 30 days post-randomization. A total of 268 men were randomized in a 1:1 ratio. 134 patients receiving proxalutamide and 134 receiving placebo were included in the intention-to-treat analysis. The 30-day hospitalization rate was 2.2% in men taking proxalutamide compared to 26% in placebo, P < 0.001. The 30-day hospitalization risk ratio was 0.09; 95% confidence interval (CI) 0.03-0.27. Patients in the proxalutamide arm more frequently reported gastrointestinal adverse events, however, no patient discontinued treatment. In placebo group, 6 patients were lost during follow-up, and 2 patients died from acute respiratory distress syndrome. Here we demonstrate the hospitalization rate in proxalutamide treated men was reduced by 91% compared to usual care.

Androgenetic alopecia and COVID-19: A review of the hypothetical role of androgens

The coronavirus disease 2019 (COVID‐19) has become the most emerging health issue globally. A prompt investigation regarding disease management and treatment is crucial for decreasing the burden of the disease. Many explorations and hypotheses have been posed, but the definite treatment has not been determined for COVID‐19. Recent studies described a substantial prevalence of COVID‐19 and also a higher rate of morbidity and mortality in men afflicted with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. The gender‐related discordance in COVID‐19 infection may be due to hormonal differences, socioeconomic factors, genetic susceptibility, gender‐related comorbidities, and habits like alcohol consumption. On the other hand, several studies proposed that androgens could improve the immune system and have a protective role in COVID‐19, and decreased levels of androgens might be associated with unsatisfactory outcomes. In the field of dermatology, androgenetic alopecia (AGA) is correlated with a hyperandrogenic state and may be related to COVID‐19 severity. Furthermore, recent research has assessed the plausible association of AGA and COVID‐19. In this review, we investigate all evidence on AGA and its relationship with COVID‐19, including the possible role of androgens in COVID‐19 severity and outcomes as well as candidate androgen‐related drugs for the treatment of COVID‐19.

Role of ACE2 polymorphism in COVID-19: impact of age

More than 2 million people have died as a result of the COVID-19 outbreak. Angiotensin-converting enzyme 2 (ACE2) is a counter-regulatory enzyme that converts angiotensin-2 to Ang-(1-7) form in the renin-angiotensin system. Several studies have been analyzed the correlation between ACE2 and COVID-19. Indeed, ACE2/Ang (1-7) system protects the lung against acute respiratory distress syndrome by its anti-inflammatory/anti-oxidant function. However, SARS-Cov-2 can use ACE2 for host cell entry. Expression of ACE2 can be altered by several factors, including hypertension, diabetes and obesity, which also could increase the severity of COVID-19 infection. Besides, since androgens increase the expression of ACE-2, males are at higher risks of COVID-19 infection. Although reported statistics showed a significantly different infection risks of COVID-19 between adults and children, the reason behind the different responses is still unclear. This review proposes the effect of ACE polymorphism on the severity of SARS-COV-2 induced pneumonia. The previous meta-analysis regarding the effect of ACE polymorphism on the severity of pneumonia showed that polymorphism only affects the adult's illness severity and not the children. Two recent meta-analyses examined the effect of ACE polymorphism on the prevalence and mortality rate of COVID-19 and reported contradicting results. Our opinion paper suggests that the effect of ACE polymorphism on the severity of COVID-19 depends on the patients age, same as of the pneumonia.

Increased COVID-19 infections in women with polycystic ovary syndrome: a population-based study

OBJECTIVE

Several recent observational studies have linked metabolic comorbidities to an increased risk from COVID-19. Here we investigated whether women with PCOS are at an increased risk of COVID-19 infection.

DESIGN

Population-based closed cohort study between 31 January 2020 and 22 July 2020 in the setting of a UK primary care database (The Health Improvement Network, THIN).

METHODS

The main outcome was the incidence of COVID-19 coded as suspected or confirmed by the primary care provider. We used Cox proportional hazards regression model with stepwise inclusion of explanatory variables (age, BMI, impaired glucose regulation, androgen excess, anovulation, vitamin D deficiency, hypertension, and cardiovascular disease) to provide unadjusted and adjusted hazard risks (HR) of COVID-19 infection among women with PCOS compared to women without PCOS.

