Received: 25 January 2023 | Accepted: 8 September 2023
DOI: 10.1111/jdv.19514
C OV I D -19 SPE C I A L F ORU M - L E T T E R T O T H E E DI T OR
The Gabrin sign's potential for identifying high-­risk patients for
COVID-­19 with androgenic alopecia
Dear Editor,
The coronavirus disease 2019 (COVID-­19) is a markedly
transmissible infection resulting from the severe acute res-
piratory syndrome coronavirus 2 (SARS-­CoV-­2). The high
prevalence and rapid spread of this virus have led to a global
health emergency. Recent studies have reported that 20% of
COVID-­19 cases result in hospitalization and admission to
the intensive care unit (ICU), with a mortality rate of 10% in
patients with associated comorbidities.1,2
Multiple studies have shown that males are more likely
to contract COVID-­19 and have worse outcomes than fe-
males.1,2 The term ‘Gabrin sign’ pertains to the absence or
thinning of hair on the crown of the head, aligning with
at least the third stage on the Hamilton–­Norwood scale.3
Although the exact cause and the involvement of andro-
gens, androgenic receptors and their impact on the severity
of COVID-­19 are not fully understood, it is believed that
androgens may play a crucial role in the disease's patho-
genesis.4 In dermatology, studies have found a higher prev-
alence of androgenetic alopecia (AGA) in patients with
SARS-­CoV-­2.5
However, the prevalence of AGA in men is already signif-
icant by the age of 50. Therefore, it is important to carefully
evaluate AGA in both men and women with COVID-­19 to
assess its potential as a risk factor. This study aims to link
the associated severity of COVID-­19 infection with different
forms of androgenic alopecia.
This observational study encompasses individuals of
both genders who were hospitalized due to COVID-­19 in-
fection and required oxygen support. The real-­time reverse
transcription-­polymerase chain reaction (RT-­ qPCR) test
and the COVID-­19 rapid antigen test (RAT) were used to
detect the presence of the virus.
Subjects were divided into two groups: non-­severe: no
signs of severe disease, and severe: oxygen saturation ≤ 90%,
signs of pneumonia or respiratory distress and/or requiring
life support, having acute respiratory distress syndrome,
sepsis or septic shock. AGA was graded with Hamilton–­
Norwood scale (HNS) from 1 to 7 for men and Ludwig scale
(LS) from 1 to 3 for women. HNS 1–­2 and LS-­1 were graded
as ‘mild AGA’. HNS 3–­5 and LS-­2 as ‘moderate AGA’ and
HNS 6–­7 and LS-­3 as ‘severe AGA.’ Additionally, moderate
and severe AGA were also labelled as Gabrin sign positive,
while those with mild AGA as Gabrin sign negative.
© 2023 European Academy of Dermatology and Venereology.
e128 | wileyonlinelibrary.com/journal/jdv

In cases of clinical uncertainty, we employed dermoscopy
to assess anisotrichosis (hair diameter diversity), brown dots
and perifollicular white scales, confirming AGA diagnosis.
Additionally, a hair pull test was utilized to rule out telogen
effluvium.
The sample size was determined by assuming a power of
80%, with a confidence level of 95% and a significance level
of 0.05.
A total of 749 cases with confirmed COVID-­19 infection
were admitted to ICU and evaluated in this study. The male-­
to-­female ratio was 1.6:1. The overall frequency of AGA
among individuals with confirmed COVID-­19 was 58.7%
(62.7% in males and 52.4% in females).
There was a significantly higher proportion of severe
cases and fatalities in patients with AGA than without AGA
(p-­value −0.003 and 0.029, respectively). Similarly, there
was a significant association between severe COVID-­19 in-
fections and the presence of Gabrin sign (p-­value <0.0001;
Table 1).
On multivariate analysis, the risk factors independently
associated with significantly higher risk of severe COVID-­19
infection included as follows: AGA (p-­0.008), age ≥ 65 years
(p < 0.001), male gender (p-­0.04), Spo2 < 90% (p < 0.0001),
absolute lymphocyte count <1 K/μL (p-­0.03), creatinine
>1.5 mg/dL (p-­0.02) and LDH >280 U/L (p-­0.04) (Table 2).
Research has shown that androgen activity plays a role
in the pathogenesis and course of COVID-­19. Gabrin sign is
associated with a poorer prognosis and higher mortality in
COVID-­19 patients.3,6
Our findings showed a highly significant association be-
tween positive Gabrin signs of severe COVID-­19 and risk of
fatality. This association aligns with previous studies, such
as the one conducted by Wambier et al.6 where a higher prev-
alence of androgenetic alopecia was found in hospitalized
COVID-­19 patients compared with the general population
of the same age.
Another interesting finding from our study is the pres-
ence of AGA and male gender as independent risk factors
for severe COVID-­19. This highlights the potential role of
androgen receptor expression and sensitivity in the develop-
ment and severity of COVID-­19. Studies by Cadegiani et al.
and Subramanian et al.7,8 further support this by showing
a correlation between hyperandrogenic manifestations and
more severe symptoms of COVID-­19 in females.
J Eur Acad Dermatol Venereol. 2024;38:e128–e130.
LETTER TO THE EDITOR     | e129

