Abstract
Coronavirus disease 2019 (COVID-19) vaccines significantly impacted
world health and well-being. However, various adverse events have been
observed following severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) vaccination. Cutaneous reactions have been prevalent
following many vaccines, including COVID-19 vaccines. Here, we present a
case of new-onset lichen planus in a patient who received the COVID-19
vaccine at the same time as being infected with SARS-CoV-2. A
52-year-old woman presented to the clinic with extensive pruritic skin
lesions. The eruptions had appeared a week after her second dose of the
Sinopharm COVID-19 vaccine. She mentioned a history of SARS-CoV-2
infection approximately ten days following the first dose of her
vaccine, causing a one-month delay in getting the second dose. Her past
medical history was not significant. On examination, erythematous and
squamous papules were demonstrated predominantly on the extremities,
including inguinal and axillary folds. Moreover, desquamation of the
lips was visible, and buccal lesions were also found. After consultation
with a dermatologist, a skin biopsy was indicated for the patient, but
she refused to undergo the procedure. Therefore, considering the typical
appearance of the eruptions, lichen planus was suspected, for which she
was treated with oral antihistamines and topical corticosteroids.
Keywords: SARS-CoV-2; COVID-19; Dermatology; Lichen planus
Introduction
Coronavirus disease 2019 (COVID-19) vaccines significantly impacted
world health and well-being. However, various adverse events have been
observed following severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) vaccination. Cutaneous reactions have been prevalent
following many vaccines, including COVID-19 vaccines. The SARS-CoV-2
infection per se has led to different dermatologic manifestations.
Psoriasis and seborrheic dermatitis are among the most common
long-lasting dermatologic disorders triggered or flared up following
this viral infection or related vaccines [1, 2]. Nonetheless, lichen
planus has been reported less commonly after SARS-CoV-2 infection or
COVID-19 vaccination, necessitating its careful discussion [3, 4].
Here, we present a case of new-onset lichen planus in a patient who
received the COVID-19 vaccine at the same time as being infected with
SARS-CoV-2.
Case presentation
A 52-year-old woman presented with extensive pruritic skin lesions was
referred to the infectious diseases clinic. The eruptions had appeared a
week after her second dose of the Sinopharm (BBIBP-CorV) COVID-19
vaccine. She mentioned a history of SARS-CoV-2 infection approximately
ten days following the first dose of her vaccine, causing a one-month
delay in getting the second dose. Her past medical history was not
significant. On examination, erythematous and squamous papules were
demonstrated predominantly on the extremities, including inguinal and
axillary folds (Figures 1 & 2). Moreover, desquamation of the lips was
visible, and buccal lesions were also found. After consultation with a
dermatologist, a skin biopsy was indicated for the patient, but she
refused to undergo the procedure. Therefore, considering the typical
appearance of the eruptions, lichen planus was suspected, for which she
was treated with oral antihistamines and topical corticosteroids. She
was then visited during her follow-up with evidence of a favorable
response to the treatment.
Discussion
Unspecific skin complications, such as injection site induration,
urticaria, and maculopapular rash, have frequently been observed
following various vaccines, including SARS-CoV-2 vaccines, often
transient and self-limited [5]. However, dermatologic disorders,
such as psoriasis, and lichen planus, have been reported less commonly,
but their durability and complex treatment pose significant challenges
for the patients.
Lichen planus is a chronic, inflammatory, autoimmune dermatologic
disorder that involves the skin and mucosal membranes. Cutaneous lesions
usually present with planar, purple, polygonal, pruritic, papules, and
plaques, known as the six Ps. Mucosal surfaces that are commonly
affected include oral and genital mucosa. Moreover, skin appendages such
as nails and scalp hair are sometimes engaged [6]. Lichen planus
frequently presents acutely and involves the flexor surfaces of the
upper and lower extremities [7]. Its cutaneous lesions are often
covered by Wickham striae, manifested as reticular purple pruritic
papules and plaques in flexural areas and oral lesions on the lips and
buccal mucosae. Our patient had typical cutaneous and mucosal
involvement, but her nails and hair were spared.