RESULTS

We identified 21 292 women with a coded diagnosis of PCO/PCOS and randomly selected 78 310 aged and general practice matched control women. The crude COVID-19 incidence was 18.1 and 11.9 per 1000 person-years among women with and without PCOS, respectively. Age-adjusted Cox regression analysis suggested a 51% higher risk of COVID-19 among women with PCOS compared to women without PCOS (HR: 1.51 (95% CI: 1.27-1.80), P < 0.001). After adjusting for age and BMI, HR reduced to 1.36 (1.14-1.63)], P = 0.001. In the fully adjusted model, women with PCOS had a 28% increased risk of COVID-19 (aHR: 1.28 (1.05-1.56), P = 0.015).

CONCLUSION

Women with PCOS are at an increased risk of COVID-19 infection and should be specifically encouraged to adhere to infection control measures during the COVID-19 pandemic.

SIGNIFICANCE STATEMENT

Women with polycystic ovary syndrome (PCOS) have an increased risk of cardio-metabolic disease, which have been identified as a risk factor for COVID-19. To investigate whether the increased metabolic risk in PCOS translates into an increased risk of COVID-19 infection, we carried out a population-based closed cohort study in the UK during its first wave of the SARS-CoV-2 pandemic (January to July 2020), including 21 292 women with PCOS and 78 310 controls matched for sex, age and general practice location. Results revealed a 52% increased risk of COVID-19 infection in women with PCOS, which remained increased at 28% above controls after adjustment for age, BMI, impaired glucose regulation and other explanatory variables.

Potential risk for developing severe COVID-19 disease among anabolic steroid users

A severe case of COVID-19 was observed in an otherwise healthy 28-year-old man who had taken oxandrolone 40 mg/day as an anabolic steroid. The patient had been taking oxandrolone for enhanced bodybuilding 30 days prior to presenting to an outpatient clinic with COVID-19 symptoms. The patient reported that his symptoms have rapidly worsened over the course of 4 days prior to presenting at the clinic. As part of an experimental antiandrogen treatment for hyperandrogenic men suffering from COVID-19, he was administered a single 600 mg dose of the novel antiandrogen proxalutamide. Twenty-four hours after administration of this dose, marked improvement of symptoms and markers of disease severity were observed. To our knowledge, this is the first case that potentially links anabolic steroid use to COVID-19 disease severity.

Proxalutamide Significantly Accelerates Viral Clearance and Reduces Time to Clinical Remission in Patients with Mild to Moderate COVID-19: Results from a Randomized, Double-Blinded, Placebo-Controlled Trial

Background The entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into type II pneumocytes is dependent on a modification of viral spike proteins by transmembrane protease serine 2 (TMPRSS2) expressed on the surface of human cells. TMPRSS2 is regulated by the androgen receptor, hence, SARS-CoV-2 infectivity is indirectly dependent on androgenic status and phenotype. Previously, we have reported that men affected by androgenetic alopecia (AGA) are overrepresented in severe coronavirus disease 2019 (COVID-19). Additionally, we have reported that men taking antiandrogenic drugs, e.g., 5-alpha-reductase inhibitors (5ARis), are less likely to have severe COVID-19. Here we aimed to test whether the androgen receptor antagonist, Proxalutamide, would be a beneficial treatment for subjects with SARS-CoV-2 infection. Methods Male and female subjects were recruited to a double-blinded, randomized, prospective, investigational study of Proxalutamide for the treatment of COVID-19. Mild to moderate, non-hospitalized subjects, who were confirmed positive for SARS-CoV-2, were treated with either Proxalutamide 200 mg/day or placebo. Endpoints for the study were remission time (days) and the percentage of subjects confirmed negative for SARS-CoV-2 on Day 7 after treatment. A negative SARS-CoV-2 test was defined by concentration-time (Ct)>40 determined by real-time reverse transcription-polymerase chain reaction (rtPCR). Results Two-hundred thirty-six (2360 subjects were included in the study (108 female, 128 male); 171 were randomized to the Proxalutamide arm and 65 were in the placebo group. On Day 7, SARS-CoV-2 became non-detectable with rtPCR (cT>40) in 82% of the subjects in the Proxalutamide group versus 31% in the placebo group (p < 0.001). The average clinical remission time for patients treated with Proxalutamide was 4.2 ±5.4 days versus 21.8 ±13.0 days in the placebo arm (p < 0.001). Conclusion Proxalutamide significantly accelerated viral clearance on Day 7 in mild to moderate COVID-19 patients versus placebo. Further, the time to clinical remission was significantly reduced in patients treated with Proxalutamide versus placebo.

