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ORIGINAL ARTICLE
Year : 2022 | Volume
: 26
| Issue : 2 | Page : 70-72
Delayed-onset urticaria following vaccination for COVID-19
Brandon L Clark1, Brad A Yentzer2
1 Lake Erie College of Osteopathic Medicine, Elmira, NY, USA
2 Finger Lakes Dermatology, Freeville, NY, USA
Correspondence Address:
Dr. Brad A Yentzer
Finger Lakes Dermatology, 2141 Dryden Road, Freeville, NY 13068
USA
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jdds.jdds_67_22
Background: As COVID-19 vaccines continue to be administered worldwide, there are an increasing number of studies documenting cutaneous reactions following vaccination. Systemic reactions, such as urticarial diseases, occur. Purpose: The main objective of this study was to investigate the association between urticaria and recent vaccination for COVID-19. Methods: A retrospective chart review examining the association of urticaria and COVID vaccination was conducted. Results: We report 17 patients who developed an urticarial reaction following vaccination against COVID and one patient who developed an urticarial reaction following a COVID infection. The vast majority of the patients were women with a mean age of 42.8 years. Conclusion: Cutaneous manifestations often follow COVID vaccination and infection. It may be helpful to inquire about recent infections and vaccinations in patients presenting with urticarial diseases.
Keywords: Acute urticaria, chronic urticaria, dermatographia, dermatographic urticarial, dermatographism
With 12.3 billion COVID-19 vaccines administered worldwide, robust surveillance and reporting have allowed for the identification of adverse side effects, including cutaneous manifestations following vaccination.[1] There are an increasing number of studies documenting cutaneous reactions following vaccination. Cutaneous eruptions that have occurred range from self-limiting local injection site reactions to more systemic findings such as urticaria and morbilliform eruptions.[2] We present a retrospective chart review from a solo practice in rural New York, examining the association of urticaria and COVID vaccination.
MethodsA retrospective chart review was completed for patients presenting with the diagnosis of urticaria at an outpatient private dermatology practice in Freeville NY. A list of patients was generated by searching the clinic's electronic medical record for patient charts that contained the terms “urticaria,” “chronic urticaria,” “acute urticaria,” “dermatographia,” “dermatographism,” and “dermatographic urticaria.” The date range was set to include visits from January 2021 to June 3, 2022. The start date was chosen because COVID vaccines did not become widely available until January 2021. A retrospective chart review was completed to search for suspected connections between the patients' symptoms and a recent vaccination against COVID and/or a recent infection with COVID. The sole dermatologist at the practice had noted in the patients' charts if a connection was suspected. The patients' sex and age were documented for all visits. If a connection to COVID was noted in the chart, the patient's past history of urticarial reactions, progression to chronic urticaria, if applicable, treatment plan, and follow-up visits were also recorded.
ResultsBetween January 1, 2021, and June 3, 2022, 88 patients sought treatment for urticarial reactions. Of those, 17 (19%) had recently received a COVID vaccination and one (1%) had a recent COVID infection. Of those who had recently been vaccinated, the mean age was 43 years and 88% of them were women. The patient who was recently infected was a 33-year-old male (Patient 17). Of those who did not have a connection to a recent COVID infection or vaccination, the mean age was 47 years and 64% were women [Table 1]. Only one of the patients who developed symptoms after vaccination had a history of urticaria (Patient 4). She reported a similar reaction following an exposure to COVID in the past. In addition, this same woman was the only recently vaccinated patient to return to the office for the management of chronic urticaria. The condition of the patient who was recently infected with COVID also progressed to chronic urticaria.
Fifteen of the patients who developed symptoms after receiving the vaccine were treated with antihistamines. One patient was offered an antihistamine and declined treatment (Patient 18). Another patient's symptoms were already improving without treatment at the time of her appointment, and she was advised to take an antihistamine 1 week before future doses of the vaccine (Patient 3). The woman whose condition progressed to chronic urticaria failed treatment with antihistamines and colchicine. She was started on Xolair. The only patient who was recently infected with COVID was treated with antihistamines and colchicine. Only two other patients had a follow-up visit at the time of this paper. Patient 1's dermatographism had improved approximately 2 months after the initial diagnosis. Patient 5's dermatographism had resolved approximately 2 months after the initial diagnosis [Table 2].
Table 2: Treatments prescribed and follow up status for patients with documented recent COVID-19 infection or vaccination Discussion Delayed onset urticaria can occur following COVID vaccination. After the Moderna and Pfizer, mRNA vaccines were authorized in December 2020, 414 cutaneous reactions to the vaccines were reported between December 2020 and February 2021.[3] Of those cases, 34 reactions were characterized as urticaria that occurred at least 24 h after vaccination.[3] In addition, from January 1, 2020, to September 27, 2021, 48,470 reported cutaneous reactions occurred following vaccination; 440 of those reactions were urticarial in nature, with a median time of onset of 22 h after vaccination.[2] One case series documented eight patients who developed chronic spontaneous urticaria, with a median time of onset of 8.6 days after being vaccinated.[4] Another case series reported 12 patients who developed delayed urticarial reactions after being vaccinated. 58.3% of the patients developed symptoms within 8–24 h, 16.7% of patients within 24–28 h, and 25% of patients developed symptoms after 48 h.[5] Interestingly, the patient demographics from these two case series were similar. In the first study mentioned, the mean patient age was 56.5 years, and 75% were women, and in the second study, the mean patient age was 52 years, and 75% were women.[4],[5] A similar trend was noticed at our solo practice in rural New York, and a retrospective chart review examining the association of urticaria and COVID vaccination was completed. We report 17 patients who developed an urticarial reaction following vaccination against COVID and one patient who developed an urticarial reaction following a COVID infection.
The mechanism of urticarial reactions following vaccination against COVID is currently unknown. The intradermal edema that characterizes urticaria is mediated by the release of histamine and other vasoactive molecules from activated mast cells.[6] Numerous factors can initiate mast cell activation and degranulation, including allergens binding to immunoglobulin (Ig) E antibodies, autoreactive IgE antibodies binding to self-antigens, IgG antibodies crosslinking with IgE antibodies, as well as certain drugs.[7] We suspect that the urticarial reactions are an autoimmune response secondary to high levels of antibodies following vaccination or infection. Patients were informed that this is not a true allergy to the vaccine.
There are three main limitations of our study. We lack follow-up data and treatment outcomes for most of the patients. Patients were instructed to follow-up if their symptoms persisted beyond 2 months despite following the prescribed treatment plan. As a result, the majority of patients were not seen again after the initial diagnosis. In addition, there is a possible lack of documentation of associations between urticaria and COVID vaccination. Recent COVID vaccinations may not have been documented in patient charts despite suspicions that their urticarial symptoms were a manifestation of the vaccine. Finally, we lack accurate data regarding the onset of symptoms following vaccination or infection.
ConclusionThis retrospective chart review documents 17 cases of urticarial reactions following COVID vaccination and one case of urticaria following COVID infection. The sex and age demographics included in this study are similar to the findings of other case reports that report the same phenomenon. The vast majority of the patients were women with a mean age of 43 years. Future studies would be needed to investigate if these urticarial reactions are more prevalent in women. These findings contribute to the growing body of literature that continues to document cutaneous manifestations following COVID vaccination and infection and highlights the need for physicians to inquire about recent infections and vaccinations in patients presenting with urticarial diseases.
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Conflicts of interest
There are no conflicts of interest.
References
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