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Table of Contents
Year : 2023  |  Volume : 41  |  Issue : 1  |  Page : 52-53

Dyshidrotic bullous pemphigoid developing after Moderna mRNA-1273 vaccination

Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan

Date of Submission30-Jul-2022
Date of Decision27-Nov-2022
Date of Acceptance17-Dec-2022
Date of Web Publication27-Mar-2023

Correspondence Address:
Prof. Tsen-Fang Tsai
Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ds.DS-D-22-00121

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How to cite this article:
Hsieh TS, Chen JS, Tsai TF. Dyshidrotic bullous pemphigoid developing after Moderna mRNA-1273 vaccination. Dermatol Sin 2023;41:52-3

How to cite this URL:
Hsieh TS, Chen JS, Tsai TF. Dyshidrotic bullous pemphigoid developing after Moderna mRNA-1273 vaccination. Dermatol Sin [serial online] 2023 [cited 2023 May 31];41:52-3. Available from: https://www.dermsinica.org/text.asp?2023/41/1/52/372602

Dear Editor,

A 94-year-old female presented to our dermatology department in late February 2022 with sudden onset of large bullae eruption on the soles of her feet 18 days after her second dose of the Moderna mRNA-1273. She was otherwise healthy, except for itching skin and rashes on her trunk—diagnosed as winter pruritus—11 days after the second dose. She denied any concurrent use of medication during the vaccination period. At presentation to our department, the patient had several tense bullae, first over bilateral feet [Figure 1]a. The bullae then rapidly enlarged [Figure 1]b. Several tense vesicles also develop on the palms [Figure 1]c. Based on a diagnosis of pompholyx or dyshidrotic bullous pemphigoid (BP), oral prednisolone, 30 mg, and KMnO4 soaking were administered. Blood tests showed enzyme-linked immunosorbent assay (ELISA) BP 180 immunoglobulin G (IgG) (Euroimmun) was over 200 RU/mL, but the indirect immunofluorescence result was negative. One week afterward, the patient started to develop itchy erythematous papules on the trunk and bilateral thighs [Figure 1]d, which failed to respond to topical clobetasol propionate. A biopsy from the right thigh showed perivascular and interstitial infiltrate of lymphocytes, as well as numerous eosinophils in the dermis accompanied by basal vacuolar degeneration [Figure 1]e, with C3 linear deposition at the basement membrane zone [Figure 1f]. The picture was consistent with BP. The eruption resolved after oral prednisolone, 30 mg, for 1 week. The dose of oral prednisolone was gradually tapered to 10 mg currently with no new vesicles. The ELISA BP 180 IgG (Euroimmun) also decreased to 177 RU/mL a month later.
Figure 1: (a) First appearance of tense vesicles and bullae on the right sole (b) Tense bullae on the right sole (c) Some smaller vesicles also developed on the erythematous base of the left palm (d) Erythematous papules on the right thigh 1 week after the eruption of vesicles on palms and soles (e) Perivascular and interstitial infiltrate of lymphocytes and numerous eosinophils in the dermis, accompanied by basal vacuolar degeneration (H and E, ×20) (f) Linear deposition of C3 noted on DIF. DIF: Direct immunofluorescence

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BP is an autoimmune subepidermal blistering disorder characterized by autoantibodies against basement membrane zone antigens. Dyshidrotic pemphigoid (DP) is a rare variant of localized BP that primarily affects the hands and feet which presents with tense hemorrhagic blisters and bullae on palms or soles, which tends to spread to other parts of the body. It exhibits the same histopathological, immunofluorescence features, and treatment response as the classic BP.[1]

Several case reports exist for the development of BP following either the first or second dose of COVID-19 vaccination.[2] The latency time varies from 12 hours to 21 days, with a mean of 7 days. The appearance of BP and other autoimmune bullous diseases are also observed after other vaccinations, including influenza, hepatitis B, tetanus, and herpes zoster vaccines.[3] The clinical presentation of our patient is similar to a case reported by Hung 2022,[4] both cases have predominantly lesions on palms and soles. The differences include the time interval of developing the lesions-1 month after the first vaccination and the underlying disease of psoriasis, which may be possible triggering factors.

Gambichler et al. utilized methods of TCRMatch and suggested some of the expanded T-cell clones in the patients might also be reactive to SARS-CoV-2 derived epitopes,[5] which may provide an explanation and possible causal relationship of BP developing after COVID-19 vaccination.

Although it is challenging to establish the exact causal relationship, drug-associated BP should be considered in an acute and definite resolution following the withdrawal of the drug.[6] A similar concept might also theoretically apply to vaccination-induced BP. Seven out of 12 cases in the patients with BP following COVID-19 vaccination showed either improving or resolved lesions.[2] In our case, the clinical course of DP appears transient and has complete resolution following the treatment. Although there are limited cases of DP following COVID vaccination reported to our knowledge,[4],[7] DP should be considered in patients who present with vesiculobullous eruptions on the soles and/or palms shortly following COVID-19 vaccination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent, in which the patient has given consent for her images and other clinical information to be reported in the journal. The patient understands that the name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

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Conflicts of interest

Prof. Tsen-Fang Tsai, an editorial board member at Dermatologica Sinica, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.

  References Top

Basseri S, Ly TY, Hull PR. Dyshidrotic bullous pemphigoid: Case report and review of literature. J Cutan Med Surg 2018;22:614-7.  Back to cited text no. 1
Tomayko MM, Damsky W, Fathy R, McMahon DE, Turner N, Valentin MN, et al. Subepidermal blistering eruptions, including bullous pemphigoid, following COVID-19 vaccination. J Allergy Clin Immunol 2021;148:750-1.  Back to cited text no. 2
Kasperkiewicz M, Woodley DT. Association between vaccination and autoimmune bullous diseases: A systematic review. J Am Acad Dermatol 2022;86:1160-4.  Back to cited text no. 3
Hung WK, Chi CC. Incident bullous pemphigoid in a psoriatic patient following mRNA-1273 SARS-CoV-2 vaccination. J Eur Acad Dermatol Venereol 2022;36:e407-9.  Back to cited text no. 4
Gambichler T, Hamdani N, Budde H, Sieme M, Skrygan M, Scholl L, et al. Bullous pemphigoid after SARS-CoV-2 vaccination: Spike-protein-directed immunofluorescence confocal microscopy and T-cell-receptor studies. Br J Dermatol 2022;186:728-31.  Back to cited text no. 5
Verheyden MJ, Bilgic A, Murrell DF. A systematic review of drug-induced pemphigoid. Acta Derm Venereol 2020;100:adv00224.  Back to cited text no. 6
Shanshal M. Dyshidrosiform bullous pemphigoid triggered by COVID-19 vaccination. Cureus 2022;14:e26383.  Back to cited text no. 7


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