Combo Therapy Relieves Delayed Rash Symptoms in AD Following mRNA Vaccine

New mRNA COVID-19 vaccines may be linked to delayed generalized hypersensitivity reactions in patients with atopic dermatitis (AD), but these reactions can be well tolerated with medications like dupilumab (Dupixent).

This was supported by a recent case report published in Cureus of an 83-year-old woman with AD and a history of chronic kidney disease (CKD).

In this rare case, the patient had presented to the hospital with widespread pruritic urticarial indurated papules on her arms, legs, and palms 6 months after receiving the mRNA booster dose. The symptoms reportedly appeared the day after she received a booster dose of the Moderna mRNA COVID-19 vaccine and worsened over the next 6 months; she said she had not been exposed to any known irritants or new skin care products.

The patient initially tried taking oral prednisone to relieve her symptoms, but the rash spread and became so severe that it disrupted her sleep, daily functioning, and mental state, leading her to seek emergency medical care. She had no history of cancer or family history of autoimmune disease, but her uncle and daughter had rheumatoid arthritis.

Upon arrival at the hospital, the patient had a normal body temperature and an oxygen saturation of 98%, but she also had high systolic blood pressure and a rapid heart rate. Laboratory tests showed high levels of white blood cells with a predominance of eosinophils, indicating leukocytosis and eosinophilia. Other significant findings included normocytic anemia, elevated inflammatory markers, increased creatinine and blood urea nitrogen, reduced estimated glomerular filtration rate, and a slightly elevated procalcitonin level. Exams showed that she did not have COVID-19 or lung disease, and an electrocardiogram revealed sinus tachycardia and a prolonged QTc interval.

Tests ruled out HIV, hepatitis C, urine porphyrin, and antinuclear antibodies (ANA). The patient was then given oral dexamethasone, diphenhydramine, and intravenous famotidine, as well as intravenous antibiotics for sepsis due to a potential skin infection. She was also given oral prednisone and hydrocortisone cream, which greatly improved her symptoms. After discharge, a punch biopsy was performed on the rash, and additional tests of hematoxylin and eosin staining and direct immunofluorescence assay were done to investigate autoimmune diseases such as lupus, connective tissue disease (CTD), and bullous disease.

Blood work was also conducted, including Lyme serology, complement system levels, ANA, rheumatoid factor, lupus antibodies, and inflammatory markers. The patient was prescribed permethrin for scabies and continued with oral prednisone, hydrocortisone cream, and an oral antihistamine. The dermatopathology report showed a hypersensitivity reaction in the skin, but no evidence of scabies or CTD. Further lab results showed a speckled pattern ANA, normal erythrocyte sedimentation rate, high M-spike and alpha-2 globulin via serum protein electrophoresis, C3 and C4 levels, negative Lyme serology, and dsDNA.

The patient was then started on dupilumab subcutaneous injection and oral prednisone 10 mg, leading to significant improvement in her symptoms. Dupilumab is an interleukin-4 receptor inhibitor used to treat moderate to severe AD by suppressing the TH2 immune reaction associated with cutaneous symptoms.

Live attenuated vaccines, like the smallpox vaccine, pose risks for people with eczema. However, COVID-19 vaccines from Pfizer and Moderna, which do not contain live virus, are unlikely to cause severe skin reactions, but may lead to delayed hypersensitivity reactions like “COVID arm.”

Other studies have shown various cutaneous reactions to mRNA COVID-19 vaccines, with delayed local reactions being the most common, followed by local injection site reactions, urticarial eruptions, and morbilliform eruptions, all of which may start several days after the initial vaccine dose. The late onset of skin lesions may be typical in this context and resemble urticarial eruptions seen in COVID-19 infection, indicating an immune response to viral mRNA or cytokines.

The researchers concluded that COVID-19 vaccines are safe. This conclusion has also been reached in prior large studies, which found that there is a very small percentage of people who may develop flare of their eczema symptoms following mRNA vaccination.

“Our data support that the skin reactions are minor and self-limited but sometimes can be extensive and require medical management; however, it should not prevent or discourage people from getting the vaccine,” the authors wrote. “Cutaneous reaction symptoms often respond well to treatment, so this should not preclude people from getting the vaccination.”

Reference

Hanoodi M, Logee K. A rare case of delayed hypersensitivity following COVID-19 booster necessitating treatment with dupilumab. Cureus. Published online April 13, 2023. doi:10.7759/cureus.37544