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COVID-19 Impacts on Hair Loss, Pemphigus, Urticaria, and Rare Diseases

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Explore recent research that shed light on potential associations and manifestations post-COVID-19 infection or vaccination.

Researchers have made significant progress in understanding the impact of the COVID-19 virus on dermatologic conditions, including hair loss, pemphigus, urticaria, and rare diseases.Recent studies have shed light on the potential associations and manifestations post-COVID-19 infection or vaccination.

This week, Dermatology Times is highlighting recent COVID-19 research affecting skin, hair, and nails in recognition of 4 years since the start of the pandemic.

Correlating COVID-19 and Hair Shedding

One study investigated the relationship between COVID-19 and telogen effluvium (TE) in Saudi Arabia. Conducted through a cross-sectional design from March to September 2022, it involved 392 participants with confirmed COVID-19 infections. Data were collected via online questionnaires. Results indicated that hair shedding post-COVID-19 affected 60% of participants, with various onset times and durations. Women with a history of TE and antiviral treatment for COVID-19 were identified as having more significant risks for hair shedding. Limitations of the study included lack of clinical evaluation by dermatologists. The study emphasized the importance of recognizing COVID-19-related hair shedding and highlighted the need for further objective assessment studies. It aimed to contribute to medical literature on COVID-19, urging healthcare providers to be vigilant and considerate of potential cutaneous manifestations in patients. The study proposed future research to explore the association between COVID-19 and chronic TE and suggested enhanced clinical evaluation methods for a more precise understanding.1

Post-COVID-19 Vaccine Case Reports of Pityriasis Rosea and Pityriasis Rosea-like Eruptions

Various cutaneous reactions have been reported following COVID-19 vaccination globally. A registry-based study highlighted delayed large local reactions as the most common, with mRNA vaccines showing distinct reactions compared to viral vector vaccines. Three cases of pityriasis rosea (PR) and PR-like eruptions following COVID-19 vaccination were described in Oman Medical Journal. Two patients received Pfizer-BioNTech mRNA vaccines, while the third received the Oxford-AstraZeneca viral vector vaccine.2

Case 1 involved a 19-year-old male presenting with PR-like eruption after the first dose of Pfizer-BioNTech vaccine. Case 2 was a woman experiencing PR after the first Pfizer-BioNTech dose, with a milder recurrence post-second dose. Case 3, a man in his seventies, developed PR-like eruption following the second dose of Oxford-AstraZeneca vaccine.Cutaneous reactions post-COVID-19 vaccination are diverse, including PR and PR-like eruptions. These reactions can occur with both mRNA and viral vector vaccines. Mechanisms may involve immune dysregulation and viral reactivation. Diagnosis and management rely on clinical presentation and histopathological examination. PR and PR-like eruptions post-COVID-19 vaccination are rare but possible. Vigilance in monitoring skin reactions following vaccination is crucial. Further studies are needed to understand the relationship between vaccination and cutaneous reactions, especially regarding viral reactivation.

Risk of Delayed Adverse Events in COVID-19 Vaccination for Patients With Autoimmune Diseases

Despite documented safety profiles of COVID-19 vaccines, vaccine hesitancy persists among individuals with immune-mediated inflammatory diseases (IMIDs), especially due to limited data on long-term safety. This study aimed to assess delayed adverse events (DAEs) occurring over seven days post-vaccination in systemic lupus erythematosus (SLE) and other rheumatic and non-rheumatic autoimmune diseases (rAIDs and nrAIDs) compared to healthy controls (HCs). Data were collected via the COVAD-2 online survey from over 150 centers in 106 countries between February and June 2022. Logistic regression analysis, adjusting for confounders, compared adverse events among groups.3

Among 7203 participants, SLE patients reported higher rates of major DAEs and hospitalizations compared to HCs. They also experienced more severe rashes compared to individuals with rAIDs and higher hospitalization rates compared to those with nrAIDs. Differences in adverse events were observed between vaccine types, with Moderna recipients experiencing more hospitalizations. SLE patients without autoimmune multimorbidity reported fewer minor DAEs compared to those with comorbid nrAIDs.SLE patients had a higher risk of hospitalization post-vaccination compared to HCs. Close monitoring of SLE patients post-vaccination can aid in early detection of adverse events, informing patients, especially those with multiple autoimmune conditions, and providing necessary support.

