A Case of Onset of Guttate Psoriasis After COVID-19 Vaccination

A case of new onset of severe plaque psoriasis following COVID-19 vaccination was reported. A 63-year-old woman presented with multiple plaques for 2 months after the second dose of COVID-19 vaccination. Dermatological examination revealed diffuse erythematous papules and plaques on trunk and limbs. Her lesions responded well to the treatment of secukinumab 150 mg per week. In this case, we presented the potential association between COVID-19 vaccination and the onset of psoriasis. It is essential to recognize the possible adverse events as vaccination against COVID-19 continues worldwide.

Recently, COVID-19 vaccination-induced exacerbation or new-onset of psoriasis have been reported. Underlying immune pathogenesis is unclear and different mechanisms are assumed. Further, clinical- and vaccine-related features and characteristics are partly inconsistent and remain to be elucidated. To add to the understanding of COVID-19 vaccination-triggered psoriasis, we report five cases with exacerbation or new-onset of psoriasis. In our cohort, one patient experienced the new onset of psoriasis, while four had an exacerbation following COVID-19 vaccination. In most patients, exacerbation or new onset occurred after the 2nd or 3rd vaccination. The mean latency from the day of vaccination was 7.2 (1.8) days (SD). The clinical impact with a mean PASI increase following COVID-19 vaccination of 7.2 (5.6) was considered relevant. In most cases, psoriatic lesions almost cleared after applying topical steroids in addition to current treatment, while one patient with psoriatic arthritis required systemic treatment. New onset and exacerbation of psoriasis have also been noted following COVID-19 infections. Hence, the underlying inflammatory response is most likely the culprit agent triggering psoriasis. This underscores that the benefits of COVID-19 vaccination far outweigh the risks, as also in patients with psoriasis.

BackgroundVaccination has been promoted to control viral transmission in response to the coronavirus disease 2019 (COVID-19) pandemic. Cases of new-onset or exacerbation of psoriasis, an immune-mediated inflammatory disease, were reported following COVID-19 vaccination. However, a comprehensive review examining the association between COVID-19 vaccination and the occurrence or exacerbation of psoriasis has yet to be performed.ObjectiveThe aim of this systematic review is to investigate the demographics, clinical variables, and outcomes associated with psoriasis following COVID-19 vaccination.MethodsA systematic literature search was conducted using the PubMed, Embase, Web of Science, and Cochrane databases from database inception to April 25, 2022. The review included studies with relevant terms, including ‘psoriasis,’ ‘psoriasis vulgaris,’ ‘guttate psoriasis,’ ‘pustular psoriasis,’ ‘palmoplantar pustulosis,’ ‘psoriatic erythroderma,’ ‘psoriatic arthritis,’ ‘COVID-19,’ and ‘vaccine.’ We included all studies reporting at least one patient who developed new-onset psoriasis or experienced a psoriasis flare following at least one dose of any COVID-19 vaccine. A flare was defined as the worsening of disease conditions after vaccination according to the study by Gregoire et al. The appraisal tool described by Murad et al. was used to assess the quality of case reports and series, whereas the National Institute of Health quality assessment tool was used to assess observational studies.ResultsThe initial search yielded 367 results, including 7 studies reporting new-onset psoriasis, 32 studies reporting psoriasis flares, and 4 studies reporting both. The most commonly observed psoriasis subtype was plaque-type psoriasis. mRNA vaccines, including those produced by Moderna and BioNTech/Pfizer, were frequently associated with subsequent psoriasis episodes. First, second, and third vaccine doses were associated with psoriasis incidents, with the second dose most frequently associated with psoriasis flares. Delayed onset was observed, ranging from 2 to 21 days in the new-onset group and from 1 to 90 days in the flare group. Most patients experienced favorable outcomes, with improvement or resolution occurring within 3 days to 4 months.ConclusionsBoth new-onset psoriasis and psoriasis flares were reported as cutaneous adverse events following COVID-19 vaccination. Psoriatic patients may require regular follow-up before and after COVID-19 vaccination.Trial RegistrationReview registration number PROSPERO database: CRD42022304157.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40257-022-00721-z.

