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Table of Contents 
Year : 2022  |  Volume : 67  |  Issue : 6  |  Page : 802-804
Vaccine-related eruptions of papules and plaques following COVID-19 vaccination – A case series

1 Department of Dermatology, Venereology and Leprology, Sardar Patel Medical College, Bikaner, Rajasthan, India
2 Department of Preventive and Social Medicine, Sardar Patel Medical College, Bikaner, Rajasthan, India
3 Department of Pathology, Sardar Patel Medical College, Bikaner, Rajasthan, India

Date of Web Publication23-Feb-2023

Correspondence Address:
Alpana Mohta
Department of Dermatology, Venereology and Leprology, Sardar Patel Medical College, Bikaner, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_562_22

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How to cite this article:
Mohta A, Mohta A, Ghiya BC, Mehta RD, Kumar V. Vaccine-related eruptions of papules and plaques following COVID-19 vaccination – A case series. Indian J Dermatol 2022;67:802-4

How to cite this URL:
Mohta A, Mohta A, Ghiya BC, Mehta RD, Kumar V. Vaccine-related eruptions of papules and plaques following COVID-19 vaccination – A case series. Indian J Dermatol [serial online] 2022 [cited 2023 Jun 6];67:802-4. Available from:


Vaccination for COVID-19 infection was first developed in December 2020. Ever since the advent of these vaccines, various localized and systemic reactions are being increasingly reported.[1] However, these reactions have opened up Pandora's box with myriad clinical presentations, each having a different underlying pathophysiological picture. In view of such wide variations in clinical features, clinicopathological correlation is the ideal way to classify the reactions. However, there is still a paucity of literature regarding the histopathological features of these reactions. In this series, we provide a histopathological perspective of various mucocutaneous reactions following COVID-19 vaccination.

We included patients who developed any skin reactions within 3 weeks of vaccination. Patients were subjected to detailed history taking and clinical examination. Patients with any pre-existing skin lesions, history of any similar skin lesions in the past, any known drug allergies and any other suspected triggers for the skin reactions were excluded. All cases were subjected to a detailed serological profile, sputum test and chest X-ray to rule out any other infections including COVID-19. Patients with any active infections or positive serologies were excluded. Only immunocompetent subjects were included. Histopathological analysis from the biopsy specimen of the most characteristic lesion was done in all cases.

In this case series, we observed 52 cases with the following histopathological patterns: The most common patterns were spongiotic dermatitis (n = 21) and lichenoid dermatitis (n = 12). Other histopathological patterns included pseudovasculitis (n = 11) and leukocytoclastic vasculitis (n = 6).

Cases with spongiotic dermatitis had two clinical patterns. The first was a mild maculopapular or papulosquamous rash (resembling pityriasis rosea) seen in 13 cases. On histopathology, these cases had only mild epidermal involvement with spongiosis and lymphocytic infiltration over the dermo-epidermal junction [Figure 1]a, [Figure 1]b, [Figure 1]c. The second variant was generalized vesicular eruption resembling flared-up acute eczema seen in eight cases. These cases had features of intense spongiosis with exuberant interface dermatitis [Figure 2]a and [Figure 2]b. Both these variants were labelled as vaccine-related eruptions of papules and plaques (VREPP).
Figure 1: (a) Mild VREPP with spongiotic dermatitis showing intercellular oedema, interface dermatitis and salute sign (black arrow) (Haematoxylin and Eosin, ×400); (b) pityriasis rosea like eruptions; (c) non-specific maculopapular scaly lesions

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Figure 2: (a) Robust VREPP with intense spongiosis and intraepidermal splitting with minimal dermal involvement (Haematoxylin and Eosin, ×400); (b) vesicular lesions

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It was McMahon et al.[2] who first coined the term VREPP. Clinically, VREPP usually manifests as pityriasis rosea (PR) like eruptions and vesicular rash. PR-like eruptions have been reported following many viral and bacterial infections and vaccinations.[3],[4],[5] In our patients, there was an average latency of 17.4 days between vaccination developments of VREPP. This suggests the role of delayed type 4 hypersensitivity reaction. In fact, we also observed that VREPP developed following the first dose of vaccination itself in 12 cases. All these cases had a history of COVID-19 infection in the past, with a mean duration of 5.3 months between COVID-19 infection and the first dose of vaccination. While in the remaining nine cases, VREPP developed after the second dose of vaccination. Only one out of these nine cases had developed COVID-19 infection in the past (6 and 8 months back, respectively). This strongly suggests that while the first dose of vaccination or an attack of COVID-19 infection is responsible for the induction of hypersensitivity reaction, the subsequent dose of vaccination leads to the elicitation of reaction. This was a novel finding in this series.

Though PR-like lesions have been extensively reported following COVID-19 vaccination,[5] the report of papulovesicular lesions is still sparse. Although both these lesions have completely different clinical features, they share common a histopathological picture. It is, therefore, imperative to use a histopathological classification to better characterize post-vaccine mucocutaneous reactions.

Although a causality assessment was done on all the patients, to rule out other possible explanations for these reactions, this series had a few limitations. These included an absence of immunological analysis and a lack of dermatoscopic correlation.

In conclusion, our series intends to provide a visual description of histopathological in the skin following COVID-19 vaccination. All the patients in our study had only benign cutaneous reactions with an excellent prognosis. It is essential to explain the benign and idiosyncratic nature of these reactions to the patients, in order to avoid the already prevailing vaccine hesitancy. This series further supports the fact that the benefit of COVID-19 vaccination greatly exceeds its adverse effects.


We thank all the healthcare providers at our centre who entered cases' history during vaccination and referred the cases to us following any AEFI.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

McMahon DE, Amerson E, Rosenbach M, Lipoff JB, Moustafa D, Tyagi, et al. Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases. J Am Acad Dermatol 2021;85:46-55.  Back to cited text no. 1
McMahon DE, Kovarik CL, Damsky W, Rosenbach M, Lipoff JB, Tyagi A, et al. Clinical and pathologic correlation of cutaneous COVID-19 vaccine reactions including V-REPP: A registry-based study. J Am Acad Dermatol 2022;86:113-21.  Back to cited text no. 2
Drago F, Ciccarese G, Javor S, Parodi A. Vaccine-induced pityriasis rosea and pityriasis rosea-like eruptions: A review of the literature. J Eur Acad Dermatol Venereol 2016;30:544-5.  Back to cited text no. 3
Drago F, Ciccarese G, Parodi A. Pityriasis rosea and pityriasis rosea-like eruptions: How to distinguish them?. JAAD Case Rep 2018;4:800-1.  Back to cited text no. 4
Khattab E, Christaki E, Pitsios C. Pityriasis Rosea Induced by COVID-19 Vaccination. Eur J Case Rep Intern Med 2022;9:003164.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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