Commentary on "Potential risk factors for Varicella-zoster virus reactivation after COVID-19 vaccination".

Dear Editor,

We read with great interest the article “Potential risk factors for Varicella‐zoster virus reactivation after COVID‐19 vaccination” by May Lee et al. recently published in the Journal of Cosmetic Dermatology. As stated by the authors, various vaccines have been developed to control the spread of the virus during the COVID‐19 pandemic period, and more and more attention is paid to the negative effects of their application. The authors made an update by analyzing 93 cases and assessed the risk of Varicella‐zoster virus (VZV) reactivation after COVID‐19 vaccination. There was no significant difference between men and women (44 men and 49 women). Most of the cases with VZV reactivation occurred secondary to mRNA vaccines. Most cases developed after the first dose of the vaccine rather than the second dose (67 vs. 21; 5 not specified). Post‐injection onset time was highly variable (between 1 and 38 days), with a mean of 8.6 ± 7.2 days. The mean age of the patients was 57.8 ± 17.3 years. Most patients improved with standard antiviral therapy (acyclovir or valacyclovir).

Here, we would like to take the opportunity to point out two more patients who developed VZV reactivation after the first dose of whole‐virion inactivated SARS‐CoV‐2 vaccine (CoronoVac). Both patients, a 74‐year‐old man (Figure 1A and B) and a 43‐year‐old woman (Figure 1C–E), respectively, had no previous history of shingles and had started seven days after the first dose of the vaccine. Case 1, who was 74 years old, had no history of disease. Case 2 had undergone an operation for ovarian carcinoma one year ago and then received chemotherapy and radiotherapy for six months, but she had not been using any medication for the last six months. Both of our patients had no history of emotional or physical stress, any other infection, sun exposure, or immunosuppression. The shingles lesions of case 1 were in the T11‐T12 dermatomes, and the lesions of case 2 were in the L3‐L4 dermatomes. The development of shingles after vaccination was seven days in both of our patients, which is close to the average in the review of May Lee et al. Again, both of our patients were successfully treated with valacyclovir in accordance with the literature.

FIGURE 1

(A and B) Clinical appearance of case 1, (C) clinical appearance of case 2 at first admission; (D and E) appearance of case 2 on the fifth day of treatment

COVID‐19 is an emerging multisystem disease that can present with a wide variety of skin manifestations.  Morbilliform erythematous rash, chickenpox‐like lesions, diffuse urticaria, COVID toe, and miscellaneous lesions are the major cutaneous manifestations announced during COVID‐19 outbreaks. ,  This pandemic caused significant changes in the profile of patients who applied to dermatology outpatient clinics. Both COVID‐19 and viral transmission, non‐replicating viral vector vaccines, DNA or RNA‐based vaccines, and inactivated vaccines have been improved lately. In some countries including Turkey, which started the vaccination program in January 2021, the use of a whole‐virion inactivated SARS‐CoV‐2 vaccine is permitted. The most frequently reported side effects of inactivated vaccines are swelling at the injection site and pain, nausea, vomiting, headache, fever, and skin rash. ,

VZV remains hidden in neurons of the dorsal root ganglion, autonomic ganglion, and cranial nerve ganglion after a chickenpox attack. The shingles caused by reactivation of VZV may occur spontaneously or be triggered by fever, immunosuppression, stress, or trauma. , As a possible explanation for VZV reactivation, in an agreement with May Lee et al, we also support the hypothesis of an immunomodulation mechanism triggered by vaccination.

CONFLICT OF INTEREST

We declare that there is no conflict of interest of all authors in this work. No financial support was provided for the conduct, collection, preparation, interpretation, analysis, and writing of the report. Informed consent and permission for publication of medical images were obtained from the patient.

AUTHOR CONTRIBUTION

Dursun Turkmen involved in supervision, conceptualization, visualization, and writing—original draft. Nihal Altunisik involved in conceptualization and data curation. Sibel Altunisik Toplu involved in data curation.

INFORMED CONSENT

The patients gave the consent for photograph acquisition and publication.

ETHICAL APPROVAL

Prepared in accordance with ethical rules.