2020-January 18<\/p>\n\n\n\n
The coronavirus disease 2019 (COVID-19) pandemic has led to the development and approval of vaccines against the responsible virus \u2014 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). More than 100 companies and institutions worldwide have developed vaccine candidates. How do the COVID-19 vaccines differ? Current approved vaccines rely on a nucleic-acid-based vaccine platform Messenger ribonucleic acid (mRNA) eg, Pfizer\/BioNTech + Fosun Pharma, Moderna + National Institute of Allergy and Infectious Diseases Viral vector platforms eg, AstraZeneca + University of Oxford, Janssen Pharmaceutical Inactivated virus eg, Sinopharm + China National Biotec Group Co Protein subunit vaccines eg, Novavax (not yet approved in any country) What are the common types of skin reaction to COVID-19 vaccines? The majority of current literature regarding cutaneous reactions relate specifically to mRNA COVID-19 vaccinations. The spectrum of reported cutaneous reactions after mRNA vaccination include: Local site reaction <\/p>\n\n\n\n
o Swelling, erythema, and pain in the vaccinated arm. <\/p>\n\n\n\n
o Median onset of 1 day after vaccination. Urticaria <\/p>\n\n\n\n
o Median onset reported on day 2\u20133 after vaccination. o Common sites include arms (68%), trunk (57%), and legs (46%). Morbilliform eruptions <\/p>\n\n\n\n
o Median onset reported on day 2\u20133 after vaccination. o Common sites include the arm (62%), legs (27%), and trunk (42%). Delayed large local reaction (\u201cCOVID arm”) <\/p>\n\n\n\n
o The COVID-19 vaccines may cause a delayed localized hypersensitivity reaction presenting as a pruritic and painful erythematous reaction near the injection site. <\/p>\n\n\n\n
o Median development of 7 days after vaccine administration with a median duration of 5 days, but can persist for up to 21 days. o Pink plaques are variably oedematous and typically homogenous or less commonly annular. <\/p>\n\n\n\n
o Sweet syndrome-like local reactions have been reported. <\/p>\n\n\n\n
o Treatments include topical steroids, oral antihistamines, and cool compresses, but lesions are usually self-limiting. <\/p>\n\n\n\n
o Eosinophilic pustular folliculitis may be triggered by Covid vaccines. How common are cutaneous reactions after COVID-19 vaccination?<\/p>\n\n\n\n
In one study, cutaneous reactions within 3 days after receiving the vaccine were reported in 1.9% of individuals after receiving their first dose of the mRNA COVID vaccine (Pfizer-BioNtech and Moderna). The majority of cutaneous reactions after COVID-19 vaccination occur in women (around 90%). Erythema and itching (other than at the injection site) was the most common cutaneous reaction, which was reported by 1%. In a study (May, 2021) of those with a self-reported cutaneous reaction to the first dose, 95% received their second dose. Among those who completed a symptom survey after the second dose, 83% reported no recurrent cutaneous reactions. However, a different study (July, 2021) reported that 43% of patients receiving an mRNA COVID-19 vaccine who reported first-dose reactions, experienced a second-dose recurrence. What are the uncommon mild skin reactions to COVID-19 vaccines? Filler reactions <\/p>\n\n\n\n
o Swelling at the site of cosmetic fillers has been reported after COVID-19 vaccination. Reports have identified patients with facial swelling after both Moderna and Pfizer vaccines associated with prior use of injectable cosmetic filler. <\/p>\n\n\n\n
o May indicate delayed hypersensitivity to filler following introduction of an immunologic trigger. Similar reactions have been previously noted after other viral illnesses and influenza vaccines. Erythromelalgia o Erythromelalgia has also been reported in response to other vaccines such as those for influenza and hepatitis B. Pernio\/chilblains <\/p>\n\n\n\n
o Mimics dermatologic manifestations of COVID-19 (COVID toes) <\/p>\n\n\n\n
o Potentially suggests that the host immune response to the virus is being replicated by the vaccine Pityriasis rosea <\/p>\n\n\n\n
o Reported with both COVID-19 infection and COVID-19 vaccines. Varicella zoster and herpes simplex flares <\/p>\n\n\n\n
o Case reports have documented flares following COVID-19 vaccination. Raynaud phenomenon <\/p>\n\n\n\n
o A case has been reported occurring 2 weeks after the COVID-19 vaccine. What are the uncommon serious skin reactions to COVID-19 vaccines? Bullous pemphigoid o Relapses of autoimmune bullous disease have been reported <\/p>\n\n\n\n
o Onset within 3 days \u2013 2 weeks following vaccination. Subacute cutaneous lupus erythematosus <\/p>\n\n\n\n
o Induction and flares have been reported. <\/p>\n\n\n\n
o Onset days to weeks following vaccination. Exacerbation of underlying skin condition <\/p>\n\n\n\n
o COVID-19 vaccination may trigger exacerbation of a pre-existing inflammatory skin condition such as psoriasis and atopic dermatitis. However, a recent study involving over 2000 individuals did not show that vaccination statistically significantly exacerbated either atopic eczema or psoriasis. Lichen planus <\/p>\n\n\n\n
