Clinical and pathologic correlation of cutaneous COVID-19 vaccine reactions including V-REPP: A registry-based study - 05/10/21

Doi : 10.1016/j.jaad.2021.09.002

Devon E. McMahon, MD ^a, Carrie L. Kovarik, MD ^b, William Damsky, MD, PhD ^c, Misha Rosenbach, MD ^b, Jules B. Lipoff, MD ^b, Anisha Tyagi, BA ^d, Grace Chamberlin, BA ^d, Ramie Fathy, AB ^b, Rosalynn M. Nazarian, MD ^e, Seemal R. Desai, MD ^f,^g, Henry W. Lim, MD ^h, Bruce H. Thiers, MD ⁱ, George J. Hruza, MD, MBA ^j, Lars E. French, MD ^k,^l, Kimberly Blumenthal, MD, MSc ^m, Lindy P. Fox, MD ⁿ, Esther E. Freeman, MD, PhD ^a,^d,^⁎
^a Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
^b Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
^c Department of Dermatology, Yale-New Haven Hospital, New Haven, Connecticut
^d Medical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
^e Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
^f Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, Texas
^g Innovative Dermatology, Plano, Texas
^h Department of Dermatology, Henry Ford Health System, Detroit, Michigan
ⁱ Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina
^j Department of Dermatology, St. Louis University, St. Louis, Missouri
^k Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany
^l Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
^m Division of Rheumatology, Allergy, Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
ⁿ Department of Dermatology, University of California San Francisco, San Francisco, California

^∗Correspondence to: Esther E. Freeman, MD, PhD, Massachusetts General Hospital, Department of Dermatology, 55 Fruit St, Boston, MA 02114.Massachusetts General HospitalDepartment of Dermatology55 Fruit StBostonMA02114

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Abstract

Background

Cutaneous reactions after COVID-19 vaccination have been commonly reported; however, histopathologic features and clinical correlations have not been well characterized.

Methods

We evaluated for a history of skin biopsy all reports of reactions associated with COVID-19 vaccination identified in an international registry. When histopathology reports were available, we categorized them by reaction patterns.

Results

Of 803 vaccine reactions reported, 58 (7%) cases had biopsy reports available for review. The most common histopathologic reaction pattern was spongiotic dermatitis, which clinically ranged from robust papules with overlying crust, to pityriasis rosea-like eruptions, to pink papules with fine scale. We propose the acronym “V-REPP” (vaccine-related eruption of papules and plaques) for this spectrum. Other clinical patterns included bullous pemphigoid-like (n = 12), dermal hypersensitivity (n = 4), herpes zoster (n = 4), lichen planus-like (n = 4), pernio (n = 3), urticarial (n = 2), neutrophilic dermatosis (n = 2), leukocytoclastic vasculitis (n = 2), morbilliform (n = 2), delayed large local reactions (n = 2), erythromelalgia (n = 1), and other (n = 5).

Limitations

Cases in which histopathology was available represented a minority of registry entries. Analysis of registry data cannot measure incidence.

Conclusion

Clinical and histopathologic correlation allowed for categorization of cutaneous reactions to the COVID-19 vaccine. We propose defining a subset of vaccine-related eruption of papules and plaques, as well as 12 other patterns, following COVID-19 vaccination.

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Key words : Ad26.COV2.S, AZD1222, BNT162b2, bullous pemphigoid, chilblains, COVID-19, delayed large local, dermal hypersensitivity reaction, dermatology, dermatopathology, erythema multiforme, erythromelalgia, Johnson & Johnson Janssen, lichen planus, Moderna, morbilliform, mRNA-1273, Oxford-AstraZeneca, papular, papulosquamous, pathology, pernio, Pfizer-BioNTech, pityriasis rosea, psoriasis, registry, SARS-CoV-2, Stevens-Johnson syndrome, urticaria, vaccine, zoster

Abbreviations used : IQR, V-REPP

Plan

	Funding sources: The COVID-19 dermatology registry is supported by a grant from the International League of Dermatological Societies and by in-kind support from the American Academy of Dermatology.
	IRB approval status: The registry was reviewed by the Partners Healthcare (Massachusetts General Hospital) Institutional Review Board and it was determined that it did not meet the definition of human subjects research.
	Reprints not available from the authors.