Researchers have made significant progress in understanding the impact of the new coronavirus on skin diseases such as hair loss, pemphigus, hives and rare diseases. Recent studies have shed light on potential links and symptoms following COVID-19 infection and vaccination. .
This week, Dermatology Times is featuring research into recent COVID-19 infections that affect skin, hair and nails, marking four years since the start of the pandemic.
Correlation between new coronavirus infection and hair loss
A study investigated the relationship between the novel coronavirus disease (COVID-19) and telogen effluvium (TE) in Saudi Arabia. It was conducted in a cross-sectional design from March to September 2022, and 392 participants with confirmed coronavirus infections participated. Data were collected through an online questionnaire. The results showed that post-COVID-19 hair loss affected 60% of participants, with varying onset and duration. Women with a history of TE and receiving antiviral treatment for coronavirus disease (COVID-19) were identified as having a more significant risk of hair loss. Limitations of this study include the lack of clinical evaluation by a dermatologist. This study highlighted the importance of recognizing hair loss associated with COVID-19 and highlighted the need for further objective evaluation studies. This document aims to contribute to the medical literature on COVID-19 and urges healthcare providers to be alert and considerate of potential skin symptoms in their patients. This study suggested future studies to investigate the association between COVID-19 and chronic TE and suggested enhanced clinical assessment methods for a more precise understanding. 1
Case report of pityriasis rosea and pityriasis rosea-like rash after COVID-19 vaccination
Various skin reactions have been reported around the world after receiving the COVID-19 vaccine. Registry-based studies highlighted that mRNA vaccines have different responses compared to viral vector vaccines, with delayed large-scale local reactions being the most common. Three cases of pityriasis rosea (PR) and PR-like rash following COVID-19 vaccination were described in the Oman Medical Journal. Two patients received the Pfizer-BioNTech mRNA vaccine and the third received the Oxford-AstraZeneca viral vector vaccine. 2
Case 1 involved a 19-year-old male who presented with a PR-like rash after the first dose of the Pfizer-BioNTech vaccine. Case 2 is a woman who experienced a PR after the first dose of Pfizer-BioNTech and had a mild relapse after the second dose. Case 3 is a man in his 70s who developed a PR-like rash after receiving the second dose of the Oxford-AstraZeneca vaccine. Skin reactions after vaccination with the new coronavirus are diverse, including PR-like rash and PR-like rash. These reactions can occur with both mRNA and viral vector vaccines. Mechanisms may involve immune dysregulation and viral reactivation. Diagnosis and management depend on clinical symptoms and histopathological examination. PR and PR-like rashes after COVID-19 vaccination are rare but possible. It is important to carefully monitor skin reactions after vaccination. Further research is needed to understand the relationship between vaccination and skin reactions, especially viral reactivation.
Risk of delayed side effects when administering COVID-19 vaccination to patients with autoimmune diseases
Despite the well-documented safety profile of COVID-19 vaccines, limited data on long-term safety, especially in patients with immune-mediated inflammatory diseases (IMID) Vaccine hesitancy continues among the population. This study investigated delayed adverse events (DAEs) occurring more than 7 days after vaccination in systemic lupus erythematosus (SLE) and other rheumatic and non-rheumatic autoimmune diseases (rAID and nrAID) compared to healthy controls (HC). ). Data was collected through the COVAD-2 online survey from February to June 2022 from more than 150 facilities in 106 countries. Adverse events between groups were compared by logistic regression analysis adjusting for confounders. 3
Among 7,203 participants, SLE patients reported higher rates of major DAEs and hospitalizations compared to HC. They also had more severe rashes compared to rAID patients and higher hospitalization rates compared to nrAID patients. Differences in adverse events were observed by vaccine type, with more hospitalizations occurring in Moderna recipients. SLE patients without autoimmune complex diseases reported fewer mild DAEs than patients with concomitant nrAIDs. SLE patients had a higher risk of hospitalization after vaccination compared to HC. Close monitoring of SLE patients after vaccination can help in early detection of adverse events and can inform patients and provide necessary support, especially those with multiple autoimmune diseases.
