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Skin reactions to COVID-19 vaccines

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. Further updated May 2023


What are the COVID-19 vaccines?

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. 

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
    • Swelling, erythema, and pain in the vaccinated arm.
    • Median onset of 1 day after vaccination.
  • Urticaria
    • Median onset reported on day 2–3 after vaccination.
    • Common sites include arms (68%), trunk (57%), and legs (46%).
  • Morbilliform eruptions
    • Median onset reported on day 2–3 after vaccination.
    • Common sites include the arm (62%), legs (27%), and trunk (42%).
  • Delayed large local reaction (“COVID arm")
    • The COVID-19 vaccines may cause a delayed localized hypersensitivity reaction presenting as a pruritic and painful erythematous reaction near the injection site.
    • Median development of 7 days after vaccine administration with a median duration of 5 days, but can persist for up to 21 days.
    • Pink plaques are variably oedematous and typically homogenous or less commonly annular.
    • Sweet syndrome-like local reactions have been reported.
    • Treatments include topical steroids, oral antihistamines, and cool compresses, but lesions are usually self-limiting
    • Eosinophilic pustular folliculitis may be triggered by Covid vaccines.

How common are cutaneous reactions after COVID-19 vaccination?

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
    • 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.
    • 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
    • Erythromelalgia has also been reported in response to other vaccines such as those for influenza and hepatitis B.
  • Pernio/chilblains
    • Mimics dermatologic manifestations of COVID-19 (COVID toes)
    • Potentially suggests that the host immune response to the virus is being replicated by the vaccine

What are the uncommon serious skin reactions to COVID-19 vaccines? 

  • Bullous pemphigoid
    • Relapses of autoimmune bullous disease have been reported
    • Onset within 3 days – 2 weeks following vaccination.
  • Exacerbation of underlying skin condition
    • COVID-19 vaccination may trigger exacerbation of a pre-existing inflammatory skin condition such as psoriasis and atopic dermatitisHowever, a recent study involving over 2000 individuals did not show that vaccination statistically significantly exacerbated either atopic eczema or psoriasis.
  • Lichen planus
    • The vaccine leads to increased levels of IL-2, TNF-α, and IFN-γ — the exact cytokines involved in the development of lichen planus. Reports of this condition following vaccination have been made.
  • Erythema multiforme
    • Linked to the first dose of Moderna COVID-19 vaccine.
    • 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–Johnson syndrome, toxic epidermal necrolysis).
  • Anaphylaxis
    • Rare even with rates of 4.7 cases/million doses of the Pfizer-BioNTech and 2.5 cases/million doses of the Moderna vaccine
    • 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.
    • Common signs and symptoms include generalised urticaria, angioedema, and respiratory and airway obstruction symptoms.
    • 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.



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