A study of COVID-19 vaccine (Covishield) induced dermatological adverse effects from India.

Abstract

In India, two vaccines are approved for use – ChAdOx1 nCoV-19 Corona virus recombinant vaccine (Covishield) and the whole-virion inactivated SARSCoV-2 antigen (Covaxin).1 Both the vaccines are injected intramuscularly with a minimum gap of 4 weeks. In India, initially, population above 45 years of age were being administered with the vaccine followed by age bracket from 18 to 45 years.2 Both the vaccines mention rash as possible adverse effect. We conducted a prospective study to further explore the cutaneous adverse effects of Covishield vaccine. We conducted a cross-sectional study of the cutaneous adverse effects of Covishield vaccine in a population being immunized in a tertiary care hospital in northern India over period of last 3 months. (September 2021 to November 2021). Ethical clearance was obtained from the institutional ethics committee. Participants who developed COVID-19 infection or any other systemic infections after vaccination were excluded from the study. The symptoms of obvious pain, discomfort, erythema at the vaccination site were discounted from our study as adverse effect considering it as an exaggeration of local inflammatory response to vaccine. The participants were apprised of possible cutaneous adverse effects of vaccine at the time of first dose and were asked to report them to the researchers when they appear. An effort to actively contact the participants through phone call and following them up for any dermatological adverse effect was also carried out. At the time of vaccination, a proforma was filled recording basic demographic profile of the participant with any history of prior dermatoses and allergies. A total of 4063 individuals were vaccinated with Covishield between September 2021 and November 2021; 63% of them were males. The maximum and minimum age of those vaccinated were 19 and 86 years, respectively, with mean age of 36.7 years of age. Fifty (1.23%) patients reported adverse cutaneous reactions to vaccines (Fig. 1). One patient developed anaphylaxis after the first dose of vaccine and was managed successfully. He did not have any history of allergy or urticaria. Eighteen (36%) reported excessive hair fall starting from as early as 5 weeks after the first dose of the vaccine and were diagnosed to have telogen effluvium by hair pull test and trichoscopy. Three of them were already suffering from telogen effluvium and complaint of even increased hair shedding after receiving vaccine. Twelve (24%) patients in total developed wheals. Most of them developed them as early as same day of the first dose of vaccine. Only two of them had prior history of urticaria. Three of the patients with urticaria also reported associated angio-oedema. Four patients reported generalized pruritus without any wheals. Four patients developed maculo-papular rash while one patient developed non-blanchable petechial rash. Two patients were diagnosed to develop lichen planus after vaccination. Three of the patients developed pityriasis rosea, while two patients were diagnosed to have eruptive pseudoangiomatosis. One patient reported herpes simplex labialis. One patient developed pemphigus vulgaris 2 weeks after the second dose of the vaccine. One patient was diagnosed as post-vaccine cheiro-pedo pompholyx. Eighteen (36.7%) of total patients with cutaneous adverse effects developed telogen effluvium. The second most common adverse effect seen in our study was urticaria – not only exacerbated but also induced by vaccine. Although there are many reports of COVID-19 infection induced telogen effluvium,3, 4 no such cases have been reported post COVID-19 vaccination, although a study has been done which indicates hair loss as a rare adverse effect of vaccines.5 A study by Catala et al reported urticaria as the most common adverse effect (14.6%) after injection site reactions.6 Four of our patients developed generalized pruritus without any evidence of rash. The pruritus appeared from 2 days to 2 weeks of receiving vaccine. Although many studies have reported pruritus limited to injection site, none have mentioned generalized pruritus as an adverse effect of vaccine.7, 8 Since there may be a lag period of days to weeks between COVID-19 vaccine and onset of pruritus, patients may not always associate the two and hence pruritus associated with vaccine may be under-reported. Four patients had maculo-papular rash. Morbiliform as well as delayed skin rash have been reported post COVID-19 vaccination.9, 10 Rest of the adverse effects reported in our study were infrequent as compared to telogen effluvium and urticaria. Our study is limited to a population sample receiving Covishield vaccine in India, and the findings cannot be extrapolated to other COVID-19 vaccines available worldwide. As with other studies reporting various adverse effects of COVID-19 vaccine citing chronology of adverse effects after receiving vaccine, our study is limited by lack of definite association. More studies with larger sample size with longer follow-up periods are needed to further elucidate the dermatological adverse reaction of COVID-19 vaccines. None. None. None. The data that support the findings are available from the corresponding author Pankaj Das, upon reasonable request.