Patients with delayed cutaneous reactions to COVID-19 vaccine tolerate subsequent doses
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Key takeaways:
- Common delayed cutaneous reactions to COVID-19 vaccination were urticarial-like, diffused itchy rash and angioedema.
- Patients with angioedema were more likely to have another reaction with revaccination.
Most patients who had a delayed immune-mediated adverse event following COVID-19 vaccination tolerated revaccination, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
Patients who experience these events may be concerned about more severe reactions, deterring them from getting needed subsequent vaccinations, Joseph F. De Luca, MBBS, a PhD student in the department of infectious diseases at Austin Health in Australia, and colleagues wrote.
The study involved 42 adults (67% women; median age, 54 years) referred to a specialist vaccine immunization service between April 2021 and September 2021 after experiencing a suspected delayed immune-mediated adverse event following immunization (DIM-AEFI) with the ChAdOx1-S (Oxford/AstraZeneca) or BNT162b2 (Pfizer-BioNTech) vaccine.
The researchers defined DIM-AEFIs as the appearance of one symptom or more consistent with a hypersensitivity reaction such as rash, itch or swelling 4 or more hours after vaccination.
Index reactions included urticarial-like symptoms (42%), unspecified itchy rash (26%), angioedema (19%), maculopapular exanthem (5%), unspecified rash with skin ulceration or blisters (7%) and erythema multiforme (2%).
Thirty-six patients (84%) received treatment for these reactions, including 19 (44%) who received corticosteroids, 26 (60%) who received antihistamines and 11 (26%) who were hospitalized, although no one needed adrenaline or admission to the ICU.
Subsequent vaccinations among the 42 patients included 33 patients (79%) who received the same vaccine they received earlier and eight (19%) who received an alternative class.
Also, 34 patients (81%) tolerated revaccination without experiencing the index reaction again, including 28 of the 33 (85%) who used the same vaccine and six of the eight (75%) who used an alternative.
The seven patients (17%) who had another adverse event with revaccination included five of the 33 (15%) who received the same vaccine and two of the eight (25%) who received an alternative. The most common DIM-AEFIs with revaccination included urticarial-like rash, angioedema, nonspecific rash and itch.
Using univariable analysis of the 33 patients who received the same vaccine twice, De Luca and colleagues found that patients who had angioedema during their index reaction were more likely to have an adverse event with revaccination, including 11% of those in the tolerated group and 80% in the group with adverse events (P = .004). However, the researchers wrote, further studies should confirm this association.
Considering the 81% majority of patients who were revaccinated without any adverse events, the researchers noted that most reactions probably do not represent a hypersensitivity mediated by T cells.
With a lack of severe or life-threatening adverse events upon further COVID-19 vaccination, the researchers concluded that patients who experience an adverse event after initial vaccination are very likely to tolerate revaccination.
Perspective
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These are important findings that further our understanding of the characteristics of delayed adverse events following vaccination. The findings are helpful as they enable physicians to provide evidence-based advice and reassurance to our patients who have experienced these reactions.
Also, these findings are very much in line with my experience seeing many patients with a variety of delayed adverse reactions. Similar to De Luca and colleagues, I have seen that most patients with delayed adverse reactions have cutaneous involvement, and many go on to tolerate subsequent vaccination without difficulty.
Doctors can use these data to speak to patients about the likelihood of subsequent delayed adverse reactions occurring after an initial episode. Reassuringly, many patients tolerate subsequent vaccines, and when adverse reactions do occur, they are generally mild and self-limited.
As De Luca and colleagues noted, we do not have prospective data in this area, so that would be a target for future research.
Perspective
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These findings are significant because they show that these delayed skin reactions are not interfering with further immunizations with the COVID-19 vaccine, indicating that they likely are not T-cell mediated and not a true contraindication, unlike anaphylaxis, which possibly could be.
Also, these findings are not surprising for me or for any practicing allergist, as we have been seeing many of these cases and treating and successfully vaccinating individuals with repeat doses.
Doctors can reassure their patients that these reactions are not only not life-threatening, but that these reactions also will not exclude them from receiving further COVID-19 vaccines or other vaccines. Doctors can work with their local allergists, who are well-versed in these reactions, for further guidance if needed.
The next step in this research should be to further elucidate the mechanism of these reactions to further provide clarity and reassurance to patients and clinicians.
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