Reply to "Psoriasis exacerbation after COVID-19 vaccination: report of 14 cases from a single centre" by Sotiriou E et al.

Conflict of interest

None.

Funding sources

None.

Author contributions

Matteo Megna: conceptualization, validation, visualization, writing – original draft preparation, writing – review and editing. Luca Potestio: data curation, formal analysis, investigation, visualization, writing – original draft preparation. Lucia Gallo: data curation, investigation, methodology, visualization, writing – original draft preparation. Giuseppina Caiazzo: data curation, formal analysis, validation. Angelo Ruggiero: data curation, validation, visualization, writing – original draft preparation. Gabriella Fabbrocini: conceptualization, validation, visualization, writing – review and editing, supervision. All authors read and approved the final version of the manuscript.

Ethical approval

Not required.

Dear Editor,

We have read with great interest the article recently published by Sotiriou et al. who reported 14 patients with psoriasis worsening after COVID‐19 vaccination suggesting the possibility of the association between COVID‐19 vaccines and psoriasis flares, especially in patients who do not receive any treatment for their psoriasis.

In our experience at the Dermatology Centre of the University of Naples Federico II, we observed 11 cases (8 male 72.7%, mean age 54.5 ± 8.9 years) of psoriasis exacerbation after COVID‐19 vaccination with Pfizer mRNABNT162b2, Moderna mRNA‐1273 or AstraZeneca‐Oxford AZD1222 from February 2021 to July 2021 (Table 1). In line with Sotiriou et al., psoriasis flares were observed within 14 days from the vaccination (mean 8.5 ± 2.8 days) and mainly after the 2nd dose (81.8%). According to Sotiriou et al., plaque form is the most frequent clinical presentation (10/11, 90.9%). Moreover, psoriasis flare possibility does not seem to be linked to the type of COVID‐19 vaccine (72.7% with mRNA technology vaccines and 27.3% with adenovirus vaccine).

Table 1

Psoriasis flares after COVID‐19 vaccine

	Sex	Age	Vaccine/dose	Days	PASI	Type of psoriasis flare	Previous treatment	New treatment
1	M	55	mRNABNT162b2 / 2	5	14.8	Plaque	None	Methotrexate
2	M	49	mRNABNT162b2 / 2	6	17.3	Plaque	None	Adalimumab
3	M	45	AZD1222 / 1	10	9.9	Plaque	Secukinumab	Secukinumab†
4	M	61	mRNABNT162b2 / 2	12	11.9	Plaque	Adalimumab	Ixekizumab
5	M	62	mRNA‐1273 / 2	8	15.9	Plaque	None	Brodalumab
6	M	47	mRNABNT162b2 / 2	9	4.3	Guttate	Ixekizumab	Ixekizumab†
7	F	70	mRNABNT162b2 / 2	8	7.6	Plaque	Calcip/betam	Adalimumab
8	F	39	AZD1222 / 2	7	5.2	Plaque	Guselkumab	Guselkumab†
9	M	58	mRNABNT162b2 / 2	5	4.3	Plaque	Secukinumab	Secukinumab†
10	F	55	AZD1222 / 2	10	13.9	Plaque	Nb‐UVB	Risankizumab
11	M	59	mRNABNT162b2 / 1	14	9.2	Plaque	Etanercept	Ixekizumab

M, male; F, female; AZD1222, AstraZeneca‐Oxford AZD1222; mRNA‐1273, Moderna mRNA‐1273; mRNABNT162b2, 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. Calcip/betam, topical calcipotriol/betamethasone combination; nbUVB, narrowband ultraviolet B.

Biologic treatment associated with topical calcipotriol/betamethasone combination and/or phototherapy.

Concerning the Psoriasis Area Severity Index (PASI) at the moment of clinical examination, our results are similar to Sotiriou et al. (10.4 ± 4.7 vs 9.8 ± 3.5). However, we believe that patients who experienced a less severe psoriasis flare after COVID‐19 vaccination tend to self‐medicate and do not seek medical attention. A comparison between Sotiriouet et al.'s data and ours are reported in Table 2.

