Acantholytic Dyskeratosis Post-COVID-19 Vaccination: Another Case With Rapid Response to Isotretinoin.

Abstract

To the Editor: We read with interest the case report of Yang et al,1 published in your Journal. We have recently seen another similar case after Sinovac COVID-19 vaccination. A 71-year-old man was seen at the beginning of 2022 with a 1-year pruriginous eruption of the trunk. The lesions consisted of reddish macules and papules distributed on the chest, abdomen, and back. Some papules were covered by a superficial crust. A skin biopsy showed an epidermis with suprabasal acantholysis and some dyskeratotic cells compatible with acantholytic dyskeratosis; the dermis presented a moderate inflammatory infiltration, predominantly lymphocytic, with a superficial perivascular distribution. Based on those clinical and histopathologic findings, Grover disease was diagnosed. His rash had appeared 1 month after the second dose of Sinovac COVID-19 vaccine. He was initially treated with topical corticoids without response. Routine laboratory tests including complete blood cell count and liver profile were normal; the glucose level was 108 mg/dL. He was treated then with oral isotretinoin, starting with 10 mg daily. One month later, an important response was observed, with the absence of pruritus and a noticeable regression of his lesions; the dose was increased to 15 mg daily. Two months after, almost no lesions were detected; thus, isotretinoin was diminished progressively to 20 mg weekly until total suspension, with a complete recovery after 7 months and without relapses until to date. To the best of our knowledge, besides the case of Yang et al,1 there is only 1 report including 2 other cases of acantholytic dyskeratosis post–COVID-19 vaccination: a 66-year-old man, 7 days after a COVID-19 vaccine (type of vaccine not described), and another 72-year-old man, 4 days after the second dose of the Moderna vaccine.2 Oral isotretinoin has been scarcely used previously in Grover disease, with few published cases.3,4 In a series of 4 patients, the dose used was 40 mg daily, with improvement of the eruption and pruritus between the second and fourth weeks. The patients were treated for 2–4 months and had no recurrences after a 10-month follow-up period.3 In another publication, 30 mg was the initial dose for 2 months and 40 mg for another 4 months in 1 patient, being then discontinued due to extensive myalgia and replaced by topical adapalene.4 In our case, the dose of isotretinoin was significantly lower (10 mg/d) and a good response was noticed from the beginning (Fig. 1).FIGURE 1.: Red papules on the trunk, some of them covered by a crust.Adverse skin reactions to vaccine, specifically Moderna or Pfizer, have been principally eczematous or urticarial in type. More infrequent manifestations to vaccine include perniosis, pityriasis rosea, psoriasis guttata, and exceptionally acantholytic dyskeratosis.2 To the best of our knowledge, this is the first case of acantholytic dyskeratosis post–COVID-19 vaccine due to Sinovac vaccine.