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

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


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

Date of Submission09-Jun-2021
Date of Decision23-Jul-2021
Date of Acceptance24-Jul-2021
Date of Web Publication26-Aug-2021

Correspondence Address:
Namitha Chathra
Department of DVL, PES Institute of Medical Science and Research, Kuppam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cdr.cdr_48_21

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  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.

Keywords: COVID-19 vaccination, immunomodulatory drugs, skin diseases


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;5:139-43

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 Dec 7];5:139-43. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/2/139/324564




  Introduction Top


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: Current scenario of COVID-19 vaccines in India

Click here to view


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 Top


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 Top


    • 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 type
    • Anyone 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 dose
    • Administering 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 reaction
    • When the reaction does recur following the second dose, it may occur sooner but with less severity
    • Symptomatic treatment with antihistamines/ice-packs/topical corticosteroids was found to be safe and sufficient in most cases.[20]



      COVID-19 Vaccination and Dermatologic Therapies Top


    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 mofetil
      • Two weeks for methotrexate and azathioprine.


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


      • 2.5 mg/kg/day cyclosporine
      • One mg/kg/day azathioprine
      • 7.5 mg/week methotrexate
      • Systemic 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: Antibody levels following vaccination in patients receiving immunotherapy/biological[21]

    Click here to view


    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 Top
    • 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 Top


    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.



     
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