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LETTER TO THE EDITOR
SARS-CoV-2 mRNA vaccine-
associated fixed drug eruption
Dear Editor,
A 26-year-old, healthy, female nurse on no regular medica-
tion developed a mildly pruritic, erythematous, annular patch
with faint, central clearing on her left shoulder (Fig. 1a). The
patient had received the first dose of the Pfizer-BioNTech
(Pfizer Inc., New York City, NY, USA) SARS-CoV-2 mRNA
vaccine in the same arm 15 days prior to the development of
the lesion. The injection site was 7 cm distal to the evolving
patch. Over the span of 2 days, the patch developed a
(a) (b)
(c) (d)
Figure 1 FDE after the administration of the 1st (a, b) and 2nd (c, d) dose of Pfizer-BioNTech SARS-CoV-2 mRNA vaccine.
©2021 European Academy of Dermatology and VenereologyJEADV 2021
JEADV
shallow, central erosion surrounded by a halo of erythema
(Fig. 1b) and subsequently started to resolve spontaneously.
The patient had also experienced facial flushing 15 minutes
after the vaccine was administered.
An identical erythematous patch re-emerged 14 days after the
patient was administered the second Pfizer-BioNTech SARS-
CoV-2 mRNA vaccine dose. This time, the patch was accompa-
nied by prominent vesiculation within its duskier centre (Fig. 1c).
(a)
(b)
Figure 2 (a) Photomicrograph showing skin with epidermal acanthosis and focal epidermal atrophy with overlying crust. A patchy
inflammatory infiltrate is present in the upper dermis, extending into the mid dermis in a periadnexial distribution. (H&E 940) (b) A liche-
noid inflammatory pattern is seen, with lymphocytic infiltration of the epidermis associated with pigment incontinence and Civatte body
formation (H&E 9200).
©2021 European Academy of Dermatology and VenereologyJEADV 2021
2Letter to the Editor
The vesicles eventually ruptured and scabbed, giving the lesion a
targetoid appearance (Fig. 1d). Of note, the patient had self-medi-
cated with a stat dose of hydroxyzine an hour prior to receiving
the second vaccine to abate facial flushing. She had otherwise not
taken any prescribed or over-the-counter medications.
Self-medication with topical 1% hydrocortisone and terbina-
fine applied twice daily for a couple of days on the second erup-
tion proved ineffective. The patient was referred for a
dermatological opinion. A diagnosis of fixed drug eruption (FDE)
was suspected, and a diagnostic punch biopsy was carried out.
Histology showed skin covered by a variably acanthotic and
atrophic epidermis with overlying crust (Fig. 2a). A patchy lym-
phohistiocytic infiltrate was present in the upper dermis, focally
extending into the mid dermis around skin adnexal structures.
Eosinophils were inconspicuous. Lymphocytic infiltration of the
basal layer of the epidermis was noted. This was associated with
basal cell vacuolar damage, Civatte body formation and pigment
incontinence (Fig. 2b). Incipient clefting at the dermal–epider-
mal junction was also appreciated. The overall findings were
those of lichenoid interface dermatitis, consistent with a fixed
drug eruption.jd
To the best of our knowledge, this is the first reported case of
SARS-CoV-2 mRNA vaccine-associated FDE. FDEs represent a
cutaneous adverse drug reaction (ADR) clinically characterized
by the appearance of recurrent, quasi-identical, cutaneous erup-
tions in the same anatomical location upon exposure and re-ex-
posure to the offending drug. The delay between drug
administration and FDE ranges from 0 to 40 days, manifesting
most commonly as a single lesion with a propensity for the
upper limbs.
1
Intraepidermal interferon c-secreting, CD8
+
T
cells are the key cellular mediators of this type IV hypersensitiv-
ity reaction.
2
FDEs have been associated with other vaccines
including the influenza,
3
human papilloma virus
4
and yellow
fever vaccine.
5
Of the 13 794 904 COVID-19 vaccine doses administered in
the United States between December 2020 and January 2021,
6354 adverse events were reported –of which, 92.4% were non-
serious.
6
Injection site reactions account for up to 84% of ADRs
associated with the Pfizer-BioNTech SARS-CoV-2 mRNA vac-
cine,
7
with erythema and oedema being the commonest reac-
tions.
8
Other described cutaneous ADRs to the Pfizer-BioNTech
SARS-CoV-2 mRNA vaccine include lichen planus,
9
a morbilli-
form rash,
10
radiation recall
11
and urticaria.
12
Dermatologists and clinicians alike, who have now have
become experts at identifying cutaneous manifestations of
COVID-19, need to be aware of possible cutaneous ADR related
to SARS-CoV-2 vaccination. Notwithstanding, the authors
strongly recommend the administration (and uptake) of the
vaccine according to internationally established guidelines and
national vaccination strategies.
Conflicts of interest
Dr Mintoff, Dr Pisani, Dr Betts and Dr Scerri have no conflicts
of interest to declare. The patients in this manuscript have given
written informed consent to publication of their case details.
Funding source
The authors declare no funding sources.
D. Mintoff,
1,
* D. Pisani,
2
A. Betts,
2
L. Scerri
1
1
Department of Dermatology, Mater Dei Hospital, Msida, Malta,
2
Department of Pathology, Mater Dei Hospital, Msida, Malta
*Correspondence: D. Mintoff. E-mail: dillon.mintoff@gov.mt
References
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Phys 2021. (in press). https://doi.org/10.1016/j.ijrobp.2021.02.048
12 Corbeddu M, Diociaiuti A, Vinci M et al. Transient cutaneous manifesta-
tions after administration of Pfizer-BioNTech COVID-19 Vaccine: an
Italian single-centre case series. J Eur Acad Dermatol Venereol 2021.
https://doi.org/10.1111/jdv.17268
DOI: 10.1111/jdv.17390
©2021 European Academy of Dermatology and VenereologyJEADV 2021
Letter to the Editor 3