Newly developed pemphigus in a 73-year-old patient after infection with the new coronavirus
This study presents the case of a 73-year-old woman who developed pemphigus two weeks after being infected with COVID-19, adding to the limited data on the incidence of pemphigus following COVID-19 infection. The light is shining on it. The patient presented with a blistering rash on multiple parts of the body after being diagnosed with novel coronavirus disease (COVID-19), which warranted further investigation. Biopsy showed features of pemphigus vulgaris (PV) and pemphigus paraneoplastic (PNP), and subsequent malignant findings were negative. Treatment with prednisone and mycophenolate mofetil resulted in complete remission at 9-month follow-up. 4
COVID-19 is thought to be associated with autoimmune diseases, possibly through molecular mimicry and immune dysregulation mechanisms. Reports suggest that there is a time lag between the onset of coronavirus infection and pemphigus, possibly due to an abnormal immune response triggered by the virus. Interestingly, the patient showed features of both PV and PNP, suggesting a complex autoimmune response influenced by the novel coronavirus disease (COVID-19). This case highlights the need for vigilance against autoimmune symptoms post-COVID-19.
Mask-induced Koebner phenomenon in pemphigus patients
The widespread use of face masks during the COVID-19 pandemic has led to an increase in skin conditions, including reports of Koebner phenomenon, particularly in patients with psoriasis. However, the literature regarding mask-induced pemphigus lesions is limited. This study presented two cases of pemphigus patients who developed new or persistent lesions in the nose, the area most inflamed by mask use. The first case was a 56-year-old man with pemphigus who was a vegetarian and developed nasal lesions four months into the pandemic. It started at the same time as mask usage increased. Treatment with oral methylprednisolone and azathioprine resulted in mild improvement. The second case was a 47-year-old man with pemphigus vulgaris who had erosive lesions on the nasal and oral mucosa, which were exacerbated by prolonged mask wearing. Despite treatment, the nasal lesions persisted, indicating possible mask-induced Koebner phenomenon.
Although previous reports have associated pemphigus lesions with trauma or light exposure, the consistent occurrence of nasal lesions in these cases emphasizes the role of mild mask-related trauma. Although rare, the possibility of Koebner phenomenon in pemphigus patients should be considered, especially in pandemic situations where mask use is widespread.
Increased incidence and mortality of Stevens-Johnson syndrome/toxic epidermal necrolysis in patients with COVID-19 infection
This retrospective study analyzed data from the Cosmos database to investigate the incidence and mortality of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) in patients with COVID-19 infection. Of the 10,675,070 patients diagnosed with COVID-19, 270 developed SJS/TEN within 8 weeks. The mean age was 50 years, 54% were female, and most were white (70%). The incidence of SJS/TEN was twice as high in patients with COVID-19 compared to those without (2.5 vs. 1.2 per 100,000, p<0.001). The 8-week mortality rate for patients with COVID-19 SJS/TEN was significantly higher than for those without (8.5% vs. 6.8%, p < .001)6.
This study suggested an association between COVID-19 infection and increased risk of SJS/TEN, possibly due to virus-induced drug hypersensitivity. Antibiotic use in the treatment of COVID-19 infection may be contributing, as many of the antibiotics involved are commonly prescribed. However, further research is required to fully understand the underlying mechanisms.
Pyoderma gangrenosum in the breast: potential association with COVID-19 infection
A study published in the Indian Dermatology Online Journal suggested a potential association with pyoderma gangrenosum (PG). In this study, we presented three cases of PG occurring in the breast and discussed the overlapping inflammatory cytokine profiles seen in PG and COVID-19 infection. Increases in pro-inflammatory cytokines such as TNF-α, IL-1, IL-6, and IL-8 observed in both PG and COVID-19 suggest a possible association. COVID-19 vaccination can cause autoimmunity and hyperinflammation, similar to the mechanisms seen in the development of PG. However, reported cases of PG in the chest are not directly related to COVID-19 infection or vaccination. 7
Although many cases of breast PG are preceded by surgical intervention, none of the reported cases occurred after COVID-19 infection or vaccination. PG may be uniquely associated with COVID-19 infection, but further studies are needed to conclusively confirm this association. The researchers suggested that patients with immune system dysregulation, including those vaccinated against COVID-19, should undergo long-term follow-up for possible development of PG. Monitoring of PGs is critical, even in unvaccinated facilities, as they can worsen the severity of COVID-19 infection.
