Lichenoid reaction to hepatitis B vaccination

A Systematic Review of Histopathologic Surveys on Mucocutaneous Biopsies in Patients Developed COVID-19 Vaccine-Related Dermatologic Manifestations

ABSTRACT

Coronavirus 2 is an infectious agent primarily identified as the cause of a pandemic viral pneumonia. With the mass vaccination against this virus, one of the health issues is the safety of currently available vaccines considering their adverse reactions. This systematic review was conducted to assess and summarize all reported data on histopathologic findings associated with mucocutaneous reactions that developed after COVID-19 vaccination for a better pathophysiology interpretation and clinical management of these reactions. A systematic search was performed in PubMed, Web of Science, and Scopus databases as well as Google Scholar engine for relevant English articles published till July 1, 2022. This review includes 131 studies with a total number of 287 cases. Eruptions that underwent a biopsy were mostly described as erythematous maculopapular, papulosquamous, vasculitis-like, lichenoid, or urticarial lesions. Histopathology revealed spongiosis, interstitial, and perivascular lymphohistiocytic infiltration, erythrocyte extravasation, parakeratosis, endothelial inflammation, and the like. Findings were highly consistent with morbilliform erythema, psoriasiform dermatosis, leukocytoclastic vasculitis, and lichenoid or urticarial drug reactions. The majority of these reactions had a mild nature and were primarily observed in patients with underlying health conditions. Microscopic evaluation was also consistent with transient inflammatory changes, and features like neutrophilic infiltrates, subcorneal pustules, and vasculopathy were less frequently reported than what seen in COVID infection. Therefore, dermatologic reactions developing after vaccination in the general population should not hinder a complete vaccination.

Association of childhood vaccination with pediatric lichen planus: A systematic review

Lichen planus (LP) is a chronic T-cell-mediated mucocutaneous inflammatory disease, largely recognized in adults. It is uncommon in children, and the literature present still lacks comprehensive understanding mainly due to underreporting of such cases. LP shows atypical clinical features, when seen in children, mainly affecting the flexor aspect of the wrists, legs, and the oral and genital mucosae. It is largely considered an autoimmune response of the body with various etiologic factors. Its association with vaccination is still an interesting field for research. The focus of the present systematic review was to discover the link of vaccine in the pathogenesis of juvenile LP. An electronic search was carried out using MEDLINE by PubMed, Google Scholar, and Web of Science databases. Articles that reported LP in children with prior records for vaccination were selected for the present systematic review. Twenty-three published articles in the English language were included for the quantitative and qualitative syntheses. The demographic data, specific vaccine history, and clinical details of the lesions were recorded. The existing evidence supports that vaccines could play an important role in etiopathogenesis of pediatric LP.

[Vaccinations in dermatology]

Vaccinations are among the most successful prophylactic measures in medicine. As they are applied to healthy subjects, regulatory steps before licensing of any vaccination are strictly based on clinically controlled studies as well as on registry data in the further course. The probability and relevance of adverse reactions to vaccinations have to be weighed against any harm through the respective natural infection as well as the vaccination-induced protection against infections. Intolerance reactions to vaccinations are far more suspected than proven and altogether rare. Among these, specific dermatoses like psoriasis, atopic dermatitis and lichen planus are found as well as allergic reactions and a number of more nonspecific skin symptoms. Apart from provocation or exacerbation of an underlying dermatological disease, various intolerance reactions may be encountered which are classically allergologic or anaphylactoid. People with chronic dermatoses, especially those on immunosuppressive and immunomodulatory therapy, should have all recommended standard vaccinations. Vaccinations should not be administered during acute skin manifestations and relevant comedication-especially if immunomodulatory or immunosuppressive-has be taken into account in the decision to vaccinate and to define the time point of any vaccination. Inactivated vaccines may be administered even during ongoing immunosuppressive therapy, but may result in decreased immunological reactions and protection to infection. Live vaccines should be avoided.