New-Onset Pemphigus Following COVID-19 in 73-Year-Old Patient

The study presents a case of a 73-year-old woman developing pemphigus 2 weeks after contracting COVID-19, shedding light on the limited data regarding pemphigus incidence post-COVID-19 infection. The patient presented with blistering eruptions on multiple body parts post-COVID-19 diagnosis, prompting further investigation. Biopsies indicatedfeatures of pemphigus vulgaris (PV) and paraneoplastic pemphigus (PNP), with subsequent negative malignancy findings. Treatment with prednisone and mycophenolate mofetil led to complete remission at 9 months follow-up.4

COVID-19 has been linked to autoimmune diseases, possibly through molecular mimicry and immune dysregulation mechanisms. Reports suggest a time lag between COVID-19 and pemphigus onset, possibly due to aberrant immune responses triggered by the virus. Interestingly, the patient exhibited features of both PV and PNP, suggesting a complex autoimmune response influenced by COVID-19. This case underscores the need for vigilance regarding autoimmune manifestations post-COVID-19.

Mask-Induced Koebner Phenomenon in Patients With Pemphigus

During the COVID-19 pandemic, the widespread use of face masks has led to an increase in dermatoses, including reports of Koebner phenomenon, especially in patients with psoriasis. However, there has been limited documentation of mask-induced pemphigus lesions. This study presented 2 cases of patients with pemphigus developing new or persistent lesions on their noses, the area most irritated by mask usage.The first case involved a 56-year-old man with pemphigus vegetans, who developed nasal lesions four months after the pandemic began, coinciding with increased mask usage. Treatment with oral methylprednisolone and azathioprine resulted in mild improvement. The second case was a 47-year-old man with pemphigus vulgaris, exhibiting erosive lesions on the nose and oral mucosa, exacerbated by prolonged mask wearing. Despite treatment, nasal lesions persisted, indicating a possible mask-induced Koebner phenomenon.5

While previous reports linked pemphigus lesions to trauma or light exposure, the consistent occurrence of nasal lesions in these cases highlights the role of mask-related minor traumas. Despite being rare, the potential for Koebner phenomenon in pemphigus patients necessitates consideration, especially amidst pandemic conditions with widespread mask usage.

Increased Incidence and Mortality of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis in Patients With COVID-19

This retrospective study analyzed data from the Cosmos database to investigate the incidence and mortality of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) in patients with COVID-19. Among 10,675,070 patients diagnosed with COVID-19, 270 developed SJS/TEN within 8 weeks. The mean age was 50, with 54% female, and most were White (70%). The incidence of SJS/TEN was twice as high in COVID-19 patients compared to those without (2.5 vs. 1.2 cases per 100,000 individuals, p < .001). The 8-week mortality rate among SJS/TEN patients with COVID-19 was significantly higher than in those without (8.5% vs. 6.8%, p < .001).6

The study suggested a link between COVID-19 infection and increased risk of SJS/TEN, possibly due to virus-induced drug hypersensitivity. Antibiotic use in COVID-19 treatment may contribute, as many implicated antibiotics are commonly prescribed. However, further research is needed to understand the underlying mechanisms fully.

Pyoderma Gangrenosum Presenting on the Breast: Potential Link to COVID-19

Research published in the Indian Dermatology Online Journal suggested a potential link to pyoderma gangrenosum (PG). This study presented 3 cases of PG on the breast, discussing the overlapping inflammatory cytokine profiles seen in PG and COVID-19. Increased pro-inflammatory cytokines observed in both PG and COVID-19, including TNF-α, IL-1, IL-6, and IL-8, suggest a possible connection. COVID-19 vaccination can trigger autoimmunity and hyperinflammation, similar to mechanisms seen in PG pathogenesis. However, no reported cases of PG on the breast have been linked directly to COVID-19 infection or vaccination.7

While surgical interventions precede many cases of breast PG, none of the reported cases occurred post-COVID-19 infection or vaccination. Although PG may independently associate with COVID-19, further research is needed to confirm this connection conclusively. Investigators suggested that patients with dysregulated immune systems, including those vaccinated for COVID-19, should undergo extended follow-up for potential PG development. Monitoring for PG, even in non-vaccination sites, is crucial as it could exacerbate COVID-19 severity.

