Clinical Dermatology Review

REVIEW ARTICLE
Year
: 2021  |  Volume : 5  |  Issue : 2  |  Page : 139--143

COVID-19 vaccination in India: Clinical guidance for patients with dermatological diseases


Namitha Chathra1, Savitha Somaiah2,  
1 Department of Dermatology, PES Institute of Medical Science and Research, Kuppam, Andhra Pradesh, India
2 Department of Dermatology, Sapthagiri Institute of Medical Sciences & Research Centre, Bengaluru, Karnataka, India

Correspondence Address:
Namitha Chathra
Department of DVL, PES Institute of Medical Science and Research, Kuppam, Andhra Pradesh
India

Abstract

Since the advent of COVID-19 vaccines, dermatologists have frequently come across patients, especially those receiving immunomodulatory drugs, who express concerns about the safety and efficacy of vaccines. In this review, we aim to provide guidelines to dermatologists with regard to the three COVID-19 vaccines licensed for use in India. All dermatology patients, even the ones on immunomodulatory drugs, need to be encouraged to take the vaccine. COVID-19 vaccines are not contraindicated in individuals afflicted with eczema; atopic dermatitis; psoriasis; vitiligo; lichen planus; urticaria; connective tissue disorders; and bacterial, mycobacterial, viral, or fungal infections. However, those who have been seriously ill requiring hospitalization are advised to wait for 4–8 weeks. For patients on immunomodulatory drugs, when the disease is stable, the drug may be withheld or dosage reduced for 1–2 weeks following vaccination. However, the vaccination may be given without any modification in the drug/biological. People with a history of anaphylaxis/urticaria can receive a COVID-19 vaccine with 30 min postvaccination observation period. Absolute contraindications include a history of immediate hypersensitivity to any component of the vaccination and hypersensitivity following first dose of vaccination. Patients who have received vaccination can undergo procedures such as skin biopsy, cautery, cryotherapy, lasers, chemical peels, excisions, biopsy, and hair transplantation; fillers may be scheduled 2 weeks before or after the vaccination.



How to cite this article:
Chathra N, Somaiah S. COVID-19 vaccination in India: Clinical guidance for patients with dermatological diseases.Clin Dermatol Rev 2021;5:139-143


How to cite this URL:
Chathra N, Somaiah S. COVID-19 vaccination in India: Clinical guidance for patients with dermatological diseases. Clin Dermatol Rev [serial online] 2021 [cited 2021 Nov 28 ];5:139-143
Available from: https://www.cdriadvlkn.org/text.asp?2021/5/2/139/324564


Full Text



 Introduction



The exceptional speed of the development of vaccination against COVID-19 is unprecedented and is a shot in the arm to the fight against the pandemic. Due to remarkable efforts by the scientific community, several vaccines have received approval within a year of the onset of the pandemic. In India, three vaccines have received emergency use authorization (EUA), and a few others are undergoing trial and awaiting approval [Table 1].[1],[2],[3]{Table 1}

In this review, we aim to provide guidance to dermatology providers on the use of the licensed (EUA) COVID-19 vaccine and the management of patients with dermatological diseases around the time of vaccination against SARS-CoV-2. Accurate information about the vaccines will help a dermatologist in guiding a patient seeking vaccination. It will also help dermatologists in counseling patients who express hesitation about the vaccination and encourage them to take vaccination.

 COVID-19 Vaccine and Dermatological Diseases



Psoriasis and psoriatic arthritis

Since COVID-19 vaccines were expected to unleash a Th1 type response, concerns were raised about a theoretical risk of flares in diseases such as psoriasis and lupus which have a proven role of Th1 in their pathogenesis.[4],[5],[6] However, vaccination process in India is on the verge of reaching half-year mark and no such flares postvaccination have been reported. In contrast, multiple reports of COVID-19 aggravating psoriasis are available.[7],[8] Patients with psoriasis and psoriatic arthritis, irrespective of the treatment they are receiving, are encouraged to opt for the first available vaccination.[9]

Connective tissue disease

COVID-19 vaccination, akin to all other nonlive vaccines, is safe in autoimmune inflammatory diseases such as lupus erythematosus and dermatomyositis.[10] However, it is advised to receive the vaccination when the disease is in a quiescent phase and not during a flare.[11]

Infections

Fungal infections, viral infections, and bacterial infections such as leprosy and cutaneous tuberculosis are not a contraindication to receive the vaccination.Occurrence of herpes zoster following mRNA vaccines has been reported; however, these case reports are much lesser in number than reports of herpes zoster following COVID-19 infection.[12],[13],[14],[15]Patients with HIV, irrespective of the viral load or CD4 count, are recommended to take the vaccine.[16]

Others

COVID-19 vaccines are not contraindicated in individuals afflicted with eczema, atopic dermatitis, vitiligo, lichen planus, urticaria, autoimmune bullous disorder, neutrophilic dermatoses, and cutaneous malignancies.

