Case and Research Letters
Morphea and Extragenital Lichen Sclerosus et Atrophicus After Influenza Vaccination
Morfea y liquen escleroatrófico extragenital generalizados tras vacuna antigripal
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"apellidos" => "Plazas-Fernandez" ] 4 => array:1 [ "colaborador" => "on behalf to EPIQA Study Group" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901730402X?idApp=UINPBA000044" "url" => "/15782190/0000010900000001/v1_201801020547/S157821901730402X/v1_201801020547/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Morphea and Extragenital Lichen Sclerosus et Atrophicus After Influenza Vaccination" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor</span>:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "86" "paginaFinal" => "88" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Requena López, Y. Hidalgo García, S. Gómez Díez, B. Vivanco Allende" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Requena López" "email" => array:1 [ 0 => "sheilarequenalopez@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Y." "apellidos" => "Hidalgo García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Gómez Díez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "B." "apellidos" => "Vivanco Allende" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Morfea y liquen escleroatrófico extragenital generalizados tras vacuna antigripal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 650 "Ancho" => 975 "Tamanyo" => 113355 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Thin, wrinkled, atrophic skin with a cigarette-paper appearance on the patient's back.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Morphea and lichen sclerosus et atrophicus (LSA) are 2 chronic skin diseases of unknown etiology and pathogenesis. A possible relationship with genetic, autoimmune, and infectious factors has been proposed. Very few cases have been reported after the administration of vaccines.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 67-year-old woman with a past history of breast cancer treated by radical mastectomy and implantation of a silicone prosthesis 15 years earlier, was referred to our department for pruritus and progressive induration of the skin. She had not received radiotherapy after her mastectomy and was taking no drugs of interest. She reported the onset of symptoms 10 days after having received the first dose of 0.5<span class="elsevierStyleHsp" style=""></span>ml of Chiroflu, an influenza vaccine of inactivated surface antigen, administered intramuscularly into her left deltoid muscle. The lesion was initially limited to her left deltoid region, the site of injection of the vaccine. However, generalized lesions gradually developed, respecting only her face and causing difficulty of movement, particularly of her shoulders and knees. Physical examination revealed large, indurated, pearly white plaques in some areas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and atrophic and wrinkled skin in other areas (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Additional tests, including complete blood count, biochemistry, antinuclear, anti-scl 70, and anticentromere antibodies, and serology for <span class="elsevierStyleItalic">Borrelia burgdorferi</span>, were normal or negative. Skin biopsy showed an atrophic epidermis with follicular occlusion and degeneration of the basal layer, edema of the papillary dermis, collagen with a hyalinized appearance, and a band-like lymphocytic infiltrate. The same sample also showed a thickened reticular dermis with thick and compact collagen bundles and a chronic inflammatory infiltrate (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Based on these clinical and histopathological findings, we made a diagnosis of morphea and generalized extragenital LSA and started treatment with oral psoralen–UV-A (PUVA). Given the poor response after 48 treatment sessions, oral prednisone, 20<span class="elsevierStyleHsp" style=""></span>mg/d, was prescribed in combination with subcutaneous methotrexate, 15<span class="elsevierStyleHsp" style=""></span>mg/wk, leading to a significant important in the induration and in mobility after 3 months of treatment, and it was possible to discontinue treatment after 10 months.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">LSA and morphea are skin diseases of unknown etiology, though in many studies they are considered to be autoimmune diseases. They have been associated with infections, trauma, and, less frequently, with the administration of vaccines. We found 14 cases of vaccine-related morphea<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–6</span></a> and a single case of LSA.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> However, only 2 of these cases were of generalized morphea (the vaccines implicated in these cases were bacillus Calmette-Guérin [BCG]<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> and tetanus<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a>), and neither occurred concomitantly with LSA.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The vaccine implicated in our patient was the inactivated surface antigen influenza vaccine, Chiroflu. This vaccine is recommended for seasonal influenza prophylaxis in persons over 65 years of age, health staff, pregnant women, individuals with respiratory or cardiac diseases, and immunodeficient patients.