Updates on the use of vaccines in dermatological conditions

Numerous vaccines are being actively developed for use in dermatologic diseases. Advances in the fields of immunotherapy, genetics and molecular medicine have allowed for the design of prophylactic and therapeutic vaccines with immense potential in managing infections and malignancies of the skin. This review addresses the different vaccines available for use in dermatological diseases and those under development for future potential use. The major limitation of our review is its complete reliance on published data. Our review is strictly limited to the availability of published research online through available databases. We do not cite any of the authors' previous publications nor have we conducted previous original research studies regarding vaccines in dermatology. Strength would have been added to our paper had we conducted original studies by our research team regarding the candidate vaccines delineated in the paper.

Injection Site Lichenoid Dermatitis Following Pneumococcal Vaccination: Report and Review of Cutaneous Conditions Occurring at Vaccination Sites

Background

Cutaneous dermatoses and malignancies have occurred at the sites of vaccines.

Purpose

To describe a man who developed a lichenoid dermatitis at the pneumococcal vaccine injection site and to review cutaneous dermatoses and malignancies occurring at vaccination sites.

Methods

PubMed was used to search the following terms, separately and in combination: adverse, condition, cutaneous, dermatosis, dermatitis, injection, PCV13, pneumococcal, pneumonia, prevnar, reaction, skin, site, vaccination, and vaccine. All papers were reviewed, and relevant manuscripts, along with their reference citations, were evaluated.

Results

Several vaccines—including bacillus Calmette-Guerin, hepatitis B, influenza, leishmaniasis, meningitis, pneumococcal, smallpox, tetanus (alone and in combination with diphtheria, pertussis, polio, Haemophilus influenza type B or plague and yellow fever), and varicella-zoster—have been associated with post-vaccination site reactions. A 70-year-old male developed a lichenoid dermatitis that occurred at the pneumococcal vaccine injection site within 2 weeks after PCV13 vaccination; the erythematous nodule resolved spontaneously within 9 weeks following immunization.

Conclusions

Dermatoses at the injection sites of vaccines can be granulomatous, immunity-related conditions, infections, lichenoid, neutrophilic, or pseudolymphomatous. Basal cell carcinoma and squamous cell carcinoma are the most common vaccination site-associated malignancies; however, melanoma and sarcomas (dermatofibrosarcoma protuberans, fibrosarcoma, and malignant fibrous histiocytoma) are also smallpox vaccine-related site neoplasms. A cutaneous immunocompromised district that is created by vaccine-induced local immunologic changes is hypothesized to be the pathogenesis of vaccination site reactions.

Hepatitis B vaccination and associated oral manifestations: a non-systematic review of literature and case reports

Hepatitis B vaccine has been administered in children and adults routinely to reduce the incidence of the disease. Even though, hepatitis B vaccine is considered as highly safe, some adverse reactions have been reported. A literature search was carried out in PubMed, accessed via the National Library of Medicine PubMed interface, searching used the following keywords: Hepatitis B vaccine and complications from 1980 to 2014. A total of 1147 articles were obtained out of which articles, which discuss the complications occurring orally or occurring elsewhere in the body, which have the potential to manifest orally after hepatitis B vaccination were selected. A total of 82 articles were identified which included 58 case series or case reports, 15 review articles, 4 cross sectional studies, 3 prospective cohort studies, one retrospective cohort study and a case control study. After reviewing the literature, we observed that complications seen after Hepatitis B vaccination are sudden infant death syndrome, multiple sclerosis, chronic fatigue syndrome, idiopathic thrombocytopenic purpura, vasculititis optic neuritis, anaphylaxis, systemic lupus erytymatosus, lichen planus and neuro-muscular disorder. Of these complications, some are manifested orally or have the potential to manifest orally. Although, most of the complications are self-limiting, some are very serious conditions, which require hospitalization with immediate medical attention.