 COVID-19 Vaccination and Allergy



Most people with a history of anaphylaxis/urticaria can receive a COVID-19 vaccine, but they should all be observed for 30 min postvaccination.The only allergy-related contraindications are:

Immediate type 1 hypersensitivity reaction of any severity (pruritus, urticaria, flushing, respiratory distress, angioedema, and anaphylaxis) occurring within <4 h of the first dose of vaccination[17]History of anaphylaxis to any components of the COVID-19 vaccine (such as polysorbate).[17]

Persons who have had a confirmed anaphylaxis to the first dose of a COVID-19 vaccine should not receive a second dose of that same vaccine typeAnyone who has had mild allergic signs such as urticaria with the first dose (developed >4 h of first dose) would need observation for 30 min after the second doseAdministering antihistamines prior to COVID-19 vaccination to prevent allergic reactions is not recommended. Antihistamines do not prevent anaphylaxis; however, their use might mask cutaneous symptoms, leading to delayed diagnosis and treatment of anaphylaxis.[17]Delayed reactions can occur hours to days later and include pain, burning, swelling, and redness at the injection site. These reactions are not immunoglobulin E mediated, are often self-limited, and do not contraindicate administration of future doses of the same vaccine.Maculopapular rash following the first dose is not a contraindication for the next dose of vaccination.[18],[19]Individuals who have developed the delayed reactions following first dose may be counseled as follows:

Most patients have tolerated the second dose without developing a reactionWhen the reaction does recur following the second dose, it may occur sooner but with less severitySymptomatic treatment with antihistamines/ice-packs/topical corticosteroids was found to be safe and sufficient in most cases.[20]

 COVID-19 Vaccination and Dermatologic Therapies



Immunosuppressive therapy

Vaccination against COVID-19 is highly recommended for all dermatological patients, even the ones on immunomodulatory drugs and/or biologic agents.[21] Two factors in relation to the vaccine are of concern for patients on immune-modulating therapies: safety and efficacy. Safety of vaccination is largely assessed from observational studies,[22] whereas the efficacy is assessed by measuring postimmunization antibody titer, which represents humoral response.[23],[24],[25]

Safety

All the vaccine platforms available currently have a good safety profile with minimal to no risk of adverse events.[26],[27]Nonreplicating viral vector vaccine (e.g. COVISHIELD) is recommended for patients on biologic therapy.[21]

Efficacy

Ideally, COVID-19 vaccination should be completed at least 2 weeks before initiation of immunosuppressive therapies.Patients already receiving immunosuppressive therapy, especially those who are at a risk of disease flare on dosage reduction or cessation of immunotherapy, may receive nonreplicating viral vector vaccine (e.g. COVISHIELD, SPUTNIK V) or inactivated SARS-CoV-2 vaccine (COVAXIN) subtypes without significant modification of ongoing treatment.[22]Antibody levels vary depending on the immunotherapy; fair to good antibody response is expected for most biologics. [Table 2]

To obtain an optimal vaccination response, in a patient with stable disease, clinicians may consider temporary discontinuation of the following drugs from the vaccination day until: [28]One week for Janus kinase-inhibitors, cyclosporine, and mycophenolate mofetilTwo weeks for methotrexate and azathioprine.

Alternatively, the lowest dose possible may be used, for example: [29]

2.5 mg/kg/day cyclosporineOne mg/kg/day azathioprine7.5 mg/week methotrexateSystemic steroids (prednisolone) <20 mg/day.

In patients on biologicals, vaccination may be planned 7 days on either side of the biologic dosing, and a different anatomic site may be chosen for the injection to reduce the chances of local reaction. For B-cell depleting rituximab, when possible, vaccination needs to be planned 4 weeks after the last dose and 2–4 weeks before the next dose.[22],[28]Checking antibody titers after vaccination and using additional vaccinations to boost the level of protective antibodies does not have strong recommendation.[28]Speculations of inactivated whole-virus formulations or viral vector vaccine models having a theoretical potential to cause antibody-dependent enhancement (ADE) and enhanced respiratory disease (ERD) were raised.[30],[31],[32] Both ADE and ERD have been reported with dengue virus (DENV). The chances of ADE and ERD may be higher in individuals on immunomodulatory drugs who display a skewed Th2 response.[21] However, these phenomena are unlikely to occur with coronavirus diseases because they predominantly infect respiratory epithelium, unlike DENV which targets macrophages.[33]{Table 2}

Antiviral therapy

Administration of an antiviral drug at any interval before or after vaccination is unlikely to impair the development of a protective antibody response.

Isotretinoin

Patients on oral retinoids can be vaccinated without a need for dose adjustment.[29]

Antifungal drugs

Patients on oral antifungals can be vaccinated without altering the treatment regimen.

