Clinical and histopathological spectrum of delayed adverse cutaneous reactions following COVID‐19 vaccination

Abstract

Background: As more people become vaccinated against the SARS-CoV-2 virus, reports of delayed cutaneous hypersensitivity reactions are beginning to emerge. Methods:In this IRB-approved retrospective case series, biopsy specimens of potential cutaneous adverse reactions from the Pfizer-BioNTech or Moderna mRNA vaccine were identified and reviewed. Clinical information was obtained through the requisition form, referring clinician, or medical chart review.Results: Twelve cases were included. Histopathological features from two injectionsite reactions showed a mixed-cell infiltrate with eosinophils and a spongiotic dermatitis with eosinophils. Three biopsy specimens came from generalized eruptions that showed interface changes consistent with an exanthematous drug reaction. Three biopsy specimens revealed a predominantly spongiotic pattern, consistent with eczematous dermatitis. Small-vessel vascular injury was seen in two specimens, which were diagnosed as urticarial vasculitis and leukocytoclastic vasculitis, respectively. There were two cases of new-onset bullous pemphigoid supported by histopathological examination and direct immunofluorescence studies. Eosinophils were seen in 10 cases. Conclusions:Dermatopathologists should be aware of potential cutaneous adverse reactions to mRNA-based COVID-19 vaccines. Histopathological patterns include mixed-cell infiltrates, epidermal spongiosis, and interface changes.Eosinophils are a common finding but are not always present. Direct immunofluorescence studies may be helpful for immune-mediated cutaneous presentations such as vasculitis or bullous pemphigoid.

Cutaneous Adverse Reactions Associated with SARS-CoV-2 Vaccines

“…Recurrence occurred in 16% of those who experienced the first reaction. Exanthema reactions can be easily treated with systemic and/or topical corticosteroid and systemic antihistamines to relieve symptoms and shorten the disease duration [20,21]. We also observed the occurrence of uncommon rashes as SDRIFE (Figure 4).…”

“…Pruritus may be severe. A purpuric hue can be found, especially when the rash involves the inferior limbs [18][19][20][21][22][23]. A -papulovesicular or varicelliform rash is characterized by small papules/vesicles surrounded by erythema without a herpetiform arrangement [6].…”

“…Rarely, an extensive erythematous rash with blistering evolution may occur [25]. Atypical rashes reminiscent of pityriasis rosea following 4-7 days after mRNA vaccination have also been reported [6,7,19,20,25,26]. Unlike pityriasis rosea, these reactions are characterized by more itchy and diffuse lesions with a more frequent involvement of mucous membranes and no preceding herald patch [27].…”

Single-Center Clinico-Pathological Case Study of 19 Patients with Cutaneous Adverse Reactions Following COVID-19 Vaccines

“…Although the number of reports of rare cutaneous ADR increases by the week, concise dermatohistopathological observations are very limited. Only recently, a retrospective case series with twelve cases was published to identify mixed-cell infiltrates, epidermal spongiosis and interface changes as the most common features associated with COVID-19 vaccine-derived cutaneous ADR [6]. Eosinophils were also a common finding but not always present.…”

Sweet Syndrome Following SARS-CoV2 Vaccination

“…Since then, with the increasing number of vaccinated people, a variety of skin reactions to the BTN162b2 vaccine has been reported [5]. Here we present the case of a 52-year-old Caucasian male who presented with an acute febrile skin eruption after the first dose of the BTN162b2 vaccine.…”