Cases of Chronic Urticaria Following mRNA COVID-19 Booster

Earlier this year, the JAAD Case Report featured 7 patients developed chronic urticaria (CU) following mRNA-1273 COVID-19 booster vaccination. The median onset of urticaria was 11 days post-vaccination, lasting up to 16 months in some cases. While most patients were treated with antihistamines, symptom resolution occurred in only three cases. Notably, 2 patients received BNT162b2b (Pfizer-BioNTech) booster without exacerbating CU, suggesting a potential approach for future vaccinations.8

Although causation between COVID-19 vaccines and CU remains uncertain, previous literature suggests a correlation, with Moderna vaccines more frequently linked to delayed-onset CU compared to Pfizer. However, most patients tolerated subsequent vaccinations well, emphasizing the importance of shared decision-making regarding future doses. While the retrospective nature of this report limits definitive conclusions, the ability of some patients to tolerate alternative vaccineswarrants consideration in vaccine discussions. However, the necessity of such changesremains unclear, requiring further study. This case series contributes to understanding cutaneous reactions to COVID-19 vaccines and highlights the need for ongoing vigilance and research in this area.

References

  1. Bukhari AE, AlDosari DA, AlDosari MA, et al. COVID-19-induced hair shedding and related risk factors: A Saudi perspective. J Family Med Prim Care. 2023 Dec;12(12):3304-3311. doi: 10.4103/jfmpc.jfmpc_314_23. Epub 2023 Dec 21. PMID: 38361868; PMCID: PMC10866268.
  2. Al Hatmi I, Al Maqbali H, Al Waily A, Al Khalili A, Qureshi A. Pityriasis rosea and pityriasis rosea-like eruption following COVID-19 vaccinations: case series from Oman. Oman Med J. 2023 Nov 30;38(6):e579. doi: 10.5001/omj.2024.01. PMID: 38264510; PMCID: PMC10801697.
  3. Dey M, Doskaliuk B, Lindblom J, et al. COVID-19 vaccination-related delayed adverse events among patients with systemic lupus erythematosus. J Clin Med. 2023 Dec 7;12(24):7542. doi: 10.3390/jcm12247542. PMID: 38137611; PMCID: PMC10743599.
  4. Pastukhova E, Ghazawi FM. New-onset of pemphigus following COVID-19 infection: a case report. SAGE Open Med Case Rep. 2024 Feb 16;12:2050313X241231423. doi: 10.1177/2050313X241231423. PMID: 38371950; PMCID: PMC10874115.
  5. Gulsunay IE, Erdem Y, Altunay IK. Mask-induced Koebner Phenomenon in pemphigus patients during COVID-19 pandemic. SisliEtfalHastan Tip Bul. 2023 Dec 29;57(4):567-568. doi: 10.14744/SEMB.2023.38107. PMID: 38268656; PMCID: PMC10805050.
  6. Curtis KK, Dillan MM, Sharma TR, Piktel J. COVID-19 infection increases the development of Stevens-Johnson Syndrome and toxic epidermal necrolysis: a retrospective cohort analysis. J Am Acad Dermatol. 2024 Feb 27:S0190-9622(24)00417-1. doi: 10.1016/j.jaad.2024.02.029. Epub ahead of print. PMID: 38423469.
  7. Rakesh A, Deo KS, Sharma YK, Pillai NS. Pyoderma gangrenosum and COVID-19: a series of three cases involving female breast. Indian Dermatol Online J. 2023 Jul 25;15(1):126-128. doi: 10.4103/idoj.idoj_38_23. PMID: 38283008; PMCID: PMC10810412.
  8. Ryan C, Li K, Bennett R, Davis MJ, et al. Chronic urticaria after Moderna COVID-19 vaccine boosters: A case series. JAAD Case Rep. 2024 Jan 23;45:27-30. doi: 10.1016/j.jdcr.2023.11.037. PMID: 38379871; PMCID: PMC10876461.

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