Introduction:Although uncommon, several cases of new-onset and exacerbation of psoriasis have been reported after coronavirus disease 2019 (COVID-19) vaccination. This study aims to systematically review reports regarding new-onset and exacerbation of psoriasis to identify features related to that condition following COVID-19 vaccination.Materials and Methods:Three databases were utilised, namely, PubMed, Google Scholar, and EBSCOHost to search for literature published until June 2022. We used the following MeSH terms: “psoriasis,” “exacerbation,” “induced psoriasis,” and “COVID-19 vaccination.” The included literature must report the case/(s) of psoriasis exacerbation in previously-in-remission or induced psoriasis in individuals receiving any dose of COVID-19 vaccines regardless of the type.Results:Among 33 selected studies, an overall mean age was 57.52 ± 15.92 years. Female (n = 40; 54.8%) was more frequently reported than male (n = 33; 45.2%). In terms of vaccine types, Pfizer is the most commonly reported (49 cases; 67.1%), followed by Astra-Zeneca (13 cases; 17.8%), Moderna (10 cases; 13.7%), and CoronaVac (1 case; 1.4%). The onset of psoriasis after receiving the COVID-19 Vaccines was varied, ranging from 1 to 90 days (Mean ± SD: 15.75 ± 18.22). Plaque psoriasis was most commonly reported, followed by pustular, guttate and other types of psoriasis. Reported cases were frequently treated with topical steroids and monoclonal antibodies monotherapy.Conclusions:Although the cases of new-onset and exacerbation of psoriasis after COVID-19 vaccination is quite scarce, the possibility of occurrence should be acknowledged and managed properly; and patients should be informed, particularly ones with history of psoriasis without discouraging patients to take vaccine.

Dear Editor, We have read with great interest the article by Luo et al.1 entitled “Cutaneous adverse reactions following the Pfizer/BioNTech COVID-19 vaccine”, reporting several cases of cutaneous manifestations developed within 2 weeks of COVID-19 vaccination.1 Since the beginning of COVID-19 vaccination campaign, several cutaneous manifestations have been reported in literature, including relapses of pre-existing diseases, and novel described reactions. Herein, we report our experience of cutaneous manifestations related to COVID-19 infection and vaccination, registered in a southern referral centre at the University of Naples Federico II. Between January 2021 and July 2022, we registered a total of 580 cutaneous reactions following COVID-19 vaccinations. Interestingly, among reported cases, delayed large local reactions were the most common, followed by local injection site reactions (within 3 days), pityriasis rosea (PR), urticarial eruptions, and morbilliform eruptions.2 Furthermore, we reported 38 cases of PR arising after vaccination. This association has been widely discussed in the literature.3, 4 It may be linked to the decrement in T lymphocytes associated with vaccination, which may cause an immunosuppressive state that would explain the onset of PR.3, 4 Another interesting association was the onset of cutaneous herpes zoster manifestations. Particularly, we registered 8 cases of herpes zoster occurring after vaccinations; probably, even in these cases, the immunosuppression linked to the vaccination represented a possible trigger for the reactivation of the virus.5 A less frequently reported reaction was lichen planus (LP) (5 cases recorded). As already discussed in the literature, it has been shown that after such vaccines there can be a stimulation of the immune response of T helper lymphocytes type 1 (Th1), leading to the stimulation of the production of interleukin (IL)-12, tumour necrosis factor (TNF)α, and interferon (IFN)γ, cytokines involved in the pathogenesis of LP.6, 7 Another interesting finding was the worsening of chronic inflammatory skin diseases that we found in 38 patients already affected by psoriasis, presenting a worsening of their manifestations that were well controlled before vaccination. Interestingly, we also registered a post vaccination de novo onset of psoriasis in 11 patients.8 Among chronic inflammatory diseases, we also found 13 patients affected by hidradenitis suppurativa who presented a worsening of their manifestations after vaccination.9, 10 The exact pathophysiologic mechanism behind these relapses is still well clarified. However, Sahin et al.11 showed that COVID-19 vaccines may inhibit the T helper 2 cell pathway and at the same time promote the T helper 1 cell pathway, which has been showed to play a role in the development and worsening of several cutaneous inflammatory diseases, including psoriasis hidradenitis suppurativa, and pemphigus vulgaris.12 The mean time between vaccination and reported events was 17.6 ± 6.4 days. All data related to the type of vaccination received and the onset time of manifestations are reported in Table 1. To date, a total of 12,693,781 doses of COVID-19 vaccines have been administered in Campania Region. All reported reactions, as well as the worsening of pre-existing conditions, were easily managed. In conclusion, we would like to underline that all patients who had new cutaneous diseases, or worsening of pre-existing skin diseases, fully completed the three scheduled vaccination doses without any sequelae. We believe that our experience may improve the available literature on this topic, adding significant new statistical data on cutaneous adverse reaction to COVID-19 vaccines, and suggesting that although vaccination may induce various cutaneous manifestations, with promptly recognition and a correct management it does not affect the safety and efficacy of COVID-19 vaccination.12 It should also be pointed out that causality cannot be inferred from the observed associations between vaccination and non-localized skin events, and that although there may be a biological plausibility, further studies are needed to understand the exact mechanism behind these correlations. Further studies should also consider the background incidence of zoster, PR, morbilliform eruptions, and other reactions related to COVID-19 vaccination. None. None to declare. Data sharing not applicable to this article as no data sets were generated or analysed during the current study. Patient's gave the consent for photo acquisition and publication. Open Access Funding provided by Universita degli Studi di Napoli Federico II within the CRUI-CARE Agreement.

