Amidst the Coronavirus Disease 2019 (COVID-19) pandemic, vaccination against severe acute respiratory syndrome 2 (SARS-CoV-2) is recommended for everyone over 18 years in South Korea, with the exception of pregnant women. Unexpected adverse cutaneous reactions after the COVID-19 vaccination have been recently reported. Cutaneous small-vessel vasculitis (CSVV) predominantly affects small blood vessels, defined as small intraparenchymal arteries, arterioles, capillaries, and venules, without any detectable involvement of non-cutaneous organs. We report five cases of CSVV after the ChAdOx1 COVID-19 vaccination in 44- to 68-year-old women. The symptoms commonly appeared within 2 days after vaccination. The lesion was localized to the lower limbs in four patients and spread to the upper limbs in one patient. All patients demonstrated a favorable response to oral methylprednisolone, antihistamines, and topical steroids. Considering the importance of the COVID-19 vaccination, clinicians should be aware of CSVV as a potential adverse event. Further studies are required to elucidate the causative link and pathogenesis.

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Trigeminal trophic syndrome (TTS) is a rare condition characterized by anesthesia, paresthesia, and facial ulceration involving the trigeminal dermatome secondary to self-manipulation of the skin after a peripheral or central injury to the trigeminal nerve or its branches. Differential diagnosis of TTS includes conditions presenting with chronic facial ulceration, such as various infectious diseases, malignancy, vasculitis, pyoderma gangrenosum and dermatitis artefacta. We report a case of postherpetic TTS and highlight the importance of early diagnosis and prompt treatment of this condition, which may commonly be misdiagnosed.

Herpes zoster with meningitis in a vaccinated, immunocompetent childDear Editor, Meningitis is a rare complication of herpes zoster (HZ) and its incidence was reported as only 0.5%. 1 Central nervous system complication most often occurs in immunocompromised patients or the elderly by infection with wild-type varicella zoster virus (VZV), although several cases have occasionally been reported with vaccine-strain VZV. 2,3 A healthy 7-year-old boy presented with a 3-day history of left facial, painful, pruritic skin rash and 1-day history of fever and vomiting. A review of his immunization record showed a varicella vaccination at 12 months of age, and that he had never had a varicella-like illness before. His vital signs were stable with tympanic temperature of 37.3°C. Skin examination detected tender, erythematous, swollen maculopatches and vesicles along the left V1/2 dermatome ( Fig. 1a). Laboratory studies showed normal levels of blood counts and serum chemistries. He was diagnosed with HZ, and i.v. acyclovir 10 mg/ kg every 8 h was started. The following day, he complained of posterior neck pain and physical examination showed positive nuchal rigidity and Brudzinski's sign. Spinal tapping was performed immediately and cerebrospinal fluid (CSF) contained lymphocytes and increased level of protein and glucose. Polymerase chain reaction (PCR) analysis of a CSF specimen was positive for VZV. Consequent immune evaluations were within normal limits. He was treated with an anti-meningitic dose of i.v. acyclovir (15 mg/kg every 8 h) for 8 days. His symptoms and skin lesions showed rapid improvement (Fig. 1b), and repeated PCR of CSF converted to negative on hospital day 10. He was discharged and was asymptomatic with a normal physical examination 3 weeks later (Fig. 1c). No pain or dysesthesia was reported.In Korea, a single-dose varicella vaccination for children between the ages of 12 and 15 months was incorporated into the national immunization program in 2005. Vaccination coverage was 92.9% in 2012, and a significant decrease in morbidity and mortality was achieved. 4 In addition, according to a recent population-based study, HZ incidence in vaccinated children was lower than in unvaccinated children and half of cases were due to vaccinated VZV. 5 Therefore, varicella vaccination is an advantage in many aspects but it contains a live attenuated virus with the potential for reactivation.Although it is unclear, there are hypotheses that certain timing and strain of vaccine may affect this process. Based on previous study implying that primary varicella infection in the first year of life is a risk factor for childhood zoster, Han et al. 2 suggested that early vaccination may put children at increasing risk for reactivation of the vaccine strain later in life. On the other hand, in recent studies on DNA sequencing of vaccinestrain VZV causing HZ meningitis, a vaccine strain from CSF contained mutations never previously observed in vaccineassociated single nucleotide polymorphisms that would alter amino acid sequences...

The cutaneous appearance of transient or persistent livedo reticularis is characterized by violaceous, mottled, ring-shaped interconnecting lesions that form a reticular or net-like pattern. It can occur physiologically in response to cold exposure, such as in cutis marmorata, but can also be induced by pathological conditions such as vascular obliterans or venodilation. We report two cases of livedo reticularis that occurred on the lower limbs of two patients post ChAdOx1 nCoV-19 vaccination. As the patients had no other likely causes of livedo reticularis, the reticular skin lesions were suspected to occur in association with the ChAdOx1 nCoV-19 vaccination. Livedo reticularis is an uncommon adverse reaction, with few cases being reported post ChAdOx1 nCoV-19 vaccination.