Case of chronic urticaria after mRNA COVID-19 booster administration
Earlier this year, a JAAD case report featured seven patients who developed chronic urticaria (CU) after receiving the mRNA-1273 COVID-19 booster vaccine. Median onset of urticaria was 11 days after vaccination and in some cases lasted up to 16 months. Most patients were treated with antihistamines, but symptoms resolved in only three cases. Notably, two patients received a BNT162b2b (Pfizer-BioNTech) booster without worsening CU, suggesting a potential approach for future vaccination. 8
Although the causal relationship between COVID-19 vaccines and CU remains uncertain, previous literature suggests a correlation, with Moderna’s vaccine being more associated with late-onset CU compared to Pfizer’s. It has been shown that However, most patients tolerated subsequent vaccinations well, highlighting the importance of shared decision-making regarding future vaccinations. Although the retrospective nature of this report limits definitive conclusions, the ability of some patients to tolerate alternative vaccines deserves consideration in the vaccine discussion. However, the need for such changes remains unclear and requires further research. This case series contributes to our understanding of skin reactions to COVID-19 vaccines and highlights the need for continued vigilance and research in this area.
References
Buhari AE, Aldosari DA, Aldosari MA, et al. Hair loss due to COVID-19 and associated risk factors: a Saudi perspective. J Family Med Prim Care. 2023 Dec;12(12):3304-3311. doi: 10.4103/jfmpc.jfmpc_314_23. Epub 2023 12 21. PMID: 38361868; PMCID: PMC10866268.Al Hatmi I, Al Maqbali H, Al Waily A, Al Khalili A, Qureshi A. Pityriasis rosea and pityriasis rosea after COVID-19 vaccination. Eczema-like rash: A case series from Oman. Oman Med J. 2023 November 30;38(6):e579. doi: 10.5001/omj.2024.01. PMID: 38264510; PMCID: PMC10801697.Dey M, Doskaliuk B, Lindblom J, et al. Late adverse events associated with COVID-19 vaccination in patients with systemic lupus erythematosus. J Clinic Medicine. 2023 12 7;12(24):7542. doi:10.3390/jcm12247542. PMID: 38137611; PMCID: PMC10743599.Pastukhova E, Ghazawi FM. New onset of pemphigus after novel coronavirus infection: A case report. SAGE Open Med Case Rep. 2024 Feb 16;12:2050313X241231423. doi:10.1177/2050313X241231423. PMID: 38371950; PMCID: PMC10874115.Glusnai IE, Erdem Y, Altunai IK. Mask-induced Koebner phenomenon in pemphigus patients during the COVID-19 pandemic. SisliEtfalHastan Tip Bul. 2023 12 29;57(4):567-568. doi: 10.14744/SEMB.2023.38107. PMID: 38268656; PMCID: PMC10805050.Curtis KK, Dillan MM, Sharma TR, Piktel J. Increased incidence of Stevens-Johnson syndrome and toxic epidermal necrolysis due to COVID-19: a retrospective cohort analysis. J Am Acad Dermatol. 2024 2 27:S0190-9622(24)00417-1. doi: 10.1016/j.jaad.2024.02.029. Epub ahead of print. PMID: 38423469.Rakesh A, Deo KS, Sharma YK, Pillai NS. Pyoderma gangrenosum and coronavirus infection: A series of three cases involving the female breast. Indian Dermatol Online J. 2023 July 25;15(1):126-128. doi: 10.4103/idoj.idoj_38_23. PMID: 38283008; PMCID: PMC10810412.Ryan C, Li K, Bennett R, Davis MJ, et al. Chronic urticaria after Moderna COVID-19 vaccine booster vaccination: A case series. JAAD Litigator January 23, 2024;45:27-30. doi:10.1016/j.jdcr.2023.11.037. PMID: 38379871; PMCID: PMC10876461.
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