Exacerbations of generalized pustular psoriasis, palmoplantar psoriasis, and psoriasis vulgaris after <scp>mRNA COVID</scp> ‐19 vaccine: A report of three cases

Abstract

Psoriasis is a chronic immune-mediated inflammatory disease and can be provoked or exacerbated by various environmental factors, infections, drugs, and vaccines.1 Here we present three cases of psoriasis exacerbated after Pfizer-BioNTech BNT162b2 mRNA COVID-19 vaccines. A 64-year-old male patient presented with the complaint of rash on the hands, hips, elbows and legs. In his dermatological examination, the patient had sharply demarcated, erythematous, silver-colored scaly plaques on the bilateral dorsum of the hand, elbow and leg extensor surfaces, and intergluteal region (Figure 1A–E). Psoriasis area severity index (PASI) was 4.4. The patient, who first developed skin rashes in 2019, was diagnosed with psoriasis vulgaris and was in remission without treatment for more than a year after topical treatment. The patient received the third dose of mRNA COVID-19 (Pfizer-BioNTech BNT162b2) vaccine 3 months after receiving two doses of CoronaVac Covid 19 vaccine. Skin rash appeared 6 weeks after the third dose of vaccine. The patient, who had been using sodium valproate with the diagnosis of epilepsy for 30 years, had no history of any other disease, infection, or additional drug use. No pathology was detected in the system examination. Although the time between the Covid-19 vaccine and skin eruptions is long, Covid-19 vaccine was considered as a triggering factor since there was no other triggering factor for psoriasis in the patient with PASI: 0 who had not been treated for a long time. A 64-year-old male patient with no known comorbidity was admitted with the complaint of rash on the hands and feet. The patient, who described occasional similar rash for a year, was not receiving any treatment. One week after the second dose of mRNA COVID-19 vaccine (Pfizer-BioNTech BNT162b2), new rash on the left hand and exacerbation of previous rash on the right hand and soles of the feet were described. Dermatological examination revealed sharply circumscribed silver-colored scaly plaques in the hypothenar area of both palmar regions and sharply circumscribed hyperkeratotic plaques and fissures in the plantar region (Figure 1F,G). A 25-year-old female patient with no known comorbidity was admitted with the complaint of diffuse rash all over the body. Dermatological examination revealed non-follicular pustules and local desquamation on erythematous plaques on the anterior–posterior aspect of the trunk, both arms, and proximal thighs (Figure 1H,K,L,M). The patient, who had been diagnosed with pustular psoriasis for 11 years, had experienced similar clinical exacerbations three times before and had received methotrexate and cyclosporine treatments. The patient, who has been in remission without medication for the last 6 months, started to have rashes 3 days after the first dose of the mRNA COVID-19 vaccine (Pfizer-BioNTech BNT162b2). The patient had no previous history of infection, medication, or stress. Although vaccination is rarely a triggering factor for psoriasis, cases of psoriasis exacerbation have been reported after influenza (H1N1), pneumococcal pneumonia, and yellow fever vaccination.1-3 The mechanisms responsible for exacerbation of psoriasis after vaccination are not yet understood. It may be due to both the infectious components in the vaccine and the vaccine adjuvants. Most of the psoriasis exacerbations reported in the literature were associated with adjuvant influenza vaccines. In these studies, researchers stated that influenza, BCG, and tetanus-diphtheria vaccines induced the development of Th17 cells, which play an important role in the pathophysiology of psoriasis, and IL-6 production.1 In a clinical study investigating the effects of influenza vaccine in patients with psoriasis, the time taken for the onset or exacerbation of psoriasis after vaccination was found to be between 2 weeks and 2 months.1 In the three cases we presented, rash developed within the first month and a half after vaccination, and the duration was consistent with the literature. McMahon et al in their study investigating cutaneous reactions after mRNA COVID-19 vaccine, they found the most common local injection site reactions, urticaria and morbiliform eruptions in 414 cutaneous reactions. They reported that exacerbations of psoriasis occurred in only two patients, so its prevalence was rare.4 Psoriasis flare-up associated with the second dose of Pfizer-BioNTech COVID-19 mRNA vaccine and a case of de novo generalized pustular psoriasis following the Oxford-AstraZeneca COVID-19 Vaccine have been reported recently.5, 6 Onsun et al and Perna et al reported cases of generalized pustular psoriasis developing after CoronaVac and mRNA COVID-19 (Pfizer-BioNTech) vaccines, respectively, in patients with a history of plaque psoriasis.7, 8 It is noteworthy that psoriasis exacerbation was observed after mRNA COVID-19 vaccine in all three of our cases, at a time when inactivated COVID-19 vaccine was used more intensively in our country. The authors declare no conflict of interest. Imge Durmaz: Conceptualization; visualization; writing-original draft. Dursun Turkmen: Supervision, conceptualization; visualization; writing-original draft. Nihal Altunisik: Conceptualization, data curation. Sibel Altunisik Toplu: Data curation. The patients gave the consent for photo acquisition and publication. Research data are not shared.

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