Reply to ‘A case of pityriasis lichenoides et varioliformis acuta developed after first dose of Oxford‐AstraZeneca COVID‐19 vaccine’

Dear Editor,

To contain the spreading of Covid‐19, two mRNA vaccines (Moderna; mRNA‐1273 and Pfizer/BioNTech; BNT162b2) and two viral vector‐based vaccines (Johnson & Johnson; Ad26.COV2. S and AstraZeneca; AZD1222) have been authorized by the Italian Medicines Agency (AIFA). ¹ However, several vaccine‐related cutaneous reactions have been reported. ¹ , ² , ³

We read with great interest the article by Filippi et al. ⁴ entitled: ‘A case of pityriasis lichenoides et varioliformis acuta developed after first dose of Oxford–AstraZeneca COVID‐19 vaccine’ describing a case of pityriasis lichenoides et varioliformis acuta (PLEVA) developed after AZD1222 vaccination. The authors conclude by discussing how the ability viral vector‐based or Mrna‐based Covid‐19 vaccines to trigger inflammatory or immune‐mediated disorders is still a hot topic of debate; however, a cross‐reactivity between viral or adjuvant antigens and self‐antigens is plausible although this hypothesis needs further study. ⁴

Herein, we report the case of a 23‐year‐old young woman attending at our hospital for a crusted lichenoid rash affected her entire body (Figure 1a,b). At the anamnesis, the patient revealed that she underwent the second dose of mRNA‐1273 vaccination 10 days before the development of the signs and symptoms. The patients had not taken any medications or suffered from any medical condition. Routine blood examinations and blood tests for Parvovirus, Coxsackie virus, Epstein–Barr virus and cytomegalovirus were negative. Suspecting PLEVA, skin biopsy was performed confirming the clinical suspect by showing parakeratosis, spongiosis and perivascular lymphocytic infiltrate.

FIGURE 1.

Clinical features of patient at baseline (a–c) and 3 weeks after treatment with oral and topical corticosteroids (d–f).

Treatment with oral prednisolone 25 mg a day for 10 days, tapering the dose over the next 2 weeks and with topical betamethasone once a day for 14 days was started, leading to a complete resolution of PLEVA (Figure 1c,d).

To date, there are very few cases of PLEVA following Covid‐19 vaccination. In particular, Mäkilä et al. ⁵ reported a case of 21‐year‐old man who developed PLEVA following Covid‐19 infection, relapsing after the first dose of mRNABNT162b2 vaccine. The patient was successfully treated with oral prednisolone (40 mg/daily) and topical betamethasone. Similarly, Sernicola et al. ⁶ showed the case of a 31‐year‐old Caucasian woman developing PLEVA 10 days after the first dose of mRNABNT162b2 vaccine, treated with methylprednisolone 16 mg/daily.

In the literature, there are cases suggesting vaccinations as triggers of Pleva in predisposed individuals, particularly postinfluenza vaccination and postmeasles, mumps and rubella vaccine. ⁷ , ⁸

Past reports with new present ones force us to reflect: May Covid‐19 vaccination be a trigger? On the one hand, the temporal relationship of onset of manifestations allows us to correlate the two events; on the other hand, a cross‐reactivity between viral antigens could explain the reason for this association.

To the best of our knowledge, our case can be considered the first case of PLEVA following Covid‐19 vaccination with mRNA‐1273.

In conclusion, PLEVA may develop following Covid‐19 vaccination, regardless the mechanism of action (mRNA‐ or viral vector‐based vaccine). However, the occurrence is rare, not leading to life‐threating condition.

In our opinion, further studies are needed in order to highlight pathogenetic mechanisms and possible risk factors to identify ‘at risk’ subjects. Certainly, vaccination should not be discouraged.

FUNDING INFORMATION

None.

CONFLICT OF INTEREST

All the authors declare that have no conflict of interest.

ETHICS STATEMENT

The patients gave the consent for publication.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author.