Skin Disorders post Gardasil
So many Gardasil and Cervarix injured report a host of skin related disorders that appear chronic and treatment resistant in nature. The diagnoses are often incomplete, sometimes contradictory, and more often than not, and no matter the diagnosis, the treatment involves the standard topical and/or injected corticosteroid to reduce the inflammation. If there is relief, it is temporary. I have to wonder what we are missing?
My untrained hunch, from the pictures sent to me is that many of these conditions involve undiagnosed vasculitis. In some cases, the rashes may also be related to undiagnosed Hashimoto’s and other autoimmune conditions that seem to be prevalent. To offer some assistance and encourage folks to press for diagnoses, I am listing possibilities to explore with your physicians.
Acute Urticaria or Hives
We all have had urticaria or hives at one time or another, the red, blistery, itchy, rash that appears after an allergic reaction to something. The rash is generally short-lived, less than six weeks, often recurring and remitting. It can appear with angioedema or swelling and usually responds to antihistamines or anti-inflammatory medications like corticosteroids.
Chronic Urticaria, Urticarial Vasculitis
When the rash last longer than six months, it is considered chronic urticaria and in many cases has a vascular and an autoimmune component. Urticarial vasculitis is a form of cutaneous vasculitis. The acute urticaria and urticarial vasculitis look similar to the naked eye but under a microscope look quite different and emerge from different causes. Non-vascular urticaria is an allergic reaction, whereas urticarial vasculitis represents an inflammation or an attack on the blood vessel wall and may be linked to systemic vasculitis and autoimmune diseases such as Lupus and Sjogren’s.
In comparison to the itchiness of acute urticaria, urticarial vasculitis itches more intensely, is painful and burns. Of interest, many patients with urticarial vasculitis also develop photo-sensitivity (sensitivity to light), joint pain and swollen lymph nodes, fever, abdominal pain, sometimes even difficulty breathing with lung and kidney problems. For color pictures of urticarial vasculitis (I could find no non-copyrighted pictures to post), click here. For pictures of cutaneous vasculitis, click here.
The lesions also may have petechiae or purpura (bleeding or bruising under the skin), common post Gardasil, documented in published case reports and among the many reasons, vasculitis should be ruled out when dealing with chronic rashes post HPV vaccine.
Urticarial Vasculitis and the Immune System
There are two types of urticarial vasculitis, normo-complement – meaning normal complement immune function (normal complement proteins found on blood testing) and hypo-complement or low immune system functioning based on a pattern of low and low plus normal complement blood proteins. Complement proteins are made in the liver and assist or complement the innate immune system by attacking pathogens. Complement deficiency predisposes one to infection and an increased risk of autoimmune diseases like Lupus and Sjogren’s Syndrome. Patients with urticarial vasculitis plus complement deficiency have more difficulty clearing the condition.
Urticarial vasculitis is mostly idiopathic or of unknown origins but is frequently associated with autoimmune diseases like Lupus and Sjogren’s, a viral or bacterial infection of the vessel wall, drug reactions, immunoglobulin disorders and some cancers.
Distinguishing Urticaria from Urticarial or Cutaneous Vasculitis Using the Cell Phone
Diagnosis of vasculitis requires a skin biopsy. Researchers wanting to increase the at-office diagnostic capability for skin related vasculitis found that viewing the rash at 10X magnification using a dermoscope allowed them to distinguish between regular urticaria and urticarial vasculitis. This was in 2004, before camera phones with high intensity magnification existed. I think we can use the same methods using the cell phone. This may give you an at home tool to use and take to your doctor’s office to encourage further testing.
The full report is published here: Surface microscopy for discriminating between common urticaria and urticarial vasculitis. Briefly, a section of the rash is covered in olive oil to eliminate the reflection and viewed under a dermoscope at 10X magnification. A cell phone, photographed at similar or greater magnification may work just as well. The photo examples are copyrighted, so I cannot publish them here, but if you suspect urticarial vasculitis, click the link above to view the sample images and the detailed instructions. Using this method, there are clearly visible differences, even to the untrained eye.
Eczema and Atopic Dermatitis
The catch-all skin disorder for rashes of unknown origin seems to be eczema or atopic dermatitis; an allergic reaction, characterized by dry scaly patches, that are itchy, sometimes oozy and often overly sensitive to internal allergens as well as external irritants. Individuals with atopic dermatitis or eczema often also have asthma, hay fever and food allergies. Treatment is focused on re-hydrating the skin and reducing inflammation.
Hashimoto’s and Celiac or Gluten Sensitivity Rashes
Hypothyroid and autoimmune thyroiditis or Hashimoto’s is common in this population. Anecdotal comments have indicated a degree of gluten sensitivity as well. A rash associated with these condition include the celiac rash, a blistery, itchy rash that appears when one eats foods with gluten. The rash can appear anywhere, but is usually confined to the buttocks, knees, elbows, back and scalp.
Lupus Rash
Again, anecdotal reports suggest Lupus may be common in this population. Lupus is an autoimmune condition that attacks multiple organs including the skin. Symptoms include joint pain, fatigue, lymph node swelling, and when attacking the skin, a specific set of rashes appear: the butterfly rash on the face, the cutaneous rash and discoid rashes on the legs. For a slideshow with images, click here.
Testing for Lupus includes a positive antinuclear antibody test and increased erythrocyte sedimentation rate.
These are among the rashes and vascular conditions that have crossed my desk in communication with post Gardasil/Cervarix patients and parents. I am not an expert in these conditions and so this offered only as suggestions for inquiry. If you suspect a vasculitis or any of the conditions listed here, please read the linked materials, do your own research and see your physician for diagnosis. I would also recommend sharing your stories and pictures with our broader audience so that others may offer input and/or learn from your experiences. These conditions, especially the vasculitis related, are rare and difficult to diagnose. Sharing stories will spread awareness and increase understanding for all.
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