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A healthy 27-year-old woman received a COVID-19 mRNA booster vaccine (Moderna) on December 7, 2021. She had not experienced adverse effects after the first 2 vaccine doses on January 17 and February 5, 2021. Twelve days after the booster vaccination, she developed pruritic wheals on her face and bilateral, transient eyelid swelling. Over the next week, a pruritic rash spread over her neck, chest, trunk, and arms; each lesion faded without scarring within 24 hours. She did not experience lip, tongue, or neck swelling; shortness of breath; wheezing; chest pain; or palpitations. Application of pressure to her forearm in a circular motion using a pen cap elicited wheal and flare lesions (Figure, left panel). On physical examination, performed 17 days after the onset of rash, her vital signs were normal. She had no tongue, lip, or throat swelling, and her lungs were clear to auscultation bilaterally. Wheal and flare lesions developed on her upper eyelids during the examination and resolved after approximately 30 minutes (Figure, right panel). Light pressure applied to her skin with a tongue depressor elicited wheal and flare lesions within 3 to 5 minutes.
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Inducible urticaria (symptomatic dermatographism) and acute urticaria
C. Prescribe a nonsedating antihistamine at a standard dose and increase to high-dose antihistamine if symptoms persist.
The key to the correct diagnosis is recognition of urticaria and dermatographism, an exaggerated wheal and flare response that occurs within minutes of skin being stroked, scratched, or having pressure applied to it.1 Advising the patient against future COVID-19 mRNA vaccination (choice A) is incorrect because she did not have a vaccine allergy. An immediate allergic reaction occurs within 4 hours of vaccination; vaccine anaphylaxis typically occurs within 30 minutes of vaccination, is rapidly progressive, and includes systemic signs such as hypotension or hypoxemia.2,3 A preloaded epinephrine autoinjector (choice B) is not indicated for acute urticaria or angioedema, unless there is a strong suspicion of anaphylaxis.4 Systemic glucocorticoids (choice D) are not recommended for most patients with acute urticaria with or without angioedema.1,4 Moreover, glucocorticoids may alter the immunologic response to COVID-19 vaccination.4,5
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Corresponding Author: Kimberly G. Blumenthal, MD, MSc, The Mongan Institute, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 (email@example.com).
Published Online: April 14, 2022. doi:10.1001/jama.2022.5247
Conflict of Interest Disclosures: Dr Freeman reported receiving grants from the International League of Dermatologic Societies COVID-19 Dermatology Registry and National Institutes of Health (NIH) (K23); receiving royalties from UpToDate; and receiving in-kind support from the American Academy of Dermatology for the COVID-19 Dermatology Registry. Dr Blumenthal reported receiving grants from the Massachusetts General Hospital Transformative Scholar Award, Executive Committee on Research, COVID-19 Junior Investigator Support Initiative, Agency for Healthcare Research and Quality (R01HS025375), and NIH (R01 AI150295); receiving royalties from UpToDate; and receiving personal fees from Weekley, Schulte, Valdes, Murman, and Tonelli; Vasios, Kelly, and Strollo; and Piedmont Liability Trust. No other disclosures were reported.
Additional Information: We thank the patient for providing permission to share her information.
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