Spontaneous and antiviral-induced cutaneous lesions in chronic hepatitis B virus infection

AIM

To describe spontaneous, or interferon (IFN)- or immunization-induced skin lesions in hepatitis B virus (HBV) infection.

METHODS

A comprehensive literature search of all the papers presenting case reports of dermatological lesions in patients with chronic HBV infection was carried out. We included only patients with histologically proven skin lesions that appeared in the normal course of hepatitis B infection, or after immunization for hepatitis B or antiviral treatment.

RESULTS

We found 44 papers on this topic, reporting 151 cases. About 2% of patients with hepatitis B infection, mainly men, presented with skin lesions. Among patients with chronic hepatitis B, vasculitis and essential mixed cryoglobulinemia seemed to be the most frequent skin lesion (53.3%), followed by papular changes, rashes and Gianotti-Crosti syndrome, skin carcinoma and Henoch-Schönlein purpura were rare. IFN treatment seemed to be effective against HBV-associated and immunoglobulin-complex-mediated disease (vasculitis). Two cutaneous lesions (lichen planus and granuloma annulare) were described after hepatitis B vaccination. Systemic lupus and lupus-like lesions were the most frequently encountered lesions after antiviral treatment. Immunosuppressive and steroid therapy ameliorates lichen planus lesions in 50% of cases.

CONCLUSION

Vasculitis was the most frequent spontaneous skin lesion found in chronic hepatitis B. Lichen planus was most frequent after immunization and lupus/lupus-like lesions after IFN.

A local reaction at or near injection site: case definition and guidelines for collection, analysis, and presentation of immunization safety data

The need for developing a case definition and guidelines for a local reaction at or near the injection site, methods for the development of the case definition and guidelines as an adverse event following immunization as well as the rationale for selected decisions about the case definition for a local reaction at or near the injection site are explained in the Preamble section. The case definition is structured in 2 levels of diagnostic certainty: level 1 includes any description of morphological or physiological change at or near the injection site that is described or identified by a healthcare provider. Level 2 is any description of morphological or physiological change at or near injection site that is described by any other person. In Guidelines section, the working group recommends to enable meaningful and standardized data collection, analysis, and presentation of information about a local reaction at or near the injection site. However, implementation of all guidelines might not be possible in all settings. The availability of information may vary depending upon resources, geographic region, and whether the source of information is a prospectively designed clinical trial, a post-marketing surveillance or epidemiologic study, or an individual report of a local reaction at injection site.

Cutaneous adverse reactions following anti-infective vaccinations

Although widely administered, anti-infective vaccinations are rarely responsible for cutaneous adverse effects. In this context, hepatitis B and bacillus Calmette-Guerin vaccines are the most frequently incriminated products. Cutaneous adverse effects are less frequently encountered following administration of vaccines against varicella, diphtheria/tetanus/pertussis (primary and booster doses), measles, poliomyelitis, rubella, pneumococcus, tick-borne encephalitis, smallpox, Meningococcus and influenza. The adverse effects can occur at the site of or at a distance from the injection. The patho-mechanisms of local adverse cutaneous reactions include predominantly nonspecific lymphoid or granulomatous reactions. Allergic reactions to the vaccine strain, adjuvants, conservatives or other components are less frequently involved in local vaccine adverse effects. Systemic reactions are mainly mediated by immediate type or immune complex-related allergic reactions to toxoid-, ovalbumin-, gelatin- or pneumococcal-containing vaccines. Systemic reactions are sometimes related to a specific vaccine strain. Other cutaneous reactions may also occur through unknown patho-mechanisms. No vaccine type or strain is specifically associated with a particular type of cutaneous adverse effect. This article presents seven case reports of cutaneous adverse effects following anti-infective vaccination then reviews the relevant literature on this subject.