Early Antiandrogen Therapy With Dutasteride Reduces Viral Shedding, Inflammatory Responses, and Time-to-Remission in Males With COVID-19: A Randomized, Double-Blind, Placebo-Controlled Interventional Trial (EAT-DUTA AndroCoV Trial - Biochemical)

Background and objective

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cell entry and subsequent infectivity are mediated by androgens and the androgen receptors through the regulation of transmembrane protease, serine 2 (TMPRSS2). Androgenetic alopecia (AGA) predisposes males to severe coronavirus disease 2019 (COVID-19) disease, while the use of 5-alpha-reductase inhibitors (5ARis) and androgen receptor antagonists reduce COVID-19 disease severity. In this study, we aimed to determine the potential benefit of dutasteride, a commonly used broad and potent 5ARi, as a treatment for COVID-19.

Design, setting, and participants

The study was conducted at outpatient clinics. Subjects presented to the clinics with a positive reverse transcription-polymerase chain reaction (RT-PCR) test taken within 24 hours of recruitment. All subjects presented with mild to moderate symptoms.

Interventions

Subjects were given either dutasteride 0.5 mg/day or placebo for 30 days or until full COVID-19 remission. All subjects received standard therapy with nitazoxanide 500 mg twice a day for six days and azithromycin 500 mg/day for five days.

Main outcome(s) and measure(s)

The main outcome(s) and measure(s) were as follows: time to remission, oxygen saturation (%), positivity rates of RT-PCR-SARS-CoV-2, and biochemical analysis [ultrasensitive C-reactive protein (usCRP), D-dimer, lactate, lactate dehydrogenase (LDH), erythrocyte sedimentation rate (ESR), ultrasensitive troponin, and ferritin].

Results

Subjects taking dutasteride (n=43) demonstrated reduced fatigue, anosmia, and overall disease duration compared to subjects taking a placebo (n=44) (p<.0001 for all). Compared to the placebo group, on Day seven, subjects taking dutasteride had a higher virologic remission rate (64.3% versus 11.8%; p=.0094), higher clinical recovery rate (84.7% versus 57.5%; p=.03), higher mean [standard deviation: SD] oxygen saturation (97.0% [1.4%] versus 95.7% [2.0%]; p=.02), lower median [Interquartile range: IQR] usCRP (0.34 mg/L [0.23 mg/L-0.66 mg/L] versus 1.47 mg/L [0.70 mg/L-3.37 mg/L]; p<.0001), lower median [IQR] lactate (2.01 mmol/L [1.12 mmol/L-2.43 mmol/L] versus 2.66 mmol/L [2.05 mmol/L-3.55 mmol/L]; p=.0049), lower median [IQR] ESR (5.0 mm/1h [3.0 mm/1h-11.0 mm/1h] versus 14.0 mm/1h [7.25 mm/1h-18.5 mm/1h]; p=.0007), lower median [IQR] LDH (165 U/L [144 U/L-198 U/L] versus 210 U/L [179 U/L-249 U/L]; p=.0013) and lower median [IQR] troponin levels (0.005 ng/mL [0.003 ng/mL-0.009 ng/mL] versus 0.007 ng/mL [0.006 ng/mL-0.010 ng/mL]; p=.048).

Conclusions and relevance

The findings from this study suggest that in males with mild COVID-19 symptoms undergoing early therapy with nitazoxanide and azithromycin, treatment with dutasteride reduces viral shedding and inflammatory markers compared to males treated with a placebo.

