Delayed onset benign rash(s) after COVID-19 mRNA vaccination
Question:
3/7/2021
Please advise on the following situation.
-51 year old female patient (teacher, wants fully vaccinated ASAP).
-Allergy history includes mild allergic rhinitis (dander, dust mite), itching with Vicodin and Latex in the past, reaction to MRI contrast in the past (itching, swelling, nausea, vomiting, hives).
-Patient received Pfizer brand COVID-19 vaccine dose number one. - Initial tolerance was fine.
-18-24 hours later she developed 'hives'. PCP eval describes urticarial rash on the neck and face, very itchy. No further symptoms.
- Hives lingered and ultimately seemed to improve with oral steroids and antihistamines but the patient developed a (seemingly secondary) non-urticarial rash on her face that persistent for weeks (Derm consult infectious vs inflammatory).
-The allergy specific question is as follows: should the patient receive the second Pfizer vaccine dose?
-She seems to fall between CDC guidelines in that she clearing is outside of the four hour window which would indicate immediate reaction (CBC guidelines indicate even without systemic symptoms, if hives develop within four hours, then a second dose should be avoided). However her presentation was delayed (18-24 hours), yet still urticarial/ itchy (and has lingered).
https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html
Answer:
Delayed onset benign rashes after COVID-19 mRNA vaccination is not a contraindication to receiving a booster dose. The second dose is often well tolerated. No premedication will be helpful in this setting and future adverse reactions will be needed to be treated symptomatically. Oral steroids should not be given for acute urticaria.
Barniol C, Dehours E, Mallet J, Houze-Cerfon CH, Laugue D, Charpentier S. Levocetirizine and prednisone are not superior to levocetirizine alone for the treatment of acute urticaria: A randomized double-blind clinical trial. Ann Emerg Med. 2018;71:125–131.e1
Palungwachira P, Vilaisri K, Musikatavorn K, Wongpiyabovorn J. A randomized controlled trial of adding intravenous corticosteroids to H1 antihistamines in patients with acute urticaria. Am J Emerg Med. 2020 Feb 19;S0735-6757(20)30098-X.
Secondary acne on the face and neck is common after systemic corticosteroid exposures.
Waljee AK, Rogers MAM, Lin P, Singal AG, Stein JD, Marks RM, Ayanian JZ, Nallamothu BK. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ 2017;357:j1415.
Systemic corticosteroids should be avoided, if possible, for benign delated onset COVID-19 vaccine associated rashes to avoid suppressing T-cell immunity induced by the vaccine.
Please refer to the AAAAI COVID-19 Task Force webpage for additional guidance. https://education.aaaai.org/resources-for-a-i-clinicians
I hope this information is helpful for you and your patient.
Eric Macy, MD, MS, FAAAAI