Psoriasis exacerbation after COVID-19 vaccination: a report of 14 cases from a single centre.

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Editor,

High COVID‐19 vaccination rates are a prerequisite for the establishment of herd immunity. Psoriasis patients seem to be more inclined to undergo COVID‐19 vaccination, compared with matched controls suffering from other skin diseases and receiving immunosuppressive treatment (odds ratio, 1.32; 95% confidence interval: 1.28–1.36). Twenty‐one per cent of 713 asked psoriasis patients declared fear of potential postvaccination flare of their skin disease to be holding them back from receiving a COVID‐19 vaccine. Actual knowledge of the probability of this negative outcome occurring has largely been inadequate. As a number of vaccinated psoriasis patients steadily increase, the first data regarding this issue have been seeing the light of day.

Three European Medicines Agency‐approved SARS‐CoV‐2 vaccines (Pfizer mRNABNT162b2; Moderna mRNA‐1273; and AstraZeneca‐Oxford AZD1222) have been administered to the Greek population from 27 December 2020 to 10 May 2021 (study lock date). Healthcare providers, followed by older individuals and those who were at the risk of severe COVID‐19 infection due to comorbidities (including psoriasis under immunosuppressive treatment), were the first to be vaccinated in Greece.

Fourteen patients (mean age, 66.93; standard deviation, 9.68; females, 64.29%) (Table 1) presented to the emergency department of our hospital from 1 January to 10 May 2021 with sudden onset of a generalized papulosquamous rash, which was clinically diagnosed as psoriasis (Fig. 1). Of these, nine patients had had known mild psoriasis (mean duration, 16.39 years; standard deviation, 5.23), which had been left without treatment for over a year. Five patients had only been receiving topical treatment (steroids, calcipotriol/betamethasone), with which they adequately controlled their disease. Psoriasis flare was treated with topical calcipotriol/betamethasone (five cases) and systemic agents or phototherapy (nine cases) (Table 1). Most patients were older adults, which quite possibly reflects the vaccination scheme followed in Greece. Almost all patients experienced an exacerbation of their psoriasis relatively soon (meantime, 10.36 days; standard deviation, 7.71) after the second vaccine dose. Notably, there was no difference between the types of the vaccine (50% mRNA technology vaccines and 50% adenovirus vaccine) used. Similarly, PASI was not statistically different in different vaccine groups (P = 0.073, 95% confidence interval: −0.36–6.96).

Table 1

Patient demographics, vaccination details and psoriasis flare details

	Sex	Age	Vacc	Dose	Days	PASI	Pstype	Nails	Treatment
1	F	69	AZ	2	8	10.2	Plaque	Yes	PUVA
2	F	82	Moderna	2	10	6.7	Plaque	No	Calcip/betam
3	F	62	Pfizer	2	6	5.4	Plaque	No	Calcip/betam
4	M	73	Pfizer	2	7	8.2	Plaque	No	Calcip/betam
5	M	66	AZ	1	22	14.4	Plaque	Yes	Risankizumab
6	F	62	AZ	2	13	12.4	Plaque	Yes	Apremilast
7	F	78	Pfizer	2	5	6.8	Plaque	No	Calcip/betam
8	F	64	AZ	2	6	11.2	Plaque	No	PUVA
9	M	69	AZ	1	32	9.2	Plaque	Yes	nbUVB
10	M	83	Pfizer	2	9	6.6	Plaque	No	Calcip/betam
11	F	61	AZ	2	3	5.9	Guttate	No	nbUVB
12	M	49	Pfizer	2	10	13.1	Plaque	Yes	Ixekizumab
13	F	55	Pfizer	2	7	10.2	Plaque	Yes	Cyclosporine
14	F	64	AZ	2	7	16.8	Plaque	No	Guselkumab

F, female; M, male; Vacc, vaccine type; AZ, AstraZeneca‐Oxford AZD1222; Moderna, Moderna mRNA‐1273; Pfizer, Pfizer mRNABNT162b2; Dose, number of doses after which psoriasis flare occurred; PASI, Psoriasis Area and Severity Index score at presentation in our department following the psoriasis flare; Pstype, psoriasis type; Nails, Presence of nail psoriasis; Calcip/betam, topical calcipotriol/betamethasone combination.

Figure 1

Sudden psoriasis flare in a female patient who had been receiving topical treatment for mild plaque psoriasis for years, after AstraZeneca‐Oxford AZD1222 vaccine for COVID‐19. New lesions appeared in the previously uninvolved areas. Pre‐existing nail psoriasis worsened.

Significant worsening of pre‐existing chronic mild psoriasis and new‐onset, especially guttate, disease after influenza vaccination have both been described before. , Vaccination against influenza virus during the COVID‐19 pandemic was also linked with psoriasis exacerbation in four cases. Three of these patients had been on biologic agents and one on topicals at the time of vaccination. A recent Italian report, however, documented three cases of psoriasis patients on apremilast, who were vaccinated against COVID‐19 with either Pfizer mRNABNT162b2 or AstraZeneca‐Oxford AZD1222 vaccine (two doses) and did not experience any worsening of their skin disease. Similarly, another Italian paper reported the uneventful COVID‐19 vaccination of three healthcare workers with psoriasis under biologic agents (secukinumab, ixekizumab, risankizumab) with Pfizer mRNABNT162b2. Potentially, systemic treatment confers some sort of protection against vaccine‐mediated flares of psoriasis, whereas patients receiving no treatment or only topical treatment are more prone to the activation of an inflammatory process leading to new and often extensive psoriasis lesions. It has been suggested that a Th17‐mediated immunologic response underlies the sudden worsening of psoriasis postinfluenza vaccination.

The findings of our study suggest an association between COVID‐19 vaccinations with three widely used vaccines irrespective of manufacturing technology. In our opinion, psoriasis patients should be advised to be vaccinated against SARS‐CoV‐2 and contact their healthcare provider in case they notice a flare of their disease.