New‐onset and exacerbations of psoriasis after mRNA COVID‐19 vaccines: two sides of the same coin?

Abstract

With COVID-19 mass vaccination, the spectrum of cutaneous reactions to mRNA COVID-19 vaccines described is increasing.1 While some of these clinical pictures are believed to have an allergic background, others may be related to the activation of pro-inflammatory immune responses.2, 3 We present two cases of psoriasis associated to COVID-19 vaccination. The first clinical picture consisted of a 30-year-old woman, with mild plaque psoriasis since 2018, which had remained in remission for the past year with topical treatment. However, 10 days after receiving the first dose of Moderna® COVID-19 (mRNA-1273) vaccine (Moderna, Inc; Cambridge, Massachusetts), the patient experienced a new flare of her previous condition with scaly, desquamative plaques, of 10 mm in diameter, primarily on the left arm, where she had received the vaccine, and to a lesser extent on the right arm (Body Surface Area (BSA) 2.5%, Psoriasis Area Severity Index (PASI) 2.1; Fig. 1a,b). Blood tests were normal, and the patient denied any triggers (drugs, previous infections, stressors). Therefore, the flare was attributed to the vaccine. The clinical picture improved with topical steroids and topical calcipotriol. No relapse was evidenced after the second dose. The second clinical picture consisted of a 72-year-old man with new-onset generalized erythematous desquamating plaques that had appeared 6 days after receiving the second dose of the Moderna® COVID-19 (mRNA-1273) vaccine (Moderna, Inc; Cambridge, MA, USA). Past medical history included IgG-κ multiple myeloma treated with autologous hematopoietic progenitor cell transplantation. Anamnesis revealed no evident triggers and the patient was asymptomatic. Physical exam showed multiple erythematous, non-confluent papules, 3–15 mm in diameter with silvery-white desquamation involving trunk and extremities (Fig. 1c,d). A 4-mm punch biopsy was performed, which was compatible with psoriasis (Fig. 1e,f). Negative throat culture, and normal titers of antistreptolysin O (ASO) ruled out streptococcal infection. Serologies for Human Immunodeficiency Virus (HIV), hepatitis and Treponema pallidum were negative. Blood tests showed both a normal blood count and reactive C protein (RCP). No new drugs had been commenced and the patient denied any other possible triggers. Therefore, a COVID-19 vaccine-induced guttate psoriasis was diagnosed. The clinical picture presented a complete resolution with topical steroids and topical calcipotriol, and did not present relapses during follow-up. Psoriasis is a T-helper (Th)-1 and 17 immune disease characterized by Th-1 and Th-17 cytokines and a predominance of CD-8+ cells in the epidermis and CD-4+ cells in the dermis.4 The dysregulation of Th-1 and Th-17 responses play an important role in the pathogenesis of psoriasis. New-onset or exacerbations of psoriasis following vaccination are uncommon but have been described for some vaccines (influenza and tetanus-diphtheria).5 The reported cases of post-vaccinal psoriasis occur closely after vaccination and are usually forms of guttate psoriasis.5 It has been described that tetanus-diphtheria vaccines induce interleukin (IL)-6 production, which promotes the development of Th-17 cells.6 In murine models, the study of the cytokine profile after influenza vaccines, demonstrated a cellular response with enhanced Th-1 and Th-17 immunity.7 These previous findings, would be concordant with new-onset psoriasis or flares after vaccination. To date, cases of new-onset psoriasis due to mRNA COVID-19 vaccines are scarce. However, for mRNA COVID-19 vaccines, clinical trials have elicited that levels of IL-2, IL-12, tumour necrosis factor (TNF)-α and interferon (IFN)-γ may increase after vaccination.8 Therefore, there is rationale for new onset psoriasis and flares after mRNA COVID-19 vaccination. Since it has been previously described that new-onset psoriasis reactions may appear secondary to vaccines, it is plausible that the reported conditions are an uncommon adverse effect of a COVID-19 vaccine. We hypothesize that mRNA COVID-19 vaccines may lead to the activation of inflammatory pathways, which can lead to the onset or flare of psoriasis. Dermatologists need to be aware of the possibility of new-onset psoriasis and flares secondary to mRNA COVID-19 vaccines. In terms of patients' safety, vaccination should not be discontinued and patients need to be reassured that psoriasis secondary to mRNA COVID-19 vaccines has a good clinical course with good response to standard treatments. The patients in this manuscript have given written informed consent to publication of their case details David Pesqué, Emilio Lopez-Trujillo, Orianna Marcantonio and Ramon Maria Pujol declare they have no conflicts of interest to declare. Ana M Giménez-Arnau is a medical advisor for Uriach Pharma, Genentech, Novartis, FAES, GSK, Sanofi–Regeneron, Amgen, Thermo Fisher Scientific. Ana M Giménez-Arnau has research grants supported by Uriach Pharma, Novartis and has received grants from Instituto Carlos III- FEDER. Ana M Giménez-Arnau has participated in educational activities for Uriach Pharma, Novartis, Genentech, Menarini, LEO-PHARMA, GSK, MSD, Almirall, Sanofi. None. The data that support the findings of this study are available from the corresponding author upon reasonable request.

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