The cutaneous side effects of COVID‐19 vaccines are being studied and their immunogenicity is most likely linked to the pathophysiology of psoriasis. Although uncommon, several cases of exacerbation and new onset of psoriasis have been reported globally after vaccination. To contribute to the literature on this intriguing topic, we present three cases of de novo psoriasis in adult patients following COVID‐19 vaccination. Our observations and a literature review show that this occurrence is independent of the type and brand of vaccines.

Seasonal Variations of Vogt-Koyanagi-Harada Disease in Japan: A Study on Long-Term Trends and the Influence of Coronavirus Disease 2019 (COVID-19)

The Covid-19 global pandemic made the development of safe and effective vaccines against this deadly disease crucial. Three vaccines have been granted Emergency Use Approval in India: Oxford-AstraZeneca/Covishield (Serum Institute of India Pvt. Ltd.), Covaxin (Bharat Biotech), and Sputnik V.1 The ChAdOx1 nCoV-19 (Covishield) vaccine is purported to be generally safe; but is associated with a low risk of thrombocytopenia and central venous thromboembolism.2 So far, a single case of suspected delayed inflammatory cutaneous reaction after the Oxford-AstraZeneca vaccine has been reported in a 68-year-old woman with localized scleroderma. Her rash started 3 days postvaccination as pruritic, erythematous papules initially limited to her morphea lesion and later spread to the whole body.3 Patients on immunosuppressive therapy were excluded from trial cohorts of Covid-19 vaccines, and as many patients of psoriasis receive immunosuppressive drugs, they must have been under-represented in these trials.4 Hence accumulation of data regarding the propensity of different Covid-19 vaccines to aggravate or precipitate psoriasis might help update the current guidelines. Herein we report two cases of psoriasis exacerbation following administration of Covishield vaccine. The first case is of a 56-year-old lady. She was a known case of psoriasis and was in remission for 6 months, maintaining on emollients. One week after her first dose of Covishield vaccine, her lesions flared up; however, she did not seek medical advice and continued emollients. Six weeks after the first dose, she received her second dose and 2 days later developed exacerbation of psoriasis lesions (Figure 1A). Dermoscopy and histopathology confirmed the diagnosis of psoriasis (Figure 1C). The second case is of a 65-year-old man with no previous history of psoriasis. He presented with scaly erythematous papules and plaques over trunk and extremities, covering 30% of his body for 5 days (Figure 1B). Dermoscopy and histopathology confirmed the diagnosis of psoriasis (Figure 1D). The lesions had started 10 days after he received the second dose of Covishield vaccine. We treated both patients with Apremilast (10 mg on day one, increased to 30 mg twice daily by day 7), antihistamines and emollients. They responded well with 70% and 50% decrease in Psoriasis Area Severity Index score by day 7 respectively (Figure 1E, F). The most common side effects of the Covishield vaccine include injection site tenderness, malaise, fatigue, headache, fever, and flu-like symptoms.2 However, there is a paucity of data regarding the effect of Covid-19 vaccines on skin diseases, including psoriasis. Psoriasis is characterized by Th1-type CD4+ T cells producing high levels of tumor necrosis factor-α (TNF-α) and interferon-γ (IFN-γ). An increase in TNF-α and IFN-γ production by CD4+ T cells on day 14 following a single dose of ChAdOx1 nCoV-19 (Covishield) vaccination has been reported.5 Secretion of these cytokines following vaccination appears to be responsible for the development/exacerbation of psoriasis. A case of generalized pustular psoriasis flare 4 days after the CoronaVac (inactivated virus vaccine) Covid-19 vaccine in a 72-year-old man has been recently reported from Turkey.6 There have also been reports of onset or flare of psoriasis following 2009 monovalent H1N1/seasonal influenza vaccination during the 2009–2010 flu season.7 The temporal correlation between Covid-19 vaccination and psoriasis development/exacerbation, and lack of other triggers, rapid improvement here suggests a possible causal relationship. Temporality, plausibility, analogy and reversibility characteristics of Hill's criteria for investigating causality in epidemiological studies are fulfilled in the reported cases.8 However, strength, consistency and specificity can be established only if future reports of increases incidence of onset/flare of psoriasis are documented in patients receiving Covid-19 vaccines. Thus, the potential of Covid vaccination acting as a trigger for psoriasis exacerbation cannot be denied. However, since the benefits overweigh the risks, all patients must receive the vaccine. The authors declare there is no potential conflict of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.

