Autoimmune Skin Disease Exacerbations Following COVID-19 Vaccination

Abstract

Background: Vaccination against COVID-19 reduces the risk of severe COVID-19 disease and death. However, few studies have examined the safety of the COVID-19 vaccine in patients with autoimmune skin disease.

Objectives: We sought to determine the incidence of disease exacerbation in this population following COVID-19 vaccination as well as the associated factors.

Methods: We performed a chart review of all patients seen in the autoimmune skin disease clinic of the principal investigator during the study period. All patients included for analysis were systematically and prospectively asked about COVID-19 vaccination status, manufacturers, vaccine dates, autoimmune symptoms after the vaccine, and timing of symptom onset using a standardized template as part of their visit. Demographics and autoimmune disease diagnosis were also collected. Analysis used Chi-square and Fisher's exact tests.

Results: 402 subjects were included for analysis. 85.6% of patients were fully vaccinated, with 12.9% unvaccinated and 1.5% partially vaccinated. 14.8% of fully vaccinated patients reported worsening autoimmune signs and symptoms after the vaccine. Fully vaccinated dermatomyositis patients were more likely to report worsening autoimmune signs and symptoms after the vaccine (22.7%) than fully vaccinated lupus erythematosus patients (8.6%) (p=0.009). Patients fully vaccinated with the Moderna vaccine trended towards an increased likelihood of reporting worsening autoimmune signs and symptoms after the vaccine (19.1%) than those with the Pfizer-BioNTech vaccine (12.0%) (p=0.076). Of the patients who had autoimmune symptoms after vaccination, 20% had symptoms after the 1st dose, 82% after the 2nd dose, and 4% after the 3rd dose with median onset (95% confidence interval) of 7 (2,14), 14 (14,21), and 18 (7,28) days later, respectively.

Conclusions: More fully vaccinated dermatomyositis patients had exacerbation of autoimmune signs and symptoms after the vaccine than fully vaccinated lupus erythematosus patients. However, given the risks of COVID-19, clinicians should still promote vaccination in most patients with autoimmune skin disease.

Keywords: COVID-19; autoimmune; connective tissue disease; skin; vaccination.

Figure 1

The percent of fully vaccinated patients reporting symptoms of autoimmune disease exacerbation after the COVID-19 vaccine by diagnosis, highlighting the higher incidence in dermatomyositis patients compared to lupus erythematosus patients. **P ≤ 0.01.

Figure 2

The percent of fully vaccinated patients reporting symptoms of autoimmune disease exacerbation after the COVID-19 vaccine by diagnosis, highlighting the variation across all diagnoses seen.

Figure 3

The percent of fully vaccinated patients reporting symptoms of autoimmune disease exacerbation after the COVID-19 vaccine by vaccine manufacturer, highlighting the trend of increased incidence with the Moderna vaccine. NS, Not significant.

Figure 4

The COVID-19 vaccination status of lupus erythematosus and dermatomyositis patients is shown here. A higher proportion of dermatomyositis patients were fully vaccinated compared to lupus erythematosus patients.

Figure 5

The proportion of fully vaccinated lupus erythematosus and dermatomyositis patients is seen here by racial background (white and Black). In both diseases, a higher proportion of white patients were fully vaccinated compared to Black patients.

Figure 6

The percent of patients who are fully vaccinated, partially vaccinated, and unvaccinated within each diagnosis, highlighting the variation across all diagnoses seen.