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Apart from the known adverse effects of vaccination, temporally or geographically related dermatoses have been reported after the intramuscular injection of vaccines, including granuloma annulare after hepatitis B, BCG, or tetanus vaccines, lichen planus after hepatitis B vaccine, and bullous pemphigoid after hepatitis B, DTP (diphtheria, tetanus, pertussis), or influenza vaccines. A temporal relationship was observed between influenza vaccination and the onset of morphea in our patient and, in addition, the first lesion developed at the site of injection of the vaccine. The role of this vaccine in the pathogenesis of morphea is poorly understood, but, as Torrelo et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> suggest, vaccines may stimulate an immune response targeting not only specific antigens of the vaccine but also other nonspecific antigens. An alternative proposal is that the trauma of the injection may cause endothelial damage and tissue hypoxia that could favor the development of morphea-type sclerosis. Trauma is associated with inflammation and the release of cytokines and growth factors, which contribute to the wound healing process at the site of vaccination and to the appearance of sclerosis or morphea.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The coexistence of morphea and LSA continues to be controversial, as some authors consider LSA to be a variant of morphea, with more superficial involvement, while others consider the diseases to be sufficiently different, both clinically and histopathologically, to be considered distinct diseases.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8–10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A number of treatments have been attempted, including high-potency topical corticosteroids, systemic corticosteroids, methotrexate, and psoralen–UV-A PUVA, all with little efficacy.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We have described this case because of the limited number of reports of generalized morphea after vaccination. This is the first to occur after influenza vaccination.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López SR, García YH, Díez SG, Allende BV. Morfea y liquen escleroatrófico extragenital generalizados tras vacuna antigripal. Actas Dermosifiliogr. 2018;109:86–88.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 621 "Ancho" => 975 "Tamanyo" => 92980 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Large, intensely indurated, pearly white areas on the abdomen.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 650 "Ancho" => 975 "Tamanyo" => 113355 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Thin, wrinkled, atrophic skin with a cigarette-paper appearance on the patient's back.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1295 "Ancho" => 975 "Tamanyo" => 607127 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histopathology showing an atrophic epidermis, collagen with a hyalinized appearance, and a band-like lymphocytic infiltrate. The reticular dermis is thickened, and contains thick and compact collagen bundles. Stain for elastic fibers, original magnification<span class="elsevierStyleHsp" style=""></span>×100.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deep morphea after vaccination in two young children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Torrelo" 1 => "J. Suárez" 2 => "I. Colmenero" 3 => "D. Azorín" 4 => "A. Perera" 5 => "A. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 25 | 9 | 34 |
| 2024 Octubre | 162 | 47 | 209 |
| 2024 Septiembre | 183 | 35 | 218 |
| 2024 Agosto | 210 | 52 | 262 |
| 2024 Julio | 177 | 45 | 222 |
| 2024 Junio | 163 | 32 | 195 |
| 2024 Mayo | 155 | 54 | 209 |
| 2024 Abril | 138 | 31 | 169 |
| 2024 Marzo | 201 | 38 | 239 |
| 2024 Febrero | 171 | 35 | 206 |
| 2024 Enero | 168 | 32 | 200 |
| 2023 Diciembre | 168 | 30 | 198 |
| 2023 Noviembre | 181 | 51 | 232 |
| 2023 Octubre | 220 | 32 | 252 |
| 2023 Septiembre | 160 | 31 | 191 |
| 2023 Agosto | 157 | 23 | 180 |
| 2023 Julio | 223 | 46 | 269 |
| 2023 Junio | 134 | 20 | 154 |
| 2023 Mayo | 164 | 31 | 195 |
| 2023 Abril | 148 | 40 | 188 |
| 2023 Marzo | 160 | 36 | 196 |
| 2023 Febrero | 139 | 36 | 175 |
| 2023 Enero | 104 | 39 | 143 |
| 2022 Diciembre | 143 | 41 | 184 |
| 2022 Noviembre | 116 | 46 | 162 |
| 2022 Octubre | 103 | 35 | 138 |
| 2022 Septiembre | 66 | 73 | 139 |
| 2022 Agosto | 40 | 43 | 83 |
| 2022 Julio | 85 | 51 | 136 |
| 2022 Junio | 89 | 43 | 132 |
| 2022 Mayo | 172 | 57 | 229 |
| 2022 Abril | 222 | 66 | 288 |
| 2022 Marzo | 222 | 66 | 288 |
| 2022 Febrero | 246 | 47 | 293 |
| 2022 Enero | 320 | 66 | 386 |
| 2021 Diciembre | 202 | 49 | 251 |
| 2021 Noviembre | 209 | 54 | 263 |
| 2021 Octubre | 230 | 72 | 302 |
| 2021 Septiembre | 197 | 44 | 241 |
| 2021 Agosto | 179 | 71 | 250 |
| 2021 Julio | 132 | 30 | 162 |
| 2021 Junio | 144 | 37 | 181 |
| 2021 Mayo | 160 | 56 | 216 |
| 2021 Abril | 327 | 71 | 398 |
| 2021 Marzo | 229 | 40 | 269 |
| 2021 Febrero | 140 | 27 | 167 |
| 2021 Enero | 123 | 23 | 146 |
| 2020 Diciembre | 139 | 26 | 165 |
| 2020 Noviembre | 101 | 28 | 129 |
| 2020 Octubre | 89 | 26 | 115 |
| 2020 Septiembre | 76 | 26 | 102 |
| 2020 Agosto | 60 | 25 | 85 |
| 2020 Julio | 50 | 18 | 68 |
| 2020 Junio | 58 | 47 | 105 |
| 2020 Mayo | 35 | 30 | 65 |
| 2020 Abril | 30 | 15 | 45 |
| 2020 Marzo | 38 | 22 | 60 |
| 2020 Febrero | 3 | 0 | 3 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 2 | 0 | 2 |
| 2019 Julio | 6 | 0 | 6 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 5 | 0 | 5 |
| 2019 Abril | 2 | 0 | 2 |
| 2019 Marzo | 2 | 0 | 2 |
| 2018 Diciembre | 5 | 0 | 5 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Septiembre | 6 | 0 | 6 |
| 2018 Febrero | 88 | 28 | 116 |
| 2018 Enero | 206 | 37 | 243 |
| 2017 Diciembre | 12 | 21 | 33 |
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