key: cord-0727296-zls8dfir authors: Ayatollahi, Azin; Hosseini, Hamed; Firooz, Rojin; Firooz, Alireza title: COVID‐19 vaccines: What dermatologists should know? date: 2021-07-13 journal: Dermatol Ther DOI: 10.1111/dth.15056 sha: 509751b80d9d2ce4f3259cffe14868ef1e64ad82 doc_id: 727296 cord_uid: zls8dfir As COVID‐19 vaccination has started worldwide to control this pandemic, dermatologists may face various challenges with these new vaccines. In this manuscript, we review different types of available COVID‐19 vaccines and their various production platforms. Vaccination considerations in patients with skin diseases, especially those using immunomodulatory drugs will be presented. Finally, adverse cutaneous reactions of COVID‐19 vaccines will be reviewed. SARS-CoV-2 is a novel coronavirus causing COVID-19 infection with high infectivity and severe morbidity and mortality. The COVID-19 pandemic urged the world of medicine to conduct multifaceted research leading, among other things, to development of novel vaccine platforms (i.e., mRNA, DNA, non-replicating viral vectors, and so on.). 1 Since the onset of the pandemic in early 2020, dermatologists have observed that various cutaneous manifestations such as diffuse erythematous eruptions, widespread urticaria, and chickenpox-like vesicles are related to Now, with the COVID-19 vaccination effort being ramped up around the world, dermatologists also need to become aware of its considerations in patients with skin diseases, as well as possible vaccine-related cutaneous reactions. 3 This narrative review was performed by searching PubMed up to June 10, 2021, for the COVID-19 vaccine and dermatology practicerelated manuscripts. The published studies of COVID-19 vaccines have revealed excessive reactogenicity, with fever, headache, and fatigue being more common than in other vaccines. This higher than usual observed side effects may relate to the characteristic inflammatory nature of these vaccines. Older generation vaccines with lower reactogenicity are still deemed to be triggering flares of dermatological diseases like psoriasis. These observations hint that COVID-19 vaccines might cause flares in patients with dermatological diseases. These vaccines have been shown to reinforce the cellular immune system and produce a predominantly Th1 type response with high levels of TNFa, IFNg, and IL2. Therefore, theoretically, they may have a role in the flare of dermatological diseases such as psoriasis, lichen planus, vitiligo, and other diseases that have a proven Th1 role in their pathogenesis. 6 There are rare reports of severe allergic reactions to different particles of vaccines in those with a history of allergies. However, it is recommended that all atopic dermatitis (AD) patients and others with allergic skin diseases follow the routine vaccination program. The risk/ benefit of vaccination is considered promising for the overall AD population. Currently, there is no evidence to suggest that AD is an independent risk factor for acquiring SARS-CoV-2, or of having a more severe course of COVID-19. Based on European Task Force for Atopic Dermatitis (ETFAD) recommendation, Atopic dermatitis is not a contraindication to vaccination. Systemic drugs used to treat AD, except for dupilumab, may attenuate the vaccination response. It is preferable to pausing or lowering the dosage of immunosuppressant agents, typically from the vaccination day until 1 week after for Janus kinase (JAK)-inhibitors and cyclosporine, or until 2 weeks after for methotrexate and azathioprine, to possibly improve chances of appropriate vaccination response. 7 In selected cases, the use of anti-allergic medication before vaccination, such as antihistamines and oral glucocorticoids, may be helpful. These patients should be observed for 30 min after the vaccine injection. The only contraindication is related to patients with documented severe allergic reactions to ingredients of the vaccine. 8 According to National Psoriasis Foundation there is not any contraindication for COVID vaccination in psoriasis patients. The effect of psoriasis treatment on the efficacy of COVID-19 vaccines is not known completely. Based on currently available evidence, it is recommended that patients continue their therapies during the vaccination period. 9 An observational study of 941 patients (713 psoriasis patients and 228 other patients with bullous disorders, atopic dermatitis, and hidradenitis suppurativa) in Greece, who used immunosuppressive medication, revealed that patients with psoriasis were 32% more willing to receive the vaccine compared with others. Among patients with psoriasis, individuals with concomitant psoriasis arteritis were nearly 20% more likely to undergo COVID-19 vaccination. Factors such as comorbidities with diabetes, malignancies, and COPD, receiving the biological treatment, younger age, female gender, and higher education are related to the degree of willingness showed by an individual in receiving vaccines. 10 Pacific et al. recently reported the safety and efficacy of Pfizer and Astra-Zeneca-Oxford vaccines in 3 psoriasis patients treated by apremilast. There was no flare of psoriasis, and the patients had enough SARS-COV2 S1 receptor binding domain antibodies. 11 Assessing the possible benefits and risks of vaccination suggests that vaccinating all psoriatic patients who are on immunosuppressant drugs, although it may not be as effective as in healthy subjects, still provides some degree of protection against COVID-19. In the face of this pandemic, having some degree of immunity is better than having none. EADV task force on quality of life and patient-oriented outcome recently advised psoriatic patients to receive COVID-19 vaccine and those who had COVID-19 infection to continue following health measures to protect themselves and others. 