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Indian J Dermatol
Indian J Dermatol
IJD
Indian J Dermatol
Indian Journal of Dermatology
0019-5154
1998-3611
Wolters Kluwer - Medknow India

IJD-69-341
10.4103/ijd.ijd_794_23
Correspondences
A Case of Progressive Lipoatrophy due to Lupus Erythematosus Panniculitis Induced by Quadrivalent Human Papillomavirus Vaccine
Kawano Nao
Shiratori Takahiro
From the Department of Dermatology, Kishiwada City Hospital, Kishiwada, Japan E-mail: hewuiewskau0346@yahoo.co.jp
Jul-Aug 2024
19 8 2024
69 4 341342
8 2023
5 2024
Copyright: © 2024 Indian Journal of Dermatology
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
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pmcDear Editor,

Lupus erythematosus panniculitis (LEP) typically presents as deep nodules or plaques on the skin of the trunk and proximal extremities. Several cases of systemic lupus erythematosus (SLE) developing after human papillomavirus (HPV) vaccination have been reported,[1] although SLE is uncommon in LEP.

A 21-year-old Japanese woman with suspected localised scleroderma on both the upper arms and no medical or family history of autoimmune disease presented to our department. At the age of 15 years, the patient was injected with the quadrivalent HPV vaccine (Gardasil®): first, in the right upper arm; second, in the left upper arm two months later; third, in the right upper arm four months later. A few months after the third injection, skin hardening and lipoatrophy were observed around the injection sites in both upper arms, although they were more severe in the right upper arm. Subsequently, the patient was treated with topical steroids by a local physician; however, the lipoatrophy gradually expanded. When she visited our department, diffuse lipoatrophy and skin hardening with surface telangiectasia in both upper arms and 2–3 cm of subcutaneous induration on the lumbar buttocks and thighs were observed [Figure 1a and b]. Blood samples showed decreased leukocyte counts and C3 and C4 levels; however, antinuclear and autoantibodies were normal, and urinalysis was normal. Skin biopsies were obtained from the edge of the lipoatrophy in both the thighs and upper arms. Dense lymphocytic inflammatory cell infiltration around the blood vessels and mucin deposition (from the dermis to the subcutaneous adipose tissue) were observed. Subcutaneous fat showed extensive necrosis and increased hyalinised collagen bundles. Direct immunofluorescence (DIF) revealed IgM and C3 deposition along the basement membrane [Figure 2a–c]. Based on these findings, LEP was diagnosed and oral treatment with hydroxychloroquine sulphate (200 mg/day) was initiated. Currently, there has been no progression of SLE.

Figure 1 Diffuse lipoatrophy and skin hardening with surface telangiectasia in the upper arm (a, right upper arm; b, left upper arm)

Figure 2 Dense lymphocytic inflammatory cell infiltrates around the blood vessels and mucin deposition. Subcutaneous fat shows extensive necrosis and hyalinised collagen bundles (a, upper arm, hematoxylin and eosin, X10; b, DIF, IgM; c, DIF, C3)

HPV vaccines comprises an antigen and an adjuvant. The antigen component is a recombinant L1 capsid protein, which aggregates to form virus-like particles (VLPs).[2] Inoculation with VLPs alone may induce pain or myalgia at the inoculation site. While there are no reports on autoimmune diseases that develop from VLPs alone,[3] the addition of adjuvants to vaccines may be involved in the development of autoimmune diseases after vaccination. Aluminium salts are used as adjuvants in both bivalent and quadrivalent HPV vaccines. They act as an adjuvant at the inoculation site by preserving and gradually releasing the antigen.[4] Notably, some SLE cases have also occurred after hepatitis B virus vaccination with aluminium salts.[5] Thus, the association between aluminium salts and autoimmune disease development has long been suspected, yet the mechanism of action is unclear. In this case, because LEP onset commenced after HPV vaccination and symptom severity increased in the arm that received two vaccinations leading us to speculate that LEP was caused by the HPV vaccine. However, the relationship between HPV vaccines and autoimmune disease development following vaccination remains unclear, and further studies are required to confirm this relationship.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
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