Psoriasis flare‐up after AZD1222 and BNT162b2 COVID‐19 mRNA vaccines: report of twelve cases from a single centre

Abstract

Dear Editor, Psoriasis is a common chronic inflammatory skin disease though the prevalence varies among populations and ranges from 0.5 to 11.4 percent in adults.1 Exacerbation of psoriasis after vaccination, though rare, is reported in the literature.2, 3 There is a potential association between psoriasis flares-up and COVID-19 vaccination.4-9 There is a report of exacerbation of plaque psoriasis5 and another report of deterioration of palmoplantar psoriasis6 after second dose of BNT162b2 COVID-19 mRNA COVID-19 vaccination. In this brief report, we present twelve cases of psoriasis flare up after AZD1222 and BNT162b2 COVID-19 mRNA COVID-19 vaccination in Heraklion, Crete, Greece. A retrospective case-series study was performed at the Dermatology Department at the University Hospital of Heraklion in Greece from 1st of January 2021 until 31st of July 2021 regarding patients with psoriasis who experienced a flare-up within one month after having COVID-19 vaccination and attended the outpatient dermatology clinic, Accident and Emergency (A&E), or were hospitalized as inpatients, to assess clinical features and timing of psoriasis-flare up after COVID-19 vaccines. We collected each patient’s demographic information, vaccine manufacture, medications, allergies, prior vaccination reactions, latency and duration of flare-up, other symptoms, and treatment. From 1st of January 2021 until 31st of July 2021, twelve patients with a flare up of their psoriasis attended the outpatient dermatology clinic, A&E or were inpatients, at the University Hospital of Heraklion in Heraklion, Greece. There were nine (9/12, 75%) females and three (3/12, 25%) males. The mean age of the patients was 53.33 years (SD ± 10.90), and the mean duration of their psoriasis was 24.42 years (SD ± 16.44). The mean latency period from vaccination till psoriasis’ exacerbation was 13.17 days (SD ± 8.408). The mean duration of the exacerbation of psoriasis was 2.50 months (SD ± 1). All patients were on monotherapy for their psoriasis. There was no recommended or spontaneous discontinuation of psoriasis therapy before or after vaccination. The main clinical characteristics of these twelve patients are described in Table 1. At the time of vaccination, six patients (6/12, 50%) were on biologic monotherapy treatment, and of these six patients, three (3/12, 25%) were on treatment with secukinumab for their psoriasis, two patients (2/12, 16.7%) were on treatment with adalimumab for Crohn’s disease, and one patient was on ustekinumab. All three patients on secukinumab had a mild to moderate flare-up of their psoriasis and continued on this treatment with a good recovery. One of the two patients on adalimumab had a severe exacerbation of pustular psoriasis that resulted in hospitalization and discontinuation of adalimumab treatment. After vaccination, ten patients (10/12, 83.3%) had a flare of plaque psoriasis and two patients (2/12, 16.7%) had a flare of severe pustular psoriasis. The patient who had exacerbation of his psoriasis 15 days after the first dose of AstraZeneca vaccine also developed bullous pemphigoid (BP) 60 days later. Of the two patients with pustular psoriasis, one was on adalimumab for Crohn’s disease and another on methotrexate for rheumatoid arthritis (Fig. 1), as their psoriasis was mild and did not require any additional treatment before vaccination. The close temporal association between exacerbation of psoriasis and Sars-Cov-2 vaccination pointed out a potential link between the two events. To the best of our knowledge, we have reported the first two cases of development of severe pustular psoriasis after BNT162b2 COVID-19 mRNA vaccination. Moreover, we have reported the first case of severe psoriasis flare-up and new onset of BP after the first dose of AZD1222 vaccination. It might be postulated that mRNA vaccines may cause an increase in the production of interleukin (IL)-6 and recruitment of Th17 cells that play a crucial role in pathophysiology of psoriasis.5-10 The exact pathophysiology underlying psoriasis flare-up after AZD1222 and BNT162b2 COVID-19 mRNA vaccines has still to be elucidated, and further prospective larger studies are needed. The patients in this manuscript have given written informed consent to publication of their case details. None of the authors declare any conflict of interest. No funding has supported this work. The data that support the findings of this study are available from the corresponding author, DK, upon reasonable request.

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