Two case reports of cutaneous adverse reactions following hepatitis B vaccine: lichen planus and granuloma annulare

We report two cases of adverse cutaneous reactions following hepatitis B vaccination. The first case occurred 3 weeks after the first dose of hepatitis B vaccine in a 16-year-old white girl with the onset of lichen planus lesions on her thighs and abdomen. After the second dose a disseminated lichen planus developed within 2 weeks. The second case concerns to the development of papular and patch granuloma annulare in a 58-year-old white woman 2 months after the second dose of hepatitis B vaccine. To the best of our knowledge, only a few paediatric and adult cases of lichen planus as a complication of hepatitis B vaccination have been reported in medical literature so far. This is the second case of granuloma annulare following hepatitis B vaccine. Our report, similar to earlier papers, appears to support the onset of lichen planus and granuloma annulare as a possible rare complication of hepatitis B immunization.

A review of licensed viral vaccines, some of their safety concerns, and the advances in the development of investigational viral vaccines

Viral vaccines could be considered among the most important medical achievements of the 20th century. They have prevented much suffering and saved many lives. Although some curative antiviral drugs exist, we desperately depend on efforts by academic, governmental and industrial scientists in the advancement of viral vaccines in the prevention and control of infectious diseases. In the next decade, we hope to see advancement in the development of current and investigational viral vaccines against childhood and adult infections. In this article, we will review the licensed viral vaccines, some of their safety concerns, and the advances in the development of investigational viral vaccines.

Lichen planus induced by hepatitis B vaccination: a new case and review of the literature

In May 1996, as part of his routine antihepatitis B (hepB) vaccination plan, a 28-year-old HbsAg-negative man, hospital worker, received his first dose (20 microg) of a recombinant vaccine (EngerixB-B, Smith Kline and Beecham, Belgium), administered via deltoid injection. The patient was otherwise healthy and taking no medication. Thirty days after the 2nd booster dose, several pruritic, polygonal, purple, papules appeared on the volar aspect of the patient's wrists. New lesions gradually spread to the arms and trunk (Fig. 1). The clinical diagnosis of lichen planus (LP) was confirmed by histology, which revealed hyperorthokeratosis, hypergranulosis, vacuolar degeneration of the basal layer cells and a dense, band-like lymphocytic infiltrate in the superficial dermis. The disease started to heal after treatment with topical clobetasol propionate 0.05% and sun exposure during the following summer. Five days after the 3rd booster dose, in November 1996, the dermatosis relapsed on the forearms, trunk, and legs. On that occasion, routine laboratory tests, including a complete blood count, blood chemistry and liver function tests, were within normal limits. Screening serologic tests for autoantibodies including antinuclear antibodies, antidouble-stranded DNA, anti-SS-A, anti-SS-B and anti-Sm were all negative. As a result of the inadequate levels of antihepatitis B antibodies, less than 10 IU/l in May 1998, in a high-risk patient who was frequently exposed to blood and its products, an additional booster dose was performed. Three days later a new recurrence of disseminated lichen planus occurred. The patient was successfully treated with prednisone 1 mg/kg/day for 2 weeks. There was no recurrence the following year.

Vaccines and immunotherapies for the prevention of infectious diseases having cutaneous manifestations

Although the development of antimicrobial drugs has advanced rapidly in the past several years, such agents act against only certain groups of microbes and are associated with increasing rates of resistance. These limitations of treatment force physicians to continue to rely on prevention, which is more effective and cost-effective than therapy. From the use of the smallpox vaccine by Jenner in the 1700s to the current concerns about biologic warfare, the technology for vaccine development has seen numerous advances. The currently available vaccines for viral illnesses include Dryvax for smallpox; the combination measles, mumps, and rubella vaccine; inactivated vaccine for hepatitis A; plasma-derived vaccine for hepatitis B; and the live attenuated Oka strain vaccine for varicella zoster. Vaccines available against bacterial illnesses include those for anthrax, Haemophilus influenzae, and Neisseria meningitidis. Currently in development for both prophylactic and therapeutic purposes are vaccines for HIV, herpes simplex virus, and human papillomavirus. Other vaccines being investigated for prevention are those for cytomegalovirus, respiratory syncytial virus, parainfluenza virus, hepatitis C, and dengue fever, among many others. Fungal and protozoan diseases are also subjects of vaccine research. Among immunoglobulins approved for prophylactic and therapeutic use are those against cytomegalovirus, hepatitis A and B, measles, rabies, and tetanus. With this progress, it is hoped that effective vaccines soon will be developed for many more infectious diseases with cutaneous manifestations.

