Morphea Triggered by COVID-19 Vaccination

Abstract

Since the onset of the COVID-19 pandemic in 2019, various vaccines have been developed to control its spread. Initially, conventional inactivated virus vaccines, such as CoronaVac (Sinovac), were introduced, followed by more advanced mRNA-based vaccines, such as BNT162b2 (Pfizer-BioNTech). COVID-19 vaccines have been associated with several adverse effects, particularly dermatological manifestations. Morphea, also known as localized scleroderma, is an inflammatory and sclerosing skin disease that leads to sclerosis and loss of skin elasticity. Genetic and environmental factors, along with immune dysregulation, are thought to play a role in its pathogenesis. We report a case of morphea in a 72-year-old woman who developed localized skin lesions at the vaccination site following CoronaVac administration. To the best of our knowledge, this is the first reported case of morphea potentially triggered by CoronaVac.

Since the beginning of the COVID-19 pandemic, several vaccines have been developed, starting with conventional inactivated virus vaccines, such as CoronaVac (Sinovac), followed by more advanced mRNA-based vaccines, such as BNT162b2 (Pfizer-BioNTech). Various adverse effects, particularly dermatological manifestations, have been associated with COVID-19 vaccines.^[1,2]

Morphea, also known as localized scleroderma, is an inflammatory and sclerosing dermatological condition that results in loss of skin elasticity and hardening. The pathogenesis of morphea is believed to involve not only genetic and environmental factors but also immune dysregulation.^[3]

Case Report

A 72-year-old woman presented to our dermatology clinic with a complaint of gradually increasing firmness and darkening of the skin on her left shoulder, which had begun approximately 2 years earlier. Her history revealed administration of three doses of the inactivated CoronaVac vaccine, followed by one dose of BNT162b2 (Pfizer-BioNTech). The skin lesions had first appeared locally at the injection site a few weeks after the first CoronaVac dose and gradually extended to involve the entire left shoulder.

Her past medical history included hypertension and atrial flutter for 30 years, gout for 6 years, gastritis, and loss of the right kidney due to nephrolithiasis 46 years earlier. The patient had been receiving long-term treatment with allopurinol and rivaroxaban for several years. There was no history of any acute life-threatening disease or newly initiated medication at the time of lesion onset.

Laboratory results showed normal biochemical parameters, including liver, kidney, and thyroid function tests, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Serological tests for ANCA, ANA, RF, anti-dsDNA, anti-Ro, anti-La, anti-Sm, and anti-RNP antibodies were negative. No abnormalities were detected in infectious markers, including HBsAg, anti-HBc IgM, HCV, and anti-HIV.

Dermatological examination revealed shiny, slightly hyperpigmented, atrophic, and indurated plaques measuring between 10×13 cm and 3×6 cm, distally forming a linear pattern on the left shoulder (Fig. 1). A punch biopsy was taken from the lesion margin. Histopathological examination showed epidermal thinning, basal vacuolar degeneration, and dense collagenization extending through the dermis into the subcutaneous tissue. Skin appendages were absent (Fig. 2). The diagnosis of morphea was made based on the clinical presentation and histopathological findings.

Figure 1.

(a, b) Shiny, slightly hyperpigmented, atrophic, indurated plaques on the left shoulder.

Figure 2.

Epidermal thinning, basal vacuolar degeneration and dense collagenization.

Following the diagnosis of morphea, topical combination therapy consisting of calcipotriol and betamethasone dipropionate was initiated. At the 1-month follow-up visit, the lesions were clinically stable, with no significant progression or regression observed. Subsequently, intralesional triamcinolone acetonide therapy was initiated at 2-week intervals. The patient is currently under regular dermatological follow-up.

Discussion

Vaccination significantly reduces the morbidity and mortality associated with infectious diseases and plays a key role in pandemic control. However, vaccines may also induce autoimmune responses and potentially trigger autoimmune diseases such as systemic lupus erythematosus, multiple sclerosis, rheumatoid arthritis, idiopathic thrombocytopenia, and Hashimoto’s thyroiditis, which have been reported in association with various vaccines.^[4] Autoimmunity is also considered to play a critical role in the pathogenesis of morphea.^[3]

There are reports associating morphea with BCG and hepatitis B vaccines, with the Koebner phenomenon suggested as a potential mechanism.^[5,6] In this process, needle-induced trauma may trigger a local inflammatory cascade characterized by antigen presentation and the release of proinflammatory and profibrotic cytokines. This immune activation may lead to the production of mediators such as transforming growth factor-β (TGF-β) and interleukin-6 (IL-6), which act as key drivers of fibroblast activation. This cascade may result in excessive collagen deposition and dermal fibrosis, as observed in morphea.^[7] Persistent immune stimulation triggered by both mechanical and immunological factors following vaccination may contribute to disease initiation or progression in susceptible individuals.

Although a few cases of morphea following COVID-19 vaccination have been reported, to the best of our knowledge, this is the first case of morphea potentially triggered by an inactivated virus vaccine, CoronaVac (Sinovac). In previously reported cases, morphea developed after mRNA-based vaccines such as BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna).^[8,9] Morphea-like lesions have also been observed following adenoviral vector vaccines, including ChAdOx1 nCoV-19 (AstraZeneca).^[10]

Conclusion

Although the exact etiology of morphea remains unknown, it is important for dermatologists to be aware of patients’ vaccination histories. Further studies are needed to clarify the mechanisms and relationships between vaccines and autoimmune diseases.

Disclosures

Ethics Approval

This is a single case report, and therefore ethics committee approval was not required in accordance with institutional policies.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Conflict of Interest

The authors declare that there is no conflict of interest.

Financial Disclosure

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Use of AI for Writing Assistance

Artificial intelligence (AI)-powered technologies were not used in this study.

Authorship Contributions

Concept – A.O., B.O.K.; Design – A.O., B.O.K.; Supervision – A.O., B.O.K., O.S., P.O.C., A.A., D.T., I.K.A.; Materials – A.O., B.O.K., D.T.; Data collection &/or processing – A.O., B.O.K., D.T.; Analysis and/or interpretation – A.O., B.O.K., O.S., P.O.C., A.A., D.T., I.K.A.; Literature search – A.O., B.O.K.; Writing – A.O., B.O.K., O.S., P.O.C., A.A., D.T., I.K.A.; Critical review – A.O., B.O.K., O.S., P.O.C., A.A., D.T., I.K.A.

Peer-review

Externally peer-reviewed.