key: cord-0890335-n1l55i16 authors: Yu, J.N.; Angeles, C.B.; Lim, H.G.; Chavez, C.; Roxas‐Rosete, C. title: Cutaneous reactions to inactivated SARS‐CoV‐2 vaccine and ChAdOx1‐S (recombinant) vaccine against SARS‐CoV‐2: a case series from the Philippines date: 2021-08-17 journal: J Eur Acad Dermatol Venereol DOI: 10.1111/jdv.17575 sha: 0edfe45ec036fb00de7274d511c94c3e9a5ed60a doc_id: 890335 cord_uid: n1l55i16 The Philippines remains one of the countries with the highest number of new COVID-19 cases in the Western Pacific region. The Philippine government granted emergency use authorizations for inactivated SARS-COV-2 (Sinovac) and recombinant ChAdOx1-S (AstraZeneca) vaccines. Early trials of these vaccines have described reactions ranging from injection site reactions to generalized urticaria. The Philippines remains one of the countries with the highest number of new COVID-19 cases in the Western Pacific region. 1 The Philippine government granted emergency use authorizations for inactivated SARS-COV-2 (Sinovac) and recombinant ChAdOx1-S (AstraZeneca) vaccines. Early trials of these vaccines have described reactions ranging from injection site reactions 2,3 to generalized urticaria. 3 We report 20 healthcare workers who developed cutaneous reactions after receiving their first dose of either Sinovac or AstraZeneca from 1 March 2021 to 31 March 2021. Seven patients received Sinovac, while 13 patients received AstraZeneca. Their median age was 37 years (range: 24-57 years). Fifteen (75%) were female, and five (25%) were male. All patients were seen by either the authors or other dermatologists. All seven patients who developed localized injection site reactions received AstraZeneca (Fig. 1a,b) . These were all delayed reactions, appearing more than 24 h postvaccination, and none reported symptoms of anaphylaxis. Of the 13 patients who developed distant site reactions, defined as cutaneous reactions that are distributed beyond the injection site, six received Astra-Zeneca, and seven received Sinovac. Six patients developed immediate cutaneous reactions: three who either had urticaria, angioedema or petechiae had anaphylactic symptoms; one experienced angioedema and transient focal neurologic deficits; and two had generalized macules and patches and urticaria but without anaphylactic symptoms. Other cutaneous reactions that appeared more than 24 h postvaccination included urticaria, angioedema, erythematous macules, patches, papules, vesicles, purpuric patches and pityriasis rosea (PR)-like eruption (Table 1 ; Fig. 1c-f ). Hypersensitivity to vaccines is often caused by excipients rather than the vaccine antigen. For AstraZeneca, the most likely cause is polysorbate, 4 whereas, for Sinovac, aluminium hydroxide may be causative. 3 Both have been implicated in hypersensitivity reactions. 4 Most vaccination reactions are classified as type I (immediate) or type IV (delayed) hypersensitivity responses. Type I responses usually occur within the first four hours and result from mast cell activation and degranulation, exemplified by anaphylaxis. Type IV responses are delayed, commonly within hours or days after exposure. 5 In our cases, the onset of localized injection site reactions was suggestive of type IV hypersensitivity. These were similarly reported in other mRNA vaccines. 6, 7 The distant site reactions were either immediate or delayed. Three of the six patients who had immediate cutaneous reactions had anaphylactic symptoms either concomitantly or within hours. While urticaria and angioedema are common in anaphylactic reactions, the petechial rash was notable in one of our cases. None of those who had delayed cutaneous reactions developed anaphylactic symptoms. A PR-like eruption, previously reported following vaccination (Moderna and Pfizer COVID-19 vaccines, as well as influenza and hepatitis vaccines) and COVID-19 infection, may be related to a T-cell mediated response to the viral epitope rather than HHV-6 and HHV-7 reactivation associated with true PR. [7] [8] [9] [10] Most cutaneous reactions observed in this case series were self-limited. However, for patients presenting with immediate cutaneous reactions within hours postvaccination, it may be prudent to monitor for further development of anaphylactic symptoms in the next 24 h for immediate control and intervention. For those presenting with cutaneous reactions 24 h postvaccination, supportive management and reassurance seem sufficient. As the widespread vaccination of COVID-19 vaccines continues worldwide, we anticipate more data regarding their side effect profile, including the mechanism and pathophysiology of such side effects. The benefits versus risks from the vaccines support their use and significant role in putting an end to the pandemic. 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The authors declare no conflicts of interest. None. Not applicable.