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Authors: Dr Sarah Elyoussfi (Dermatology Registrar) and Dr Ian Coulson (Consultant Dermatologist), Department of Dermatology, East Lancashire NHS Trust, United Kingdom. Copy edited by Gus Mitchell. December 2021
The coronavirus disease 2019 (COVID-19) pandemic has led to the development and approval of vaccines against the responsible virus — severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). More than 100 companies and institutions worldwide have developed vaccine candidates.
Current approved vaccines rely on a nucleic-acid-based vaccine platform
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:
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.
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:
Identification of risk factors for allergy symptoms after COVID-19 vaccination will guide safe vaccination practices for individuals at the highest risk.
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.
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