Table 2

Comparison between Sotiriou et al.'s population and ours

	Our data (n = 11)	Sotiriou et al. (n = 14)
Demographic features
Sex, M (%)	8 (72.7%)	5 (35.7%)
Mean age (years)	54.5 ± 8.9	66 ± 9.7
Vaccine type
AZD1222	3 (27.3%)	7 (50.0%)
1st dose	1 (9.1%)	2 (14.3%)
2nd dose	2 (18.2%)	5 (35.7%)
mRNA‐1273	1 (9.1%)	1 (7.1%)
1st dose	0 (0%)	0 (0%)
2nd dose	1 (9.1%)	1 (7.1%)
mRNABNT162b2	7 (63.6%)	6 (42.9%)
1st dose	1 (9.1%)	0 (0%)
2nd dose	6 (54.5%)	6 (42.9%)
Days after psoriasis flare	8.5 ± 2.8	10.4 ± 7.7
PASI	10.4 ± 4.7	9.8 ± 3.5
Type of psoriasis
Plaque	10 (90.9%)	13 (92.9%)
Guttae	1 (9.1%)	1 (7.1%)
Ongoing treatment during vaccination
Biologic treatment	6 (54.5%)	0 (0%)
Topical treatment and/or Phototherapy	2 (18.2%)	5 (35.7%)
No treatment	3 (27.3%)	9 (64.3%)
Treatment after psoriasis exacerbation
Biologic treatment	10 (90.9%)	3 (21.4%)
Small molecules	0 (0%)	1 (7.1%)
Immunosuppressant agents	1 (9.1%)	1 (7.1%)
Topical treatment and/or phototherapy	4† (36.4%)	9 (64.3%)

AZD1222, AstraZeneca‐Oxford AZD1222; mRNA‐1273, Moderna mRNA‐1273; mRNABNT162b2, Pfizer mRNABNT162b2; PASI, Psoriasis Area and Severity Index score at presentation in our department following the psoriasis flare.

Topical treatment and/or phototherapy added to biologic therapy.

Interestingly, differing from Sotiriou et al, we observed 6 cases (54.5%) of psoriasis flares due to COVID‐19 vaccine in subjects under biologic treatment. Among these, topical calcipotriol/betamethasone combination and/or phototherapy were added to current biologic treatment in 4 cases, while switching biologic agent was necessary in the remaining 2 patients. Although literature reported that COVID‐19 vaccine does not seem to induce psoriasis flare in patients under biologics, , we observed a small percentage of subjects that experienced this flare nevertheless being under biologic treatment. To note, we want to highlight that they represent a very limited number of patients considering that more than 1200 psoriatic patients attending our Department are being treated with biologics for psoriasis and that currently about of 60% of Italian population is vaccinated.

As regards the treatment of the 5 remaining patients, biologic therapy or methotrexate was prescribed to 4 and 1 subjects after COVID‐19 vaccine induced psoriasis worsening respectively.

Our results show a highly percentage of psoriatic flare in male patients (8/11, 72.7%) suggesting male sex as a potential predictive risk factor. However, these data may be influenced by the fact that the majority of psoriasis patients attending our centre is male (68.9%).

Previous concerns about the infectious risk of more severe COVID‐19 infection in psoriatic subjects have been solved, and the safety and effectiveness of COVID‐19 vaccines has been showed, also for these patients. ,

In the literature, there are only few cases reporting the worsening of psoriasis after COVID‐19 vaccine. , , , In our opinion, systemic treatment may reduce the risk of psoriasis flares after COVID‐19 vaccination by the protection against the inflammatory process, which can cause the worsening of the disease. Hence, patients undergoing topical treatment for psoriasis have a higher risk of psoriatic flares compared with patients treated with systemic drugs.

However, our experience showed that psoriasis exacerbation after COVID‐19 vaccination may also develop in patients undergoing biologic treatment, even if the risk is reduced and limited.

In conclusion, clinicians must keep in mind the possibility of psoriasis worsening after COVID‐19 vaccine, regardless the mechanism of action of vaccines, advising patients to self‐control their disease, especially within 14 days after vaccination, and to refer to clinicians if a worsening of the condition is noted. Being on biologic for psoriasis seems to strongly reduce but not to completely undo this risk.