Wen Sheng Zhou1*, Jian Bin Zhang2
1 Chisense Clinic, London UK
2 The Second Affiliated Hospital of Nanjing University of Chinese Medicine, China
* Correspondence should be addressed to Wen Sheng Zhou, firstname.lastname@example.org
Received: January 8, 2021, Revised January 25, 2021, Published Febuary 1, 2021
Academic Editor: Dr. Hui Zhang
Cite: Zhou WS, Zhang JB. Unrecognised underlying condition for COVID-19: perspective study of meridian and M-shaped male baldness. Ann Chin Med, 2021, 2021(1):000005.
Copyright © 2021 Zhou and Zhang. This is an open access article (CC BY-NC-ND 4.0), which permits copy and redistribute the original material without derivatives in any medium or form at any medium for non-commercial purposes, provided the original work is properly cited.
Male androgenetic alopecia (MAA) is observed as a high severity risk factor but not listed within underlying COVID-19 conditionsdue to scanty available evidence. From a Chinese medicine (CM) perspective, the pathogenesis of MAA is overlapping with many recognised underlying conditions. This article compares CM meridian theory with MAA pattern progression to illustrate 1) the morphological and topographical superposition between the MAA progressing pattern and CM meridians, 2) damp-heat dominated body constitution presences among MAA patients as well as some underlying COVID-19 conditions, 3) vulnerable body type should be alerted and recognised to avoid an increase in infectious severity rate. The fundamental acupuncture points of treatment are provided for a concrete clarification of MAA.
COVID-19; Male androgenetic alopecia; Chinese medicine meridian; Hair; Underlying condition; Damp heat
From March to June 2020, the rate of COVID-19 mortalities with “No pre-existing condition” in England and Wales, UK was nearly 10% (Table 1), placing just after dementia, heart disease, and pneumonia/influenza. Given the new strain which mutated near the end of 2020, the increased infection rate raises a huge concern for those who have an actual underlying health condition. However, an additional point of great concern is that of unrecognised health conditions which contribute toward the increased severity of COVID-19. One such unrecognised condition is male androgenetic alopecia (MAA).
MAA patients, generally bald and bushy-bearded, have no specific need to worry about their health, but the potential causes of MAA might trigger more serious illnesses. Wambier et al  observed that among hospitalised COVID-19 patients, two thirds (79% of male and 42% of female patients with an average age of 62.5 and 71) have androgenetic alopecia, much higher rates than in a similar age range Caucasian population of 31-53% and 38%. MAA’s pathogenesis is still unclear but can be studied with CM meridian theory topographically and morphologically.
This interdisciplinary anatomisation aims to explore how MAA constitutes an unrecognised health condition increasing the risk of high COVID-19 severity. The method used is based in CM, examining the common factors of underlying health concerns.
MAA starts with the frontal temple hair fading, and gradually, within years, forming an M- shape while simultaneously the vertex bald patch enlarges, where excessive androgen is found in the hairless hair follicles but not elsewhere in the body. The MAA incidence rate increases with age as hormone levels generally decrease; interestingly, however, baldness never occurs to someone with no androgen [3,4]. Researchers  have found that excessive androgen restricting the development of dermal papilla vasculature is converted from testosterone by over-activity of 5α-reductase enzymes (5αRs) which appear not only in the scalp but also in the urogenital system, the skin (particularly genital skin), and the liver.
Interestingly, in the excessive androgen bald areas of early MAA patients, histologists have detected unexplained micro-inflammation which can induce the dense connective tissue to experience fibrosis and calcify within a few years. This only occurs at galea fascia, not on its bordered muscle sections, which have better vascularisation than fasciae . This pathophysiological mechanism of micro-inflammation is still undefined but appears to indicate that the MAA pattern is related to the function of the internal organs.
MAA causes in CM
Traditionally CM studies in MAA are predominantly performed through zangfu diagnosis, identifying the MAA mechanisms as liver-kidney yin deficiency and damp-heat excess (aka. inflammation in CM) either malnourishing or blocking the scalp hair follicles . This theory may explain why castrated men never experience MAA  but does not explain the pattern of MAA and its joint feature of bushy beards and acne situating along facial stomach channels and their meridian-sinews. According to CM theory, “sparse” hair in the stomach channels is due to qi deficiency, but a hairless scalp and hairy face are inconsistent with this (Table 2) . Hence, the established zangfu theory might be too general to explain the MAA pattern.
MAA in meridian systems
CM meridian systems encompass the entire body. There are 12 zangfu-related channels and their 12 peripheral sinew-related meridian-sinews, which (i) attach all musculoskeletal systems such as galea and genitalia
The genitalia are known in CM as master-sinew, including within the outer pubic hairline, superiorly connecting the chest and diaphragm, inferiorly penetrating the pelvic base (coccyx), and anteroposteriorly rising into the scalp vertex , functionally regulated and encircled by the liver channels and their meridian-sinews. Anatomically, the genitalia bridge anteroposterior superficial back fascia line (SBFL) ascending to the galea [10,11].
The inflammation or damp-heat in CM is determined by lifestyle factors such as a rich diet, alcohol consumption, and emotional stress and initially impacts the stomach and spleen before passing on to other organs. Lingshu illustrates meridian-sinews and channels extending between the master-sinew
and galea and the confluent positions containing the lungs and the area above (ST12) (Figure 1, Table 3) . The damp-heat carried by channels influences these confluent positions. The liver and gallbladder channels appear seven times in Figure 1 and Table 3 as the most frequently emerging channels, suggesting a strong interconnection with the meridian-sinews, especially the foot-jueyin at the centre of master-sinew (the genitalia).