TA BL E 1 Distribution of patients with COVID-­19 and AGA according to gender and severity.

AGA Males (n = 461) Females (n = 288) p-­Value

Present 289 (62.7%) 151 (52.4%) 0.005
Absent 172 (37.3%) 137 (47.6%)

AGA severity Males (n = 461) Females (n = 288)

Mild (Gabrin sign negative) 55 (19.1%) 71 (51.8%)
Moderate to severe (Gabrin sign positive) 234 (80.9%) 66 (48.2%)

COVID-­19 Severity AGA (n = 426) Without AGA (n = 323) p-­Value

Mild to moderate 326 (76.5%) 275 (85.1%) 0.003
Severe 100 (23.5%) 48 (14.9%)

Mild-­to-­moderate COVID-­19
AGA severity (n = 326) Severe COVID-­19 (n = 100) p-­Value
Mild (Gabrin sign negative) 105 (32.2%) 21 (21%) <0.0001
Moderate to severe (Gabrin sign positive) 221 (67.8%) 79 (79%)

Survival status AGA (n = 426) Without AGA (n = 323) p-­Value

Survivors 387 (90.8%) 307 (95.1%) 0.029
Non-­survivors 39 (9.2%) 16 (4.9%)

TA BL E 2 Multivariate analysis of risk factors for severe COVID-­19 DATA AVA I L A BI L I T Y S TAT E M E N T
infection. The data that support the findings of this series are available
from the corresponding author with a reasonable request.
Variable p-­Value
AGA 0.008 E T H IC S S TAT E M E N T
Age ≥ 65 y (yes vs. no) 0.001 The study was conducted after obtaining due approval from
Sex (male vs. female) 0.04 the institutional ethical board(s). The authors certify that
Systolic blood pressure < 100 mm Hg 0.50 they have obtained all appropriate patient consent forms. In
the form, the patient has given his consent for his images and
Heart rate > 120 bpm 0.55
other clinical information to be reported in the journal. The
Spo2 < 90% (yes vs no) 0.0001
patient understands that his name and initials will not be
Absolute neutrophil count <1.5 K/μL 0.09 published and due efforts will be made to conceal his iden-
Absolute lymphocyte count <1 K/μL 0.03 tity, but anonymity cannot be guaranteed.
Haemoglobin <10 g/dL 0.44
Platelet count <150 K/μL 0.56 Alpana Mohta1
Creatinine >1.5 mg/dL 0.02 Sumiti Pareek1
Vijeta Prasad1
LDH >280 U/L 0.04
Achala Mohta2
Troponin I ≥ 0.06 ng/mL 0.06
Asha Nyati3
1
Department of Dermatology, Venereology and
In conclusion, our study adds to the growing body Leprology, Sardar Patel Medical College, Bikaner,
of evidence linking Gabrin sign with the severity of Rajasthan, India
2
COVID-­ 19. The association between higher grade of Department of Preventive and Social Medicine,
androgenic alopecia and higher mortality in COVID-­19 Sardar Patel Medical College, Bikaner,
patients highlights the importance of considering it as Rajasthan, India
3
a potential risk factor for severe infection and poor de- Department of Dermatology, Venereology and
velopment. Further research is needed to understand Leprosy, Government Medical College, Kota,
the mechanisms behind this association and to explore Rajasthan, India
the potential benefits of androgen-­t argeted therapies in
COVID-­19 patients. Correspondence
Alpana Mohta, Sardar Patel Medical College, Bikaner,
C ON F L IC T OF I N T E R E S T S TAT E M E N T Rajasthan 334001, India.
None declared. Email: dralpanamohta10@gmail.com
e130 |    LETTER TO THE EDITOR
ORC I D
Alpana Mohta https://orcid.org/0000-0001-7526-2089
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