key: cord-0980995-rtl82zfr
authors: Seque, C.A.; Enokihara, M.M.S.S.; Nascimento, M.M.; Porro, A.M.; Tomimori, J.
title: Rare cutaneous reactions after ChAdOx1 (Oxford‐AstraZeneca) vaccine: 12 case series from Brazil
date: 2022-04-12
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.18112
sha: 46e47dd73cd2abd9487f5dd77f03788e483be2b0
doc_id: 980995
cord_uid: rtl82zfr

nan

AstraZeneca) is the most applied vaccine. Cutaneous reactions after ChAdOx1 vaccine are mainly injection-site reactions, acute urticaria and morbilliform rash. 2 We report 12 patients with cutaneous reactions after ChAdOx1 vaccine, nine of which as rare forms.

Gender was equally distributed (six female, six male). Their median age was 52.3 years (range 27-85 years). Cutaneous reactions occurred mainly after ChAdOx1 vaccine first dose (nine patients), from 1 to 7 days after vaccine administration. Dermatologists saw all patients. Nine patients presented rare cutaneous reactions: three lichen planus, three purpura/vasculitis, two erythroderma and one fixed drug eruption (Fig. 1 eruption and urticaria accounts for the remaining three cases. Eleven patients were submitted to anatomopathological evaluation of cutaneous lesions (Table 1) . Lichen planus after ChAdOx1 vaccination was observed in three patients. One patient had history of lichen planus, and curiously reactivation occurred exactly in previous sites of the disease. Bullous lichen planus was observed in one case. Due to severity of cutaneous lesions and its symptoms, patient was hospitalized. SARS-CoV-2 is known as a possible trigger for lichen planus. 3 One case of lichen planus arising after mRNA BNT162b2 (Pfizer-BioNTech) was related. Vaccines may upregulate Th1 response, promote IL-2, TNFa and IFNc elevation, which increase basal keratinocyte apoptosis presented in lichen planus. 4 As far as the authors knows, these are the first cases of lichen planus after ChAdOx1 vaccine, and the only case of bullous lichen planus associated to SARS-CoV-2 vaccination.

Three patients presented with purpura. In two cases small vessel vasculitis was histologically confirmedone associated with systemic symptoms (fever, arthralgia, mononeuritis) and one with severe cutaneous lesions such as vesicles and necrosis. In one case purpura was caused by idiopathic thrombocytopenic purpura (ITP). Vasculitis was observed in 0.7-2.9% after mRNA vaccine (Pfizer-BioNTech and Moderna) in a study that evaluated 414 patients with cutaneous reactions. 5 No vasculitis was reported in the phase 2/3 clinical trial of Oxford-AstraZeneca vaccine. Only two published cases related vasculitis 6 and IPT after ChAdOx1 vaccine. 7 Erythroderma was observed in two patients with no previous dermatosis or allergy history. Cutaneous lesions initiated after first and second doses, from 24-48 h postvaccine administration. Laboratorial workup was normal. Both were elderly, required systemic corticotherapy and presented a late (15-30 days) resolution. Erythroderma following mRNA vaccine was related, 8 but there are no reports associating this condition to ChAdOx1 vaccine. Cutaneous reactions associated to COVID-19 vaccination are mostly mild to moderate, oligosymptomatic and self-limited. However, although rare, severe reactions may occur and demand specific treatment. Systemic corticosteroids therapy is controversial after vaccination. 7 Our patients had no improvement with topical treatment and were sorely symptomatic. Systemic corticosteroids were prescribed as short as possible, as an exception treatment with suitable response.

One patient with HIV and antiretroviral therapy presented with fixed drug eruption 24 h after ChAdOx1 both first and HIV is known to increase drug reaction risk in 100-1000 times. Two cases of fixed drug eruption following ChAdOx1 and mRNA Moderna vaccines were published. 9 Cutaneous reactions after COVID-19 vaccination are not common and generally do not contraindicate vaccination cycle accomplishment. 10 Vaccinations benefits supplants by far its inherent risks. Although rare, special forms of cutaneous reactions after COVID-19 vaccination must be recognized due to its severity, patients' impairment and particular management. As the widespread vaccination progress worldwide, these reactions might significantly increase.

The patients in this manuscript have given written informed consent to the publication of their case details.

Authors have no conflicts of interest to declare.

A statement of all funding sources that supported the work. No funder supported this article.

Data are openly available in a public repository that issues datasets with DOIs. 

Cutaneous reactions after SARS-CoV-2 vaccination: a cross-sectional Spanish nationwide study of 405 cases

Annular lichen planus associated with coronavirus SARS-CoV-2 disease (COVID-19)

Lichen planus arising after COVID-19 vaccination

Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: a registrybased study of 414 cases

Small-vessel vasculitis following Oxford-AstraZeneca vaccination against SARS-CoV-2

Cutaneous findings following COVID-19 vaccination: review of world literature and own experience

A case of erythroderma with elevated serum immunoglobulin E and thymus and activation-regulated chemokine levels following coronavirus disease 2019 vaccination

Generalized bullous fixed drug eruption after Oxford-AstraZeneca (ChAdOx1 nCoV-19) vaccination

Cutaneous adverse reactions after COVID-19 vaccines in a cohort of 2740 Italian subjects: an observational study