Reply to “The first dose of COVID‐19 vaccine may trigger pemphigus and bullous pemphigoid flares: is the second dose therefore contraindicated?” by Damiani G et al

New Onset and Exacerbation of Autoimmune Bullous Dermatosis Following COVID-19 Vaccination: A Systematic Review

BACKGROUND

Cases of autoimmune bullous dermatosis (AIBD) have been reported following COVID-19 vaccination.

OBJECTIVE

We aimed to provide an overview of clinical characteristics, treatments, and outcomes of AIBDs following COVID-19 vaccination.

METHODS

We conducted a systematic review and searched the Embase, Cochrane Library, and Medline databases from their inception to 27 March 2024. We included all studies reporting ≥ 1 patient who developed new-onset AIBD or experienced flare of AIBD following at least one dose of any COVID-19 vaccine.

RESULTS

We included 98 studies with 229 patients in the new-onset group and 216 in the flare group. Among the new-onset cases, bullous pemphigoid (BP) was the most frequently reported subtype. Notably, mRNA vaccines were commonly associated with the development of AIBD. Regarding the flare group, pemphigus was the most frequently reported subtype, with the mRNA vaccines being the predominant vaccine type. The onset of AIBD ranged from 1 to 123 days post-vaccination, with most patients displaying favorable outcomes and showing improvement or resolution from 1 week to 8 months after treatment initiation.

CONCLUSIONS

Both new-onset AIBD and exacerbation of pre-existing AIBD may occur following COVID-19 vaccination. Healthcare practitioners should be alert, and post-vaccination monitoring may be essential.

New-onset or flare-up of bullous pemphigoid associated with COVID-19 vaccines: a systematic review of case report and case series studies

Background

Numerous cutaneous manifestations have been associated with the Coronavirus Disease 2019 (COVID-19) outbreak and vaccination, but new-onset bullous pemphigoid (BP) or flaring up of pre-existing BP is a rare side effect of COVID-19 vaccines that has been mentioned to a lesser extent in the literature. Therefore, we aimed to conduct a systematic review focused on the association between the new- onset or flare-up of BP and the COVID-19 vaccination.

Method

A comprehensive literature search was conducted using PubMed (MEDLINE), Scopus, and the Web of Science databases up to 11 March 2023. The search aimed to identify English-language studies reporting new-onset or flare-ups of BP as a potential side effect of the COVID-19 vaccination. The search terms included bullous pemphigoid and COVID-19 vaccination-related MeSH terms.

Results

The systematic review of 40 articles investigating the incidence of BP in individuals who received various COVID-19 vaccines revealed pertinent findings. Among the 54 patients with new-onset BP, the median age was 72.42 years, and most were men (64%). Conversely, the median age of the 17 patients experiencing a flare-up of BP was 73.35 years, with a higher proportion of women (53%). Regarding vaccination types, a significant number of patients (56%) developed new-onset BP after receiving the BNT162b2 vaccine (Pfizer-BioNTech).

Conclusion

This study indicates a potential association between COVID-19 vaccinations, particularly mRNA vaccines, and the occurrence of BP. It suggests that this rare autoimmune disorder may be triggered as an adverse event following the COVID-19 vaccination. However, it is important to note that the majority of BP patients in our study were unaffected by the COVID-19 vaccine, and even those who experienced worsening of their conditions were managed without significant consequences. These findings provide additional evidence supporting the safety of COVID-19 vaccines. Physicians should be mindful of this uncommon adverse event and encourage patients to complete their planned vaccination schedules.

Cutaneous vasculitis and vasculopathy in the era of COVID-19 pandemic

Cutaneous vasculitides encompass a heterogeneous group of clinicopathological entities, which may occur as single-organ vasculitis of the skin or present as skin-limited variant of systemic vasculitis (i.e., skin-limited ANCA-associated vasculitis), and are triggered by various factors, including infections, drugs and vaccines. The COVID-19 pandemic has challenged us with a variety of both disease- and vaccine-associated skin manifestations, including vasculitis. Among the latter, cutaneous small-vessel vasculitis, previously known as leukocytoclastic vasculitis, seems to be the most reported in either scenario, i.e., natural infection and vaccination. Vasculopathy without true vasculitic changes on histology develops in but a minority of cases, mostly severe/critical COVID-19 patients, and appears to be the result of endothelial injury due to pauci-immune thromboembolic mechanisms. Herein, we provide an overview of the available literature on COVID-19-associated and anti-SARS-CoV-2-vaccine-associated cutaneous vasculitis. Although evidence is mostly limited to isolated reports, with a proportion of cases lacking histopathological confirmation, ample overlap with pre-pandemic forms is shown.

Exacerbation of Autoimmune Bullous Diseases After Severe Acute Respiratory Syndrome Coronavirus 2 Vaccination: Is There Any Association?

Background and Aim

There have been concerns regarding the potential exacerbation of autoimmune bullous diseases (AIBDs) following vaccination against COVID-19 during the pandemic. In the current study, vaccine safety was evaluated in patients with AIBDs.

Methods

In this study, patients with AIBDs were contacted via face-to-face visits or phone calls. Patient demographics, vaccine-related information, pre- and post-vaccine disease status, and complications were recorded. The exacerbation was considered either relapse in the remission/controlled phase of the disease or disease worsening in the active phase. The univariate and multivariate logistic regression tests were employed to determine the potential risk factors of disease exacerbation.

Results

Of the patients contacted, 446 (74.3%) reported receiving at least one dose of vaccine injection (54.7% female). Post-vaccine exacerbation occurred in 66 (14.8%) patients. Besides, there were 5 (1.1%) patients with AIBD diagnosis after vaccination. According to the analysis, for every three patients who received vaccines during the active phase of the disease one experienced disease exacerbation. The rate of disease exacerbation increased by three percent with every passing month from the last rituximab infusion. Active disease in the past year was another risk factor with a number needed to harm of 10.

Conclusion

Risk of AIBD exacerbation after the COVID-19 vaccine is not high enough to prevent vaccination. This unwanted side effect, can be reduced if the disease is controlled at the time of vaccination.