o The vaccine leads to increased levels of IL-2, TNF-\u03b1, and IFN-\u03b3 \u2014 the exact cytokines involved in the development of lichen planus. Reports of this condition following vaccination have been made. Erythema multiforme <\/p>\n\n\n\n
o Linked to the first dose of Moderna COVID-19 vaccine. o It should be noted that major-type EM is considered to be a continuous spectrum with life-threatening toxic anti-epithelial reactions (e.g., Stevens\u2013Johnson syndrome, toxic epidermal necrolysis). Neutrophilic and Pustular Drug Reactions o Both acute generalized exanthematous pustulosis (AGEP) and a pustular flare of psoriasis associated with an inactivated viral vector COVID-19 vaccine have been published. <\/p>\n\n\n\n
o A further case report was classified as an overlap between AGEP and drug reaction with eosinophilia and systemic symptoms (DRESS) associated with COVID-19 vaccination. Anaphylaxis <\/p>\n\n\n\n
o Rare even with rates of 4.7 cases\/million doses of the Pfizer-BioNTech and 2.5 cases\/million doses of the Moderna vaccine<\/p>\n\n\n\n
o Anaphylaxis to vaccines generally is usually due to individual vaccine components, such as egg protein, gelatin, and other additives. However, the cause of vaccine anaphylaxis with the COVID-19 vaccine cases is unclear, but polyethylene glycol (PEG 2000) is a candidate allergen. <\/p>\n\n\n\n
Common signs and symptoms include generalised urticaria, angioedema, and respiratory and airway obstruction symptoms. <\/p>\n\n\n\n
o Onset is typically within minutes to hours of administration. Although the Pfizer\/BioNTech vaccine contains a number of excipients, PEG 2000 is the only one reported to cause anaphylaxis. The Oxford-AstraZeneca vaccine does not contain PEG 2000 so is an alternative for people with a history of allergy to PEG 2000. However, there is occasional cross-reactivity between PEG and polysorbate 80, an ingredient in the Oxford-AstraZeneca vaccine. Evaluation by an allergy specialist may be advisable before vaccination in anyone with a suspected PEG allergy. Contraindications for receipt of the mRNA COVID-19 vaccines include: Known history of a severe allergic reaction to any vaccine component, including the excipient PEG 2000 An allergic reaction to a previous dose of an mRNA vaccine. Identification of risk factors for allergy symptoms after COVID-19 vaccination will guide safe vaccination practices for individuals at the highest risk. How are the COVID-19 skin reactions treated? Severe cutaneous adverse reactions are very rare. The established vaccines have a satisfactory safety profile. Management should be directed at the presenting skin condition, however most of the encountered skin reactions are self-limiting. Anaphylaxis requires prompt treatment with intramuscular adrenaline and oxygen. Unlike anaphylaxis, cutaneous adverse reactions alone are not a contraindication to re-vaccination. The available evidence supports that cutaneous reactions to COVID-19 vaccination are generally minor, self-limiting, and should not discourage vaccination. <\/p>\n\n\n\n
Bibliography Al-Jighefee HT, Najjar H, Ahmed MN, Qush A, Awwad S, Kamareddine L. COVID-19 Vaccine Platforms: Challenges and Safety Contemplations. Vaccines (Basel). 2021;9(10):1196. doi: 10.3390\/vaccines9101196. PubMed Central Busto-Leis JM, Servera-Negre G, Mayor-Ibarguren A, et al. Pityriasis rosea, COVID-19 and vaccination: new keys to understand an old acquaintance. J Eur Acad Dermatol Venereol. 2021;35(8):e489\u2013e491. doi:10.1111\/jdv.17301. PubMed Central Hiltun I, Sarriugarte J, Mart\u00ednez-de-Espronceda I, et al. Lichen planus arising after COVID-19 vaccination. J Eur Acad Dermatol Venereol. 2021;35(7):e414\u2013e415. doi:10.1111\/jdv.17221. PubMed Central Johnston MS, Galan A, Watsky KL, Little AJ. Delayed Localized Hypersensitivity Reactions to the Moderna COVID-19 Vaccine: A Case Series. JAMA Dermatol. 2021;157(6):716\u201320. Journal Joseph AK, Chong BF. Subacute cutaneous lupus erythematosus flare triggered by COVID-19 vaccine. Dermatol Ther. doi: 10.1111\/dth.15114. Journal Lospinoso K, Nichols CS, Malachowski SJ, Mochel MC, Nutan F. A case of severe cutaneous adverse reaction following administration of the Janssen Ad26.COV2.S COVID-19 vaccine. JAAD Case Rep. 2021;13:134\u20137. doi:10.1016\/j.jdcr.2021.05.010. PubMed Central McMahon DE, Amerson E, Rosenbach M, et al. Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases. J Am Acad Dermatol. 2021;85(1):46\u201355. doi:10.1016\/j.jaad.2021.03.092. PubMed Central Niebel D, Novak N, Wilhelmi J, et al. Cutaneous Adverse Reactions to COVID-19 Vaccines: Insights from an Immuno-Dermatological Perspective. Vaccines (Basel). 2021;9(9):944. doi:10.3390\/vaccines9090944. PubMed Central Robinson LB, Fu X, Hashimoto D, et al. Incidence of Cutaneous Reactions After Messenger RNA COVID-19 Vaccines. JAMA Dermatol. May 2021;157(8):1000\u20132. doi:10.1001\/jamadermatol.2021.2114. Journal Sellaturay P, Nasser S, Islam S, Gurugama P, Ewan PW. Polyethylene glycol (PEG) is a cause of anaphylaxis to the Pfizer\/BioNTech mRNA COVID-19 vaccine. Clin Exp Allergy. 2021;51(6):861\u20133. doi: 10.1111\/cea.13874. Journal Shimabukuro TT, Cole M, Su JR. Reports of Anaphylaxis After Receipt of mRNA COVID-19 Vaccines in the US <\/p>\n\n\n\n
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