Androgens, the kidney, and COVID-19: an opportunity for translational research

Coronavirus disease 2019 (COVID-19) has reached pandemic proportions, affecting millions of people worldwide. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the causative agent of COVID-19. Epidemiological reports have shown that the severity of SARS-CoV-2 infection is associated with preexisting comorbidities such as hypertension, diabetes mellitus, cardiovascular diseases, and chronic kidney diseases, all of which are also risk factors for acute kidney injury (AKI). The kidney has emerged as a key organ affected by SARS-CoV-2. AKI is associated with increased morbidity and mortality in patients with COVID-19. Male sex is an independent predictor for AKI, and an increased death rate has been reported in male patients with COVID-19 worldwide. The mechanism(s) that mediate the sex discrepancy in mortality due to COVID-19 remain(s) unknown. Angiotensin-converting enzyme (ACE)2 is the receptor for SARS-CoV-2. Alterations in the ACE-to-ACE2 ratio have been implicated in renal diseases. This perspective aims to discuss data that suggest that androgens, via alterations in the intrarenal renin-angiotensin system, impair renal hemodynamics, predisposing patients to AKI during COVID-19 infection, which could explain the higher mortality observed in men with COVID-19. Clinicians should ensure early and effective cardiometabolic control for all patients to ameliorate the compensatory elevation of ACE2 and alterations in the ACE-to-ACE2 ratio. A better understanding of the role of androgens in SARS-CoV-2-associated AKI and mortality is imperative. The kidney could constitute a key organ that may explain the sex disparities of the higher mortality and worst outcomes associated with COVID-19 in men.

Impact of chronic exposure to 5-alpha reductase inhibitors on the risk of hospitalization for COVID-19: a case-control study in male population from two COVID-19 regional centers of Lombardy, Italy

BACKGROUND

There are sex differences in vulnerability to Coronavirus disease 2019 (COVID-19). The coronavirus S protein mediates viral entry into target cells employing the host cellular serine protease TMPRSS2 for S-protein priming. The TMPRSS2 gene expression is responsive to androgen stimulation and it could partially explain sex differences. We hypothesized that men chronically exposed to 5-alpha reductase inhibitors (5ARIs) for benign prostate hyperplasia (BPH) have a lower risk of hospitalization for COVID-19.

METHODS

This is a population-based case-control study on consecutive patients positive for SARS-CoV-2 virus who required hospitalization for COVID-19 (cases), age-matched to beneficiaries of the Lombardy Regional Health Service (controls). Data were collected by two high-volume COVID-19 regional centers of Lombardy (Italy). The primary outcome was to compare the prevalence of patients chronically exposed to 5ARIs, who required hospitalization for COVID-19, with the one of controls.

RESULTS

Overall, 943 males were enrolled; 45 (4.77%) were exposed to 5ARI. COVID-19 patients aged >55 years under 5ARI treatment were significantly less than expected on the basis of the prevalence of 5ARI treatment among age-matched controls (5.57 vs. 8.14%; P=0.0083, 95% CI: 0.75-3.97%). This disproportion was higher for men aged >65 (7.14 vs. 12.31%; P=0.0001, 95% CI: 2.83-6.97%). Eighteen 5ARIs-patients died; the mean age of men who died was higher than those who did not: 75.98±9.29 vs. 64.78±13.57 (P<0.001). Cox-regression and multivariable models did not show correlation between 5ARIs exposure and protection against intensive care unit admission/death.

CONCLUSIONS

Men exposed to 5ARIs might be less vulnerable to severe COVID-19, supporting its use in disease prophylaxis.

