Clinical and pathologic correlation of cutaneous COVID-19 vaccine reactions including V-REPP: A registry-based study

Devon E. McMahon, Carrie L. Kovarik, William Damsky, Misha Rosenbach, Jules B. Lipoff, Anisha Tyagi, Grace Chamberlin, Ramie Fathy, Rosalynn M. Nazarian, Seemal R. Desai, Henry W. Lim, Bruce H. Thiers, George J. Hruza, Lars E. French, Kimberly Blumenthal, Lindy P. Fox, Esther E. Freeman

Research output: Contribution to journalArticlepeer-review

87 Scopus citations


Background: Cutaneous reactions after COVID-19 vaccination have been commonly reported; however, histopathologic features and clinical correlations have not been well characterized. Methods: We evaluated for a history of skin biopsy all reports of reactions associated with COVID-19 vaccination identified in an international registry. When histopathology reports were available, we categorized them by reaction patterns. Results: Of 803 vaccine reactions reported, 58 (7%) cases had biopsy reports available for review. The most common histopathologic reaction pattern was spongiotic dermatitis, which clinically ranged from robust papules with overlying crust, to pityriasis rosea-like eruptions, to pink papules with fine scale. We propose the acronym “V-REPP” (vaccine-related eruption of papules and plaques) for this spectrum. Other clinical patterns included bullous pemphigoid-like (n = 12), dermal hypersensitivity (n = 4), herpes zoster (n = 4), lichen planus-like (n = 4), pernio (n = 3), urticarial (n = 2), neutrophilic dermatosis (n = 2), leukocytoclastic vasculitis (n = 2), morbilliform (n = 2), delayed large local reactions (n = 2), erythromelalgia (n = 1), and other (n = 5). Limitations: Cases in which histopathology was available represented a minority of registry entries. Analysis of registry data cannot measure incidence. Conclusion: Clinical and histopathologic correlation allowed for categorization of cutaneous reactions to the COVID-19 vaccine. We propose defining a subset of vaccine-related eruption of papules and plaques, as well as 12 other patterns, following COVID-19 vaccination.

Original languageEnglish (US)
Pages (from-to)113-121
Number of pages9
JournalJournal of the American Academy of Dermatology
Issue number1
StatePublished - Jan 2022


  • AZD1222
  • Ad26.COV2.S
  • BNT162b2
  • COVID-19
  • Johnson & Johnson Janssen
  • Moderna
  • Oxford-AstraZeneca
  • Pfizer-BioNTech
  • SARS-CoV-2
  • Stevens-Johnson syndrome
  • bullous pemphigoid
  • chilblains
  • delayed large local
  • dermal hypersensitivity reaction
  • dermatology
  • dermatopathology
  • erythema multiforme
  • erythromelalgia
  • lichen planus
  • mRNA-1273
  • morbilliform
  • papular
  • papulosquamous
  • pathology
  • pernio
  • pityriasis rosea
  • psoriasis
  • registry
  • urticaria
  • vaccine
  • zoster

ASJC Scopus subject areas

  • Dermatology


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