M-shaped baldness starts on ST8 points due to damp-heat from the mid Burner (stomach, spleen, gallbladder and liver) and manifests in abdominal distension, unsatisfied defecation, heavy legs, dull headache, thick yellow tongue coating, emotionality, and low motivation. Due to the heavy nature of dampness, perpetuated damp-heat falls to the lower Burner and results in instability of the master-sinew. The genital essence diffuses along liver channels as well as SBFL towards the scalp fascia inflaming the hair follicles, causing fibrosis and balding on the vertex around liver channels.
Accumulated damp-heat often leads to spleen yang deficiency, qi stagnation, blood stasis, food and phlegm obstruction, causes dermatological problems, and many chronic diseases but particularly diabetes, high blood pressure, and high cholesterol which are already recognised as pre-existing COVID-19 conditions. This interdisciplinary pathogenesis based approach also indicates potential risk and recommends that taking extra precautionary measures for MAA patients is vital for avoiding the risk of high severity COVID-19.
This study is not intended to diagnose or treat MAA but rather to highlight to policymakers and health beneficiaries that many underlying COVID-19 conditions remain unrecognised. However, to better understand the MAA case, it is useful to provide some treatment suggestions as concrete examples clarifying the approach. From the aforementioned analysis, to avoid further burdens on the stomach and spleen, acupuncture is preferred over herb intake. Fundamental acupuncture strategy consists of three methods each containing two phases (PH1, PH2):
1) Local needling on hairless galea to deossificate galea, improve local qi-blood, and regenerate lifeless hair follicles.
PH1: ST8, ST7, GB3, GB13, GB15, UB4, UB3, GV24
PH2: GV20, GV21, GV19, EX-HN1, BL7, GB18
2) Distal needling on impaired channels and huatuo jiaji points to biomechanically open nutrient pathways between galea and genital region, so to ameliorate jiaji and its adjacent tendon conditions. Myers  states that human structure is tension-dependent, comprehensively compensating for one fascia with the deformation of the rest, and topographically compacting the channels underneath and/or compressing and misshaping the organs.
PH1: EX-B2 selected by palpation, GB20, GV16;
PH2: EX-B2 selected by palpation, GB20, GV16, BL31-34;
3) Channel needling on damp-heat permeated channels to disperse obstructed and stagnated qi to regain body meridian homeostasis.
PH1: ST44, ST43, SP2, SP3, LI2, LI3
Yangming channels regulate master-sinew. Ying-spring and shu-stream points of stomach, spleen, and large intestine channels are employed for dispersing heat and dampness. Both yangming-meridians are in a “mother child” relation. The child large intestine reduces excessiveness from the mother stomach.
PH2: LV3, LV8, GB41, GB34, ST40
The turbid food-qi enters the stomach, spreads to liver meridian networks resulting in shrunken sinews. In addition to the previous points, shu-stream and he-sea points of the liver and its associated gallbladder channels scatter dampness and divert the counterflow qi.
The authors wish to thank M. J. Fleming for his editorial help.
 Ons. Deaths with no underlying health conditions – Office for National Statistics. https://www.ons.gov.uk/aboutus/transparencyandgovernance/freedomofinformatio nfoi/deathswithnounderlyinghealthconditions [Accessed 4 Jan. 2021].
 Wambier CG, Vaño-Galván S, McCoy J, Gomez-Zubiaur A, Herrera S, Hermosa-Gelbard Á,et al. Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: The “Gabrin sign”. J Am Acad Dermatol. 2020,83(2):680-682.
 Hamilton JB. Patterned loss of hair in man: types and incidence. Ann N Y Acad Sci, 1951, 53(3), 708-728.
 Norwood OT. Male pattern baldness: classification and incidence. South Med J, 1975, 68(11), 1359-1365.
 Aggarwal S, Thareja S, Verma A, Bhardwaj TR, Kumar M. An overview on 5α-reductase inhibitors. Steroids, 2010, 75(2), 109-153.
 El-Domyati M, Attia S, Saleh F, Abdel-Wahab H. Androgenetic alopecia in males: a histopathological and ultrastructural study. J Cosmet Dermatol, 2009, 8(2), 83-91.
 Liu W. Professor Chen Dacan’s experience on treating seborrheic alopecia. J Tradit Chin Med, 2004, (01): 10-11.
 Unschuld PU. Huang Di Nei Jing Ling Shu: The Ancient Classic on Needle Therapy. University of California Press, 2016, 587-588.
 Unschuld PU, Tessenow H. Huang Di Nei Jing Su Wen: An Annotated Translation of Huang Di’s Inner Classic–Basic Questions: 2 Volumes. University of California Press, 2011, p662.
 Myers TW. Trains, A Myofascial meridians for manual and movement therapists. Elsevier, 2009:75,99,181,187,230.
 Susan S. Gray’s anatomy: the anatomical basis of clinical practice 41ed. Elsevier, 2015:1337.  Flaws B, Philippe S. The treatment of modern Western medical diseases with Chinese medicine: A textbook & clinical manual. Blue Poppy, 2001:230,298,308.