Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases

Abstract

Background: Cutaneous reactions after messenger RNA (mRNA)-based COVID-19 vaccines have been reported but are not well characterized.

Objective: To evaluate the morphology and timing of cutaneous reactions after mRNA COVID-19 vaccines.

Methods: A provider-facing registry-based study collected cases of cutaneous manifestations after COVID-19 vaccination.

Results: From December 2020 to February 2021, we recorded 414 cutaneous reactions to mRNA COVID-19 vaccines from Moderna (83%) and Pfizer (17%). Delayed large local reactions were most common, followed by local injection site reactions, urticarial eruptions, and morbilliform eruptions. Forty-three percent of patients with first-dose reactions experienced second-dose recurrence. Additional less common reactions included pernio/chilblains, cosmetic filler reactions, zoster, herpes simplex flares, and pityriasis rosea-like reactions.

Limitations: Registry analysis does not measure incidence. Morphologic misclassification is possible.

Conclusions: We report a spectrum of cutaneous reactions after mRNA COVID-19 vaccines. We observed some dermatologic reactions to Moderna and Pfizer vaccines that mimicked SARS-CoV-2 infection itself, such as pernio/chilblains. Most patients with first-dose reactions did not have a second-dose reaction and serious adverse events did not develop in any of the patients in the registry after the first or second dose. Our data support that cutaneous reactions to COVID-19 vaccination are generally minor and self-limited, and should not discourage vaccination.

Keywords: COVID-19; Moderna; Pfizer; SARS-CoV-2; chilblains; delayed hypersensitivity; delayed inflammatory reaction; delayed large local reaction; dermatology; erythema multiforme; erythromelalgia; filler; local injection site reaction; mRNA; morbilliform; pernio; pityriasis rosea; public health; registry; shingles; urticaria; vaccine; vaccine reaction; vasculitis; vesicular; zoster.

Fig 1

Timeline representing the time to onset and duration of the top 5 most common dermatologic findings reported after the Moderna and Pfizer COVID-19 vaccines. The circles represent median time to onset of the cutaneous reaction and lines represent median duration of the cutaneous reaction. Supplemental Table I (available via Mendeley) provides detailed information about the timing of vaccine reactions.

Fig 2

A depiction of the characteristics of the subset of patients who experienced the same dermatologic finding after both the first and second COVID-19 vaccine doses. No patient experienced anaphylaxis or another severe adverse event after the second COVID-19 vaccine dose. ∗Different patient photos are used for local site injection reaction photos. All other photos follow individual patients' reaction after vaccine dose 1 and dose 2.

Fig 3

Number of days from vaccination (day 0) until the development of a cutaneous reaction after COVID-19 vaccine. A and B, First- and second-dose dermatologic findings, respectively, after Moderna (purple) or Pfizer (orange) vaccination. C and D, First- and second-dose findings, respectively, restricted to patients who received Moderna and experienced the development of a rash on the vaccinated arm, showing local injection site reactions (light blue) and delayed large local symptoms (dark blue). A,Top left. B,Top right. C,Bottom left. D,Bottom right.