Procedures

Procedures such as skin biopsy, cautery, cryotherapy, lasers, chemical peels, excisions, biopsy, and hair transplantation are not contraindicated before or after the vaccination.Dermal fillers to be scheduled 2 weeks before or after the vaccine, as there are a few rare instances where patients have developed swelling at or near the site of dermal filler following vaccination.[34]

Other vaccines

A 1–2-week buffer between shots is recommended for elective immunizations such as shingles vaccine, but not for emergency vaccines such as tetanus vaccine.[28]

 General Considerations

The protection of vaccination should extend to pregnant and lactating women.[35]In case of individuals having lab test-proven SARS-2 COVID-19 illness and in those who have been given convalescent plasma, COVID-19 vaccination to be deferred by 3 months from the date of discharge.[36]If infected with COVID-19 after the 1st dose of vaccination, the 2nd dose needs to be deferred by 3 months after clinical recovery from illness.Persons with any other serious general illness that has required hospitalization are advised to wait 4–8 weeks before getting the COVID-19 vaccine.[36]

 Disclaimer Notice



These guidelines are based on currently published research work on the subject and in the absence of high-quality data. Its applicability may vary depending on the need of each patient which is best assessed by the treating clinician. This guidance is a “dynamic document” and is subject to change in accordance with results of ongoing or future research work and government data.

