Toxic epidermal necrolysis and Stevens‐Johnson syndrome after COVID‐19 infection and vaccination

Abstract

Stevens‐Johnson Syndrome (SJS) is a rare but severe skin reaction characterized by blistering and peeling of the skin and ulcerations of mucous membranes; toxic epidermal necrolysis (TEN) is a subset of SJS characterized by the involvement of >30% of the skin. Though previously associated with drugs and infections, discussions on the association between TEN/SJS and COVID‐19 have been limited. We present a review of TEN/SJS after COVID‐19 infection and vaccination. Literature searches were conducted on PubMed and Google Scholar from 2019 to 8/2022. Thirty‐eight articles were selected based on subject relevance, and references within selected articles were also screened for relevance. As of 8/2022, there have been 34 published cases of TEN, SJS, and SJS‐TEN overlap after COVID‐19 infection and vaccination, including 12 cases after vaccination and 22 cases after infection. Multiple authors hypothesize that virotopes or excipients in COVID‐19 vaccines can activate T‐cells or cytokines to induce TEN/SJS. Meanwhile, some hypothesize that COVID‐19 infection induces immune activation that can trigger TEN/SJS or increase susceptibility to drug‐induced TEN/SJS. Treatments for post‐infection and post‐vaccination TEN/SJS vary significantly. We recommend remaining vigilant for this rare and severe potential complication.

Ophthalmic Aspects of Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis: A Narrative Review

“…Only case reports and small sample-size case series are available in the literature on the association between infection and SJS/TEN. Mycoplasma pneumoniae , coxsackievirus A6 and COVID-19 have been reported to cause SJS/TEN [ 22 , 23 ]. A microbiological study reported that higher germ counts of Pseudomonas spp., Streptococcus ssp., Acinetobacter ssp.…”

Cutaneous reactions secondary to COVID‐19 vaccination

“…Most of these reactions are self‐limiting and can be managed in primary care with emollients, antihistamines and topical corticosteroids, if required. Although less common, cutaneous reactions following vaccination that require secondary care input include inflammatory conditions such as eczema and psoriasis, neutrophilic dermatoses, and autoimmune disorders ( eg cutaneous lupus erythematous, 14‐16 alopecia areata, 16‐18 autoimmune bullous disorders and severe cutaneous adverse reactions [SCARs]) 19 …”

“…SCARs secondary to COVID‐19 vaccination are increasingly recognised in case reports and case series 19,29‐31 . SCARs include AGEP, drug reaction with eosinophilia and systemic symptoms (DRESS), SJS and toxic epidermal necrolysis (TEN).…”

“…Messenger RNA vaccines were suspected in four out of 12 patients, viral vector vaccines (Oxford/AstraZeneca) in three cases and the Sinopharm vaccine (an inactivated virus vaccine not administered in the UK) in five patients. Latency between vaccination and onset of symptoms ranged from one to 20 days 19 …”

New insights into the diagnosis and management of Stevens–Johnson syndrome and toxic epidermal necrolysis

“…Drugs especially antimicrobials, antipyretic analgesics and sulfa drugs are the primary cause of SJS/TEN, but Mycoplasma or viral infections can also be triggers [1]. In recent years, there have been reports of SJS/TEN due to immune checkpoint inhibitors (ICIs) [2] and coronavirus disease 2019 (COVID-19) vaccination or infection [3]. Clinically, severity is distinguished based on the amount of skin detachment: SJS < 10%, SJS/TEN overlap of 10-30%, and TEN > 30% [4].…”