De novo generalized pustular psoriasis following Oxford-AstraZeneca COVID-19 vaccine.

We present an interesting and novel case of a de novo generalized pustular psoriasis following administration of first dose of Oxford-AstraZeneca COVID-19 vaccine in a patient with no pre-existing psoriasis or any previous dermatological issue.

Dear Editor,

Various cutaneous manifestations have been reported with COVID‐19 infections during the pandemic, with some reports of new onset skin disease or flares of pre‐existing skin disease occurring after rollout of the vaccination programmes. We present a case of new‐onset generalized pustular psoriasis (GPP) that was considered secondary to the Oxford‐AstraZeneca COVID‐19 vaccine.

A 66‐year‐old woman presented to the emergency department with a 3‐week history of a worsening, generalized, erythematous and pustular rash. Her medical history included hypertension and depression. She had no prior dermatological issues and there was no family history of psoriasis or other skin diseases. Her long‐term medications included aspirin, sertraline, amlodipine and bisoprolol, which she had been taking for many years with no prior skin issues. No new medications had been commenced in the weeks preceding the rash and there were no recent illnesses, including COVID‐19 respiratory symptoms. The first dose of the AstraZeneca vaccine was given 3 weeks prior to onset of the rash.

Physical examination revealed an extensive erythematous pustular rash to the trunk and proximal aspect of the limbs, with no mucosal membrane or palmoplantar involvement (Fig. 1). The patient was clinically stable with normal blood test results. A COVID‐19 PCR test was not performed. Histological examination of an 8‐mm diagnostic punch biopsy confirmed the clinical suspicion of GPP (Fig. 2).

Figure 1

(a,b) Extensive, erythematous, pustular rash to the trunk and limbs; (c) closer view of the pustules overlying erythematous plaques.

Figure 2

(a) Prominent subcorneal pustule formation; the pustules were filled with a predominantly neutrophilic infiltrate and there was mild acanthosis of the underlying dermis with a mild to moderate neutrophilic infiltrate and minimal oedema; (b) closer view of perivascular infiltrate in the superficial dermis showing a mild mixed inflammatory cell infiltrate consisting of neutrophils, lymphocytes and extremely scanty eosinophils. (a,b) Haematoxylin and eosin; scale bars included in photos.

The patient was initially managed with topical steroids and later commenced on acitretin 20 mg once daily, resulting in significant improvement and resolution of the rash. Following departmental discussion, it was deemed to be in the patient’s best interest for her to receive her second vaccination dose, to which she was agreeable and she received it with no subsequent consequences to her skin. A yellow card was submitted via the Medicines and Healthcare products Regulatory Agency (MHRA). The patient remains stable on acitretin.

GPP can be triggered by viral infections, and there are a few reports in the literature associating it directly with COVID‐19 infection , , (Table 1). In one case, there was no prior history of psoriasis, and in all three reported cases, the cutaneous changes were preceded by COVID‐19 respiratory symptoms. To our knowledge, there is only one other reported case of GPP following the first dose of COVID‐19 vaccination (with the Sinovac vaccine CoronaVac). However, in that case, the patient had a known diagnosis of stable plaque psoriasis and the onset of the rash was much more acute, developing 4 days after vaccine administration. That patient was also given acitretin, but with no initial improvement, and resolution was achieved through intravenous infliximab infusions. Our patient responded very well and promptly to acitretin, and it is the preferable treatment in this current era with minimal risk of immunosuppression. Bisoprolol was considered as potential trigger, but felt less likely than the vaccine, given the prolonged use of bisoprolol and the acute eruption developing post‐vaccination.

Table 1

Summary of reported cases of generalized pustular psoriasis affiliated with COVID‐19 infections.

Patient	Sex/age, years	Pre‐existing psoriasis	Clinical description	Treatment
1	F/72	Acrodermatitis continua of Hallopeau	2‐week history of generalized pustular eruption overlying erythematous plaques mainly on lower abdomen and thighs, accompanied by fevers and malaise and preceded by COVID‐19 respiratory symptoms and positive nasal PCR test 2 weeks previously	Acitretin and infliximab with full resolution
2	F/62	None, but positive family history of psoriasis	2‐week history of palmoplantar pustules, pustular and psoriasiform rash on the extremities, trunk and scalp, 2 weeks after resolution of COVID‐19 respiratory symptoms (positive nasal PCR test)	Not reported
3	M/60	Childhood history of plaque psoriasis	2‐day history of widespread pustular and erythematous rash to trunk and limbs accompanied by fevers, 3 weeks after initial COVD‐19 symptoms and positive nasal PCR test	Acitretin with improvement

To our knowledge, this is the first reported case of de novo GPP following the first dose of the Oxford‐AstraZeneca COVID‐19 vaccine. We believe it is important for clinicians to be aware of potential adverse effects implicated with COVID‐19 vaccinations, and to enquire about recent vaccinations in any patient with new onset or flare of skin disease.