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. 2022 Jan;86(1):113-121.
doi: 10.1016/j.jaad.2021.09.002. Epub 2021 Sep 10.

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

Devon E McMahon  1 , Carrie L Kovarik  2 , William Damsky  3 , Misha Rosenbach  2 , Jules B Lipoff  2 , Anisha Tyagi  4 , Grace Chamberlin  4 , Ramie Fathy  2 , Rosalynn M Nazarian  5 , Seemal R Desai  6 , Henry W Lim  7 , Bruce H Thiers  8 , George J Hruza  9 , Lars E French  10 , Kimberly Blumenthal  11 , Lindy P Fox  12 , Esther E Freeman  13
Affiliations

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

Devon E McMahon et al. J Am Acad Dermatol. 2022 Jan.

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.

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

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Conflict of interest statement

Conflicts of interest Drs Freeman, Hruza, Rosenbach, Lipoff, Fox, and Thiers are members of the American Academy of Dermatology COVID-19 Ad Hoc Task Force. Dr French is the President and Dr Lim a board member of the International League of Dermatological Societies. Dr Thiers is the Immediate Past President of the American Academy of Dermatology. Dr Freeman is an author of COVID-19 dermatology for UpToDate. Drs McMahon, Kovarik, Damsky, Nazarian, Desai, and Blumenthall and Authors Tyagi, Chamberlin, and Fathy have no conflicts to declare.

Figures

Fig 1
Fig 1
Spectrum of V-REPP following COVID-19 vaccination by degree of spongiosis and interface changes present on histopathology. V-REPP, Vaccine-related eruption of papules and plaques.
See this image and copyright information in PMC

References

    1. Coronavirus (COVID-19) vaccinations Our World in Data. https://ourworldindata.org/covid-vaccinations
    1. McMahon D.E., Amerson E., Rosenbach M., et al. Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: a registry-based study of 414 cases. J Am Acad Dermatol. 2021;85(1):46–55. - PMC - PubMed
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