Delayed nonlocal cutaneous reactions after inactive COVID‐19 vaccinations

To the editor,

I have read the article titled “Cutaneous reactions after COVID‐19 vaccination in Turkey: A multicenter study” by Cebeci Kahraman et al. ¹ with great interest. After thanking their nice contribution to the literature, I want to raise a couple of questions on their possible working hypothesis and their experience with these patients.

The authors detected reactivations of herpetic diseases, associated with the human herpes virus family, including herpes zoster and pityriasis rosea after mRNA vaccinations. They also suggested a possible hypothetical mechanism for this reactivation indicating a strong specific immune response induced by the inactivated virus, which might overwhelm cellular immune response against a latent virus. ¹ Firstly, why such specific herpetic virus reactivations (zoster, pityriasis) rather than latent other herpes viruses (e.g., EBV and CMV) reactivations occur after vaccinations? Secondly, why such herpetic reactivations occur after mRNA vaccines rather than other inactive virus vaccines?

In this study, ¹ the most common non‐local cutaneous reactions of mRNA vaccine were reported as herpes zoster after the first dose and pityriasis rosea after the second dose. Thirdly, herpes zoster and pityriasis rosea are disorders are supposed to be related to the human herpes virus family as mentioned in the article. Why the zoster happens after the first dose and the other (pityriasis) after the second dose of vaccinations? How the authors may explain this?

The rate of serious reactions, for example, urticaria/angioedema developing within the first 24 h is higher in BioNTech than in CoronaVac, which was found to be a very important finding in this study. ¹ Fourthly, IgE‐mediated type I hypersensitivity reactions usually happen in 4–6 h. Would the cutaneous reactions observed in this study up to 24 h be delayed cutaneous reactions?

Fifthly, was there also any delayed (>24 h) urticaria/angioedema development after vaccinations, especially for mRNA vaccinations, in this study? Delayed cutaneous reactions have previously been reported by many groups as rather large local reactions such as in this study. ¹ True/systemic delayed urticaria–angioedema reactions to mRNA‐type COVID‐19 vaccines have not been reported much before. McMahon et al. reported 414 cutaneous adverse reactions, urticaria occurred in 23 subjects, 18 of whom occurred >24 h post‐vaccination after Moderna mRNA vaccination. After BioNTech mRNA vaccination, it occurred 24 h later in 16 subjects. ² Three different cases of angioedema occurring within days of administration of an mRNA COVID‐19 vaccine severe enough to warrant an emergency room visit were reported by Watts et al. ³ Although the authors mentioned McMahon et al.'s study, ¹ , ² they did not discuss non‐local/systemic delayed urticaria–angioedema reactions. I think that delayed urticaria–angioedema reactions against mRNA‐type vaccines should be discussed.

ETHICS STATEMENT

Not applicable.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.