The AndroCoV Clinical Scoring for COVID-19 Diagnosis: A Prompt, Feasible, Costless, and Highly Sensitive Diagnostic Tool for COVID-19 Based on a 1757-Patient Cohort

Introduction A major barrier for successful therapeutic approaches for COVID-19 is the inability to diagnose COVID-19 during the viral replication stage, when drugs with potential antiviral activity could demonstrate efficacy and preclude progression to more severe stages. Reasons that hamper an earlier diagnosis of COVID-19 include the unspecific and mild symptoms during the first stage, the delay in the diagnosis and specific management caused by the requirement of a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV-2 for the diagnosis of COVID-19, and the insufficient sensitivity of the RT-PCR-SARS-CoV-2, converse to what is recommended for a screening test during an outbreak. More sensitive and earlier diagnostic tools for COVID-19 should be unraveled as a key strategy for a breakthrough change in the disease course and response to specific therapies, particularly those that target the blockage of viral shedding. We aimed to create an accurate, sensitive, easy-to-perform, and intuitive clinical scoring for the diagnosis of COVID-19 without the need for an RT-PCR-SARS-CoV-2 (termed The AndroCoV Clinical Scoring for COVID-19 Diagnosis), resulting from a 1,757 population cohort, to eventually encourage the management of patients with a high pre-clinical likelihood of presenting COVID-19, independent of an RT-PCR-SARS-COV-2 test, to avoid delays and loss of appropriate timing for potential therapies. Methods This is a post-hoc analysis of clinical data prospectively collected of the Pre-AndroCoV and AndroCov Trials, which resulted in scorings for the clinical diagnosis of COVID-19 based on the likelihood of presenting with actual COVID-19 according to the number of symptoms, presence of anosmia, and known positive household contact. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and accuracy were calculated for subjects screened in two different periods and both periods together, for females, males, and both, in a total of nine different scenarios, according to combinations of one, two, or three or more symptoms or the presence of anosmia in subjects without known positive household contacts, and no symptoms, one, two, or three or more symptoms, or presence of anosmia or ageusia in subjects with known positive household contacts. Scorings that yielded the highest pre-test probability, sensitivity, and accuracy were selected. Results Of the 1,757 patients screened, 1,284 were diagnosed with COVID-19. The scoring that required: (1) two or more symptoms, or anosmia or ageusia alone, for subjects without known contact; or (2) one or more symptoms, including anosmia or ageusia alone, when with known positive contacts presented the highest accuracy (80.4%) among all combinations attempted, and higher sensitivity (85.7%) than RT-PCR-SARS-CoV-2 commercially available kit tests. Conclusion The AndroCoV clinical scoring for COVID-19 diagnosis was demonstrated to be a feasible, easy, costless, and sensitive diagnostic tool for the clinical diagnosis of COVID-19. Because the clinical diagnosis of COVID-19 avoids delays in specific treatments, particularly for high-risk populations, prevents false-negative diagnosis, and reduces diagnostic costs, this diagnostic tool should be considered as an option for COVID-19 diagnosis, at least while SARS-CoV-2 is the prevailing circulating virus and vaccination rate is below the required for herd immunity.

The role of androgens in COVID-19

BACKGROUND AND AIM

The coronavirus disease 2019 (COVID-19) pandemic is a global health emergency. According to the findings, male patients with COVID-19 infection are at an increased risk for severe complications than females. The causes of this issue are unknown and are most probably multifactorial. Sexual hormones affect the immune system, so estrogen strengthens the immune system, and testosterone suppresses it. Due to the reports of the high prevalence of androgenic alopecia in hospitalized patients with COVID-19 and a higher risk of respiratory disease and increased use of allergy/asthma medications among patients with polycystic ovary syndrome (PCOS) as a hyperandrogenism condition compared with non-PCOS women, this review aimed to evaluate androgens role in COVID-19.

METHODS

42 related articles from 2008 to 2020 were reviewed with the keywords of androgens, hormonal factors, and hair loss in combination with COVID-19 in medical research databases.

RESULTS

The evidence of transmembrane protease, serine 2 (TMPRSS2) expression in lung tissue, which is an androgen-regulated gene and expressed mainly in the adult prostate may interpret the increased susceptibility of the male gender to severe COVID-19 complications. Moreover, angiotensin-converting enzyme 2 (ACE-2) acts as a functional receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and male hormones are effective in the ACE-2 passageway and simplify SARS-CoV-2 entry into host cells.

CONCLUSION

Further studies on the severity of symptoms in patients with COVID-19 in other hyperandrogenism conditions compared to the control group are recommended.