Acknowledgment

We would like to acknowledge Dr. Prabhakar Sangolli, Dr. Venkataram Mysore, and Dr. Rasya Dixit for their valuable inputs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Ministry of Health and Family Welfare, Government of India. Information Regarding COVID-19 Vaccine. Available from: https://www.mohfw.gov.in/covid_vaccination/vaccination/index.html. [Last accessed on 2021 May 28].
2Indian Council of Medical Research. COVID-19 Vaccines under Trials in India. Available from: https://vaccine.icmr.org.in/covid-19-vaccine. [Last accessed on 2021 May 28].
3McGill COVID-19 Vaccine Tracker Team; 2021, May 28. COVID-19 Vaccine Tracker. Available from: https://covid19.trackvaccines.org/. [Last accessed on 2021 May 28].
4Sinha A, Kumar R, Singh AR. Implication of mass COVID-19 vaccination on dermatology practice in 2021. Dermatol Ther 2021;34:e14765.
5Barrett J, Ewer K, Belij-Rammerstorfer S, Sharpe H, Makinson R, Morter R, et al. T cell and antibody responses induced by a single dose of ChAdO×1 nCoV-19 (AZD1222) vaccine in a phase 1/2 clinical trial. Nat Med 2020;19:1-24.
6Coondoo A. The role of cytokines in the pathomechanism of cutaneous disorders. Indian J Dermatol 2012;57:90-6.
7Gananandan K, Sacks B, Ewing I. Guttate psoriasis secondary to COVID-19. BMJ Case Rep 2020;13:e237367.
8Nasiri S, Araghi F, Tabary M, Gheisari M, Mahboubi-Fooladi Z, Dadkhahfar S. A challenging case of psoriasis flare-up after COVID-19 infection. J Dermatolog Treat 2020;31:448-9.
9Gelfand JM, Armstrong AW, Bell S, Anesi GL, Blauvelt A, Calabrese C, et al. National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease during the pandemic: Version 2-Advances in psoriatic disease management, COVID-19 vaccines, and COVID-19 treatments. J Am Acad Dermatol 2021;84:1254-68.
10Furer V, Rondaan C, Heijstek MW, Agmon-Levin N, van Assen S, Bijl M, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2020;79:39-52.
11Campos LM, Silva CA, Aikawa NE, Jesus AA, Moraes JC, Miraglia J, et al. High disease activity: An independent factor for reduced immunogenicity of the pandemic influenza a vaccine in patients with juvenile systemic lupus erythematosus. Arthritis Care Res 2013;65:1121-7.
12Bostan E, Yalici-Armagan B. Herpes zoster following inactivated COVID-19 vaccine: A coexistence or coincidence? J Cosmet Dermatol 2021;20:1566-7.
13Pona A, Jiwani RA, Afriyie F, Labbe J, Cook PP, Mao Y. Herpes zoster as a potential complication of coronavirus disease 2019. Dermatol Ther 2020;33:e13930.
14Tartari F, Spadotto A, Zengarini C, Zanoni R, Guglielmo A, Adorno A, et al. Herpes zoster in COVID-19-positive patients. Int J Dermatol 2020;59:1028-9.
15Voisin O, Deluca N, Mahé A, Lelorc'h E, Hubert S, Ménage E, et al. Disseminated herpes zoster during COVID-19. Infect Dis Clin Pract 2021;29:e109-10.
16World Health Organization. Coronavirus Disease (COVID-19): COVID Vaccines and People Living with HIV. Available from: https://www.who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-covid-19-vaccines-and-people-living-with-hiv. [Last accessed on 2021 May 28].
17Centers for Disease Control and Prevention. Interim Clinical Considerations for use of mRNA COVID-19 Vaccines Currently Authorized in the United States. Available from: https://www.cdc.gov/vaccines/covid-19/info-byproduct/clinical-considerations.html. [Last accessed on 2021 May 28].
18Kelso JM, Greenhawt MJ, Li JT, Nicklas RA, Bernstein DI, Blessing-Moore J, et al. Adverse reactions to vaccines practice parameter 2012 update. J Allergy Clin Immunol 2012;130:25-43.
19Shimabukuro TT, Cole M, Su JR. Reports of anaphylaxis after receipt of mRNA COVID-19 vaccines in the US-December 14, 2020-January 18, 2021. JAMA 2021;325:1101-2.
20McMahon DE, Amerson E, Rosenbach M, Lipoff JB, Moustafa D, Tyagi A, 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.
21Gresham LM, Marzario B, Dutz J, Kirchhof MG. An evidence-based guide to SARS-CoV-2 vaccination of patients on immunotherapies in dermatology. J Am Acad Dermatol 2021;84:1652-66.
22Wang C, Rademaker M, Tate B, Baker C, Foley P. SARS-CoV-2 (COVID-19) vaccination in dermatology patients on immunomodulatory and biologic agents: Recommendations from the Australasian Medical Dermatology Group. Australas J Dermatol 2021;62:151-6.
23Croce E, Hatz C, Jonker EF, Visser LG, Jaeger VK, Bühler S. Safety of live vaccinations on immunosuppressive therapy in patients with immune-mediated inflammatory diseases, solid organ transplantation or after bone-marrow transplantation – A systematic review of randomized trials, observational studies and case reports. Vaccine 2017;35:1216-26.
24Amanna IJ, Messaoudi I, Slifka MK. Protective immunity following vaccination: How is it defined? Hum Vaccin 2008;4:316-9.
25Andrews NJ, Waight PA, Burbidge P, Pearce E, Roalfe L, Zancolli M, et al. Serotype-specific effectiveness and correlates of protection for the 13-valent pneumococcal conjugate vaccine: A postlicensure indirect cohort study. Lancet Infect Dis 2014;14:839-46.
26Government of Canada. Canadian Immunization Guide: Part 3 Vaccination of Specific Populations; Immunization of Immunocompromised Persons. Available from: https://www.canada.ca/en/publichealth/services/publications/healthy-living/canadian-immunization-guide-part-3-vaccination-specific-populations/page-8-immunization-immunocompromised-persons.html. [Last accessed on 2020 Dec 24].
27Poelman SM, Keeling CP, Metelitsa AI. Practical guidelines for managing patients with psoriasis on biologics: An update. J Cutan Med Surg 2019;23 Suppl 1:3S-12.
28Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass, A.R., Calabrese, C., Gravallese, E.M., Harpaz, R., Sadun, R., Turner, A., Williams, E.A. and Mikuls, T.R. (2021), American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 1. Arthritis Rheumatol, 73: 1093-1107. https://doi.org/10.1002/art.41734
29Rademaker M, Baker C, Foley P, Sullivan J, Wang C. Advice regarding COVID-19 and use of immunomodulators, in patients with severe dermatological diseases. Australas J Dermatol 2020;61:158-9.
30London AJ, Kimmelman J. Against pandemic research exceptionalism. Science 2020;368:476-7.
31Lurie N, Saville M, Hatchett R, Halton J. Developing COVID-19 vaccines at pandemic speed. N Engl J Med 2020;382:1969-73.
32Lee WS, Wheatley AK, Kent SJ, DeKosky BJ. Antibody-dependent enhancement and SARS-CoV-2 vaccines and therapies. Nat Microbiol 2020;5:1185-91.
33Halstead SB, Katzelnick L. COVID-19 vaccines: Should we fear ADE? J Infect Dis 2020;222:1946-50.
34Moderna COVID-19 Vaccine VRBPAC Briefing Document. Available from: https://www.fda.gov/media/144434/download . [Last accessed on 2021 May 28].
35Federation of Obstetric and Gynaecological Societies of India (FOGSI) Position Statement. COVID Vaccination in Pregnant and Breastfeeding Women; 2021. Available from: https://www.fogsi.org/wp-content/uploads/covid19/fogsi-statement-on-covid-vaccination-in-pregnancy-and-bf.pdf. [Last accessed on 2021 Jun 05].
36Press Information Bureau, Government of India. New Recommendations of NEGVAC Accepted by Union Ministry of Health; 2021. Available from: https://pib.gov.in/PressReleseDetailm.aspx?PRID=1719925. [Last accessed on 2021 Jun 05].