12 The ideal timing of vaccination for patients treated by Rituximab, due to the immunosuppressive effect of this drug, is unknown. However, it is recommended that individuals who have not initiated rituximab therapy get vaccinated at least 4 weeks before rituximab infusion. Those who are actively receiving rituximab often receive the influenza vaccine, 12 to 20 weeks after completion of a treatment cycle, so that the patients have at least 4 weeks before their next cycle (assuming a six-month treatment cycle). 13 Some cases of temporary swelling at the site of previous filler injection were reported after mRNA vaccine injection. These reactions can be immunologically triggered. Because these reactions are rare and temporary, the American Society for Dermatologic Surgery recommended that patients already treated with dermal fillers could receive vaccines of any kind without worry and that those who have injected vaccines should not be disallowed from receiving dermal fillers. 45 In conclusion, dermatologists should be aware of the different types of COVID-19 vaccines and keep in mind their effects on skin diseases and their cutaneous side effects. An evidence-based guide to SARS-CoV-2 vaccination of patients on immunotherapies in dermatology Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases SARS-CoV-2 mRNA vaccineassociated fixed drug eruption Encycl Virol (Third Edition) Implication of mass COVID-19 vaccination on dermatology practice in 2021 European task force on atopic dermatitis: position on vaccination of adult patients with atopic dermatitis against COVID-19 (SARS-CoV-2) being treated with systemic medication and biologics Risk of severe allergic reactions to COVID-19 vaccines among patients with allergic skin diseasespractical recommendations. A position statement of ETFAD with external experts National Psoriasis Foundation COVID-19 task force guidance for management of psoriatic disease during the pandemic: version 2 advances in psoriatic disease management, COVID-19 vaccines, and COVID-19 treatments COVID-19 vaccination intention among patients with psoriasis compared with immunosuppressed patients with other skin diseases and factors influencing their decision COVID-19 vaccines do not trigger psoriasis flares in patients with psoriasis treated with apremilast Insights into SARS-COV-2 vaccination in patients with chronic plaque psoriasis on systemic treatments Toward a COVID-19 vaccine strategy for patients with pemphigus on rituximab SARS-CoV-2 (COVID-19) vaccination in dermatology patients on immunomodulatory and biologic agents: recommendations from the Australasian medical dermatology group Risk of anaphylaxis after vaccination in children and adults Guidelines (S2) to acute therapy and management of anaphylaxis-update 2021 Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: a registrybased study of 414 cases Transient cutaneous manifestations after administration of Pfizer-BioNTech COVID-19 vaccine: an Italian single-Centre case series Chilblain lesions after COVID-19 mRNA vaccine Acral chilblain-like lesions following inactivated SARS-CoV-2 vaccination BNT162b2 mRNA Covid-19 vaccine-induced chilblain-like lesions reinforces the hypothesis of their relationship with SARS-CoV-2 Blue toes' following vaccination with the BNT162b2 mRNA COVID-19 vaccine A flare of pre-existing erythema multiforme post BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine Pityriasis rosea, COVID-19 and vaccination: new keys to understand an old acquaintance Pityriasis rosea following Cor-onaVac COVID-19 vaccination: a case report Pityriasis rosea-like eruption after Pfizer-BioNTech COVID-19 vaccination Pityriasis rosea-like eruptions following vaccination with BNT162b2 mRNA COVID-19 vaccine Leukocytoclastic vasculitis flare following the COVID-19 vaccine Asymmetric cutaneous vasculitis following COVID-19 vaccination with unusual eosinophil preponderance Lichen planus arising after COVID-19 vaccination Persistent maculopapular rash after the first dose of Pfizer-BioNTech COVID-19 vaccine Herpes zoster following inactivated COVID-19 vaccine: a coexistence or coincidence? 20 post COVID-19 vaccine related shingles cases seen at the Las Vegas dermatology clinic and sent to us via social media Herpes zoster after inactivated COVID-19 vaccine: a cutaneous adverse effect of the vaccine Ipsilateral herpes zoster after the first dose of BNT162b2 mRNA COVID-19 vaccine Recurrent varicella following SARS-CoV-2 vaccination with BNT162b2 Skin manifestations of the BNT162b2 mRNA COVID-19 vaccine in healthcare workers Recurrent injection-site reactions after incorrect subcutaneous administration of a COVID-19 vaccine Local reactions to the second dose of the BNT162 COVID-19 vaccine Purpuric lesions on the eyelids developed after BNT162b2 mRNA COVID-19 vaccine: another piece of SARS-CoV-2 skin puzzle? Radiation recall dermatitis triggered by inactivated COVID-19 vaccine COVID-19 vaccine-induced radiation recall phenomenon Covid-19 vaccine induced Steven-Johnson syndrome: a case report A generalized pustular psoriasis flare after CoronaVac COVID-19 vaccination: case report American Society for Dermatologic Surgery guidance regarding SARS-CoV-2 mRNA vaccine side effects in dermal filler patients COVID-19 vaccines: What dermatologists should know? Dermatologic Therapy. 2021;e15056 The authors declare no potential conflict of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study. https://orcid.org/0000-0001-7274-4840