Lichen planus had been known to be triggered by several factors,
including systemic comorbidities (e.g., hypertension, diabetes mellitus,
and chronic liver disease), medications (such as beta-blockers,
nonsteroidal anti-inflammatory drugs, antimalarials, diuretics, oral
hypoglycemics, and penicillamine), infections (including hepatitis B and
C viruses, and Helicobacter pylori ), tobacco chewing, and anxiety
[8-12]. Nonetheless, based on the previous studies, SARS-CoV-2
infection can be another precipitating factor for this condition
[13-16]. Moreover, SARS-CoV-2 vaccines have been other factors that
could induce this disease. Previously, hepatitis B vaccine has been
abundantly reported to cause lichen planus, and other vaccines, such as
tetanus–diphtheria–acellular pertussis (Tdap), measles-mumps-rubella
(MMR), rabies, and influenza vaccines, had also been reported to trigger
this cutaneous disorder less frequently [17-22]. However, some
reports of new-onset lichen planus occurring following COVID-19 vaccines
[3, 23, 24]. Furthermore, exacerbation of the pre-existing lichen
planus has also been observed after COVID vaccines [23]. The
pathophysiologic mechanism might be the Th1 response
that is elicited by the vaccines, which in turn leads to the elevation
of interleukin-2 (IL‐2), tumor necrosis factor-α (TNF-α), and
interferon-γ (IFN-γ) levels, and therefore, lichen planus induction
[25]. Our patient did not point out any of the risks mentioned
above, and her past medical and medication history was not significant.
Antimalarial agents are the most critical medications involved in the
rising up or exacerbation of lichen planus, but our patient had not
received hydroxychloroquine to treat her SARS-CoV-2 infection. In
addition, her laboratory tests showed a negative serology for hepatitis
B, hepatitis C, and HIV. The result of the SARS-CoV-2 RT-PCR test was
also negative.
Both SARS-CoV-2 infection and its vaccines can serve as triggering
factors of cutaneous adverse reactions like lichen planus. Since our
patient got infected with the virus in the meantime between the two
doses of the vaccines, it is difficult to determine whether she
developed this dermatologic disease due to SARS-CoV-2 infection or as a
consequence of its vaccines. Reports of lichen planus onset following
SARS-CoV-2 infection have demonstrated that the cases had occurred up to
one month after the infection [4, 26]. On the other hand, the few
reports of lichen planus following SARS-CoV-2 vaccination had occurred
about one to two weeks after receiving the vaccines [3, 27, 28]. In
a repeated and more thorough history taking, the patient recalled some
faint and scares lesions arising a few days following her first vaccine
dose on her both ankles, which faded away, and recurred soon after the
second vaccine dose with a more robust appearance, so as obliging her to
seek physician visits. Therefore, this patient’s onset of lichen planus
can almost definitely be due to COVID vaccination because her first bout
of cutaneous reactions had appeared prior to getting infected with
SARS-CoV-2. Cutaneous biopsy is the best way to confirm the diagnosis of
a dermatologic disorder, including lichen planus [29]; if punch
biopsy had been done, “saw-tooth” pattern of epidermal hyperplasia
with wedge‐shaped hypergranulosis, hyperparakeratosis and vacuolar
alteration of the basal layer of the epidermis, with predominant T cells
infiltration at the dermal-epidermal junction would be the
characteristic finding [30]; however, our patient refused to undergo
biopsy. Therefore, we considered the diagnosis based upon the typical
clinical manifestations. High-potency topical corticosteroids are the
first-line medications utilized for lichen planus treatment [31].
However, if no favorable response is demonstrated, topical calcineurin
inhibitors, such as tacrolimus and pimecrolimus, are usually applied as
second-line therapies, particularly for oral and genital lesions
[32]. Systemic corticosteroids are another choice for severe,
widespread mucosal lesions [33]. Lichen planus may resolve
spontaneously or with the treatments mentioned above within one to two
years; however, recurrences occur prevalently, especially for mucosal
lichen planus, which may persist for the lifelong duration despite
therapy [34]. Our patient’s cutaneous lesions responded favorably to
topical calcipotriol and triamcinolone in addition to systemic
antihistamines; nonetheless, her buccal mucosae and lip involvement had
not subsided. Therefore, she was started on oral prednisone.
Conclusion
Although COVID-19 vaccines and their adverse events are new scopes in
medicine, dermatologists should be aware of the probability of new-onset
or exacerbated mucosal skin disorders due to the vast range of cutaneous
adverse events following COVID-19 vaccination and actively monitor
susceptible patients.