Alopecia areata following COVID-19 vaccination: vaccine-induced autoimmunity?

Dear Editor,

We report a case of an 80-year-old man who came to our attention for a rapidly progressive loss of facial hair 7 days after the administration of the first dose of the BNT162b2 vaccine, an mRNA vaccine against SARS-CoV-2. He had no personal or family history of alopecia or autoimmunity. Before the vaccination, a COVID-19 serological test and a naso-oropharyngeal swab test gave a negative result. During the visit, we found an area of beard hair loss on the left cheek and the upper lip with a concomitant widespread involvement of the entire scalp, with a SALT score of 65% (Fig. 1a-b); no other areas were involved. A pull test gave a positive result, and cadaveric and exclamation point hairs were noted upon trichoscopy (Fig. 1c), allowing the diagnosis of alopecia areata (AA). No improvement was seen after topical application of clobetasol foam; indeed, the patient reported a progressive worsening of the condition after the second dose of the vaccine. At the 2-month follow-up visit, we observed alopecia areata totalis (Fig. 1d) and started a topical immunotherapy with squaric acid dibutylester combined with topical 5% minoxidil. At the last follow-up visit, 1 month from the start of immunotherapy, no improvement was noted.