Association of COVID-19 vaccination and Urticarial vasculitis

Dear Editor,

The occurrence of urticarial vasculitis (UV) in the current pandemic scenario has been relatively uncommon; however there is literature data on the association between COVID-19 vaccination and UV [Table 1].^[1-10] Baraldi et al. described a 78-year-old woman with mild urticaria after the first dose of the Oxford-AstraZeneca vaccine, which rapidly regressed. One week later, more accentuated urticarial lesions appeared over the extremities and the biopsy and blood tests confirmed the diagnosis of UV that improved with corticosteroids.^[1] Chang et al. reported recurrent urticaria in a 29-year-old male, which reappeared 5 days after the first dose of vaccine. The biopsy study confirmed the diagnosis of UV, which improved with antihistamines but rapidly recurred after the second vaccination.^[2] This recurrent urticaria was refractory to antihistamines but responsive to omalizumab. Daldoul et al. described a 73-year-old male with past history of chronic spontaneous urticaria, who presented with urticarial lesions on the thighs and trunk 2 days after the second dose of Pfizer-BioNTech mRNA vaccine; UV was confirmed on histopathology and there was a spontaneous improvement in 1 week.^[3] Dash et al. described a 27-year-old man with UV on the next day after the second dose of inactivated coronavirus vaccine, which was controlled by indomethacin and levocetirizine; and the authors highlighted that this was a unique example of UV caused by COVID-19 vaccination.^[4] Lapin described a 66-year-old female with UV affecting the hands after the first dose of AstraZeneca, with spontaneous clearance. The same patient presented with an intense rash, angioedema, and urticaria, 4 days after the second dose.^[5] She received treatment with fexofenadine for 6 weeks without any improvement, the biopsy study of skin lesions established the diagnosis of UV. The authors cited that this was the first occurrence of UV due to AstraZeneca vaccination and the third report in English literature of UV after vaccines against COVID-19.^[5] Larson et al. reviewed the manifestations and biopsy findings of 23 cases of dermatological disorders after the COVID-19 vaccination from January 1 to May 31, 2021, and reported a 35-year-old female presenting with UV after the first dose of the Moderna vaccination, that was treated by antihistamines plus methylprednisolone and dapsone.^[6] Magro et al. reviewed clinical and complementary data, including biopsies, of 22 cases of dermatological disorders after the Moderna or Pfizer vaccines, and urticarial lesions appeared within 4 weeks after both doses of the vaccinations.^[7] There were ten women and 12 men with a median age of 53 (range 23-96 years) and two of them had characteristic pattern of UV on histopathological analysis.^[7] McMahon et al. reviewed the reported data from December 24, 2020, to February 14, 2021 of dermatological disorders after the Moderna (83%) or Pfizer (17%) vaccines in 414 patients with 44 (36–59) years of age, and 90% women.^[8] The cutaneous vasculitis was diagnosed in two cases after the first dose of the Moderna and in 1 case after the first dose of the Pfizer vaccination.^[8] Nazzaro and Maronese reported a 27-year-old female with a dermatological reaction due to UV 10 days after receiving the first dose of the Moderna vaccine, which was successfully managed by the use of prednisolone for 2 months.^[9] Ono et al. described a 68-year-old male presenting with urticarial lesions 4 days after the third dose of the Pfizer vaccine with no adverse effects to the subsequent vaccination.^[10] The diagnosis of UV was confirmed by skin biopsy, and the initial treatment by prednisolone resulted in no improvement.^[10]

In conclusion, considered as a rare association with COVID-19 vaccination, UV may be underreported, or underdiagnosed and misdiagnosed due to a low degree of suspicion. Case reports on UV following covid vaccination contribute to enhancing the awareness of healthcare workers.