Lichen planus in children: a possible complication of hepatitis B vaccines

Lichen planus (LP) has been reported as a complication of hepatitis B vaccination in both adults and children. According to published observations, an autoimmune reaction may be triggered by the viral S epitope. In children, LP is uncommon and, because of its atypical clinical presentation, definitive diagnosis may require biopsy. We investigated the possible association of recombinant hepatitis B virus (HBV) vaccines with childhood LP or LP-like eruptions seen in our hospital over the last 3 years. Only biopsy-confirmed cases in which the clinical history could be thoroughly scrutinized were included. We report five patients less than 16 years of age in whom such an association could be supported by relevant data. Thirteen similar pediatric and 15 adult cases have been reported from various countries in the last 5 years. The data indicate that LP is a complication that rarely occurs in children receiving the HBV vaccine. It appears without known predisposing factors and has variable clinical presentations while the histologic findings are consistent and, with minor variations, typical of LP.

Lichen planus following hepatitis B vaccination in an African girl

Lichen planus is a papulosquamous disorder with distinctive clinical features. Until now the aetiology has been largely unknown, however, several postulations have been proposed. The immunopathogenic basis has been most favoured. We report a case of a 13-year-old girl who presented with Lichen planus after receiving the second dose of hepatitis B virus (HBV) vaccination. This report, similar to earlier reports, appears to support the immunopathogenic basis of Lichen planus.

Lichenoid eruption following hepatitis B vaccination: first North American case report

Lichen planus is often found in association with a variety of underlying conditions. In particular, liver diseases such as primary biliary cirrhosis, primary sclerosing cholangitis, hepatitis C, and hepatitis B have been implicated in cutaneous lichen planus. Of interest, there is mounting evidence that lichen planus-like eruptions can occur following administration of the hepatitis B vaccine, which has recently become a routine immunization in many parts of the world. We present what we believe to be the first North American case of lichenoid drug eruption associated with the hepatitis B vaccine and provide a brief review of other reported cases of lichenoid eruption seen following hepatitis B vaccination.

Lichen planus after HBV vaccination in a child: a case report from Nepal

Vaccination against hepatitis B virus has rarely been associated with lichen planus. We report a case of this kind in a child from Nepal. A 12-year-old boy had developed generalized itchy violaceous papules and plaques six weeks after the second dose of hepatitis B virus vaccine. Serum HBsAg and HBeAb were negative, but HBsAb was positive. New crops of generalized, similar eruptions developed after the booster dose of vaccine. All the lesions resolved within three months of systemic steroid therapy. There was no recurrence after one year of follow up. Awareness of such an association is necessary, especially in children, because vaccination campaigns are increasing.

Oral lichenoid lesions after hepatitis B vaccination

The association of mucocutaneous lichen planus and chronic liver disease is widely recognized. The hepatitis B and C viruses have been implicated as being important in this association, although their exact role remains unclear. Recently, lichenoid lesions of the skin after a hepatitis B vaccination have also been reported. In this case, a woman of Southeast Asian origin had lichenoid lesions affecting the oral mucous membranes develop after she was vaccinated against hepatitis B. The lesions appeared 3 weeks after the administration of the third dose of the vaccine and persisted for about 1 year. As the use of the hepatitis B vaccine becomes more widespread, more such cases can be expected to be encountered.