COVID‐19 vaccination: possible short‐term exacerbations of oral mucosal diseases

Dear Editor,

The coronavirus disease 2019 (COVID‐19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection, has become a global pandemic burden with extreme health, social, and economic implications.¹ With the rapid development and release of vaccinations against the virus, questions have been raised in regard to unforeseen effects, which may have impacted patients’ willingness to receive the vaccine.²

There are currently three vaccines authorized by the United States Food and Drug Administration (FDA) for emergency use and recommended to prevent severe illness: Pfizer/BioNTech (BNT162b2), Moderna (mRNA‐1273), and Johnson & Johnson (JNJ‐78436735).¹ The Pfizer/BioNTech and Moderna vaccines are mRNA vaccines, while the Johnson & Johnson vaccine is a viral vector vaccine. Both mRNA and viral vector vaccines are shown to upregulate T‐cell‐mediated immunity.³ In clinical trials, it was noted that the Pfizer/BioNTech vaccine elicited a robust CD8⁺ and T helper type 1 (Th1) CD4⁺ cell response, with higher serum levels of IL‐2, TNF‐α, and IFN‐γ.⁴ Studies from animal models investigating the Moderna vaccine revealed benefits of using the mRNA‐based vaccine, including T‐cell responses characterized by increasing levels of IFN‐γ.³ Consequently, administration of vaccines could lead to a surge in conditions mediated by similar processes and inflammatory markers.⁵

Patients with a diagnosis of oral lichen planus may experience a flare in their condition after the administration of the vaccine. As oral lichen planus is a T‐cell‐mediated chronic inflammatory condition of unknown etiology, the inflammatory markers involved with immune response to the administration of the vaccine mirror those involved in the disease process itself.⁴ Patients with other autoimmune or immune‐mediated conditions, such as mucous membrane pemphigoid, bullous pemphigoid, pemphigus vulgaris, chronic ulcerative stomatitis, and lichen planus pemphigoides, among others, may experience an increase in their clinical manifestations and symptoms.

Many of our patients reported an increase in their oral mucosal disease symptoms shortly after vaccination, which may or may not have been directly related to the administration of the vaccine. The symptoms quickly resolved within 2–4 weeks, and the patient returned to their baseline disease expression. A 65‐year‐old female patient with multifocal lichen planus was asymptomatic and did not endorse any active skin or oral lesions. Past medical history was significant for hyperlipidemia. Medications included rosuvastatin and vitamin D supplementation. The patient had routine surveillance appointments with no disease expression noted on follow‐up. Immediately following the administration of the COVID‐19 vaccination, the patient experienced a flare‐up of her oral lichen planus symptoms with increased soreness and inflammation in her left buccal mucosa. Approximately 3 weeks after her flare‐up, her disease expression regressed to baseline, and she no longer endorsed any symptoms.

Although the vaccine may exacerbate symptoms of existing conditions in the short term, these can be managed appropriately and should not deter patients from receiving the first available vaccine, as vaccination reduces COVID‐19‐related morbidity and mortality.⁵ At this time, there is no definitive evidence of long‐term adverse effects against chronic mucosal diseases, but as healthcare professionals, we should be aware of this possibility and counsel our patients accordingly.