What can I do if I develop papular urticaria after receiving a hepatitis B (HBV) vaccine?

Management of Papular Urticaria After Hepatitis B Vaccine

Treat the papular urticaria symptomatically with oral antihistamines and do not administer any further doses of hepatitis B vaccine, as this represents a contraindication to future vaccination. 1

Immediate Management

Symptomatic Treatment

• Administer oral antihistamines for pruritus and urticarial symptoms, as these nonspecific rashes are self-limited and respond well to symptomatic management 2
• The rash should resolve spontaneously within 2-4 days without specific intervention 2
• Avoid topical steroids, salves, creams, or ointments at any vaccination site that may still contain live virus 2

Distinguish Reaction Severity

• Papular urticaria and generalized urticaria are classified as severe allergic reactions by the CDC, which constitute an absolute contraindication to future hepatitis B vaccine doses 1
• These reactions differ from mild local reactions (pain, low-grade fever) which would allow continuation of the vaccine series 1
• True anaphylaxis (difficulty breathing, wheezing, hypotension, angioedema) requires immediate emergency management, though the incidence is only 1 per 1.1 million doses 2, 1

Future Vaccination Decisions

Discontinue Vaccine Series

• The Advisory Committee on Immunization Practices (ACIP) states that persons with a history of severe allergic reactions, including generalized urticaria, after hepatitis B vaccine should not receive any further doses 1
• This is an absolute contraindication—do not attempt rechallenge or desensitization 1
• Document this contraindication clearly in the medical record to prevent inadvertent future administration 2

Alternative Prevention Strategies

• Counsel the patient on non-vaccine hepatitis B prevention methods, including avoiding exposure to blood and body fluids, safe sex practices, and not sharing needles 1
• If the patient has already received one or two doses before the reaction, they will have incomplete immunity and should be counseled accordingly 1

Mandatory Reporting

VAERS Reporting

• Report this adverse event to the Vaccine Adverse Events Reporting System (VAERS), as required by the National Childhood Vaccine Injury Act for any clinically significant adverse event, even when causality is uncertain 2
• Submit reports online at https://vaers.hhs.gov or call 1-800-822-7967 2
• This reporting is mandatory and helps track vaccine safety patterns 2

Common Pitfalls to Avoid

• Do not confuse papular urticaria with simple adhesive reactions, which appear as sharply demarcated lines of erythema corresponding to tape placement and are not contraindications 2
• Do not attempt to "push through" with additional doses thinking the reaction will not recur—severe reactions are absolute contraindications 1
• Do not restart or continue the vaccine series after a severe allergic reaction, regardless of how many doses were previously tolerated 1