A 42-year-old man was referred to our dermatology outpatient clinic with a widespread rash. Dermatological examination showed widespread, near total-body erythema with desquamation, along with scaly erythematous plaques on the extremities. Additionally, he had severe palmoplantar hyperkeratosis and fissuring, along with mild erythematous silvery-white scaly patches on the scalp. Pitting and onycholysis were noted on his all fingernails. Detailed history revealed that the patient has suffered from plaque psoriasis and psoriatic arthritis for 20 years and undergone numerous therapies including acitretin, methotrexate, and adalimumab without significant improvement. Therefore, secukinumab was started 2 years ago and he achieved a Psoriasis area and Severity Index (PASI) 100 response during the last 2 years. Eight months ago, he had mildly symptomatic coronavirus disease 2019 (COVID-19) for which he was treated with oral favipiravir for 5 days with complete improvement. However, after 7 months of COVID-19 infection recovery, following 4 weeks after the first dose of COVID-19 Pfizer- BioNTech BNT16B2b2 mRNA vaccine, erythematous macules and scaly plaques appeared and gradually covered the entire skin. A provisional diagnosis of erythrodermic psoriasis was made (PASI: 48.6, Body surface area: 95%, Figure 1A–D). The patient had itch, pain, malaise, and fatigue. Physical examination did not reveal tachycardia, hypothermia, hyperthermia, peripheral lymphadenopathy, and facial, pedal or pretibial edema. Laboratory investigation revealed neutrophilia, leukocytosis, and elevated serum C-reactive protein levels, while serum albumin and total protein levels were normal. Four-mm punch biopsy taken from the right lateral thigh revealed hyperkeratosis, parakeratosis, and small focus of neutrophil deposits in the stratum corneum. Additionally, focal spongiosis, regular acanthosis hypogranulosis, thinning of the suprapapillary plates, and lymphohistiocytic inflammatory infiltrate in the dermis were seen indicating psoriasis (Figure 1E). Oral prednisone was initiated with a dose of 50 mg daily, followed by 10 mg weekly dose reduction. While the prednisone dose was tapered, secukinumab treatment was switched to ixekizumab. Ixekizumab was administered according to the recommended dosing schedule. Subsequently, with oral prednisone and ixekizumab therapy, the patient's erythroderma was completely, and psoriatic plaques were partially resolved on the 3rd week of treatment. Based on the clinical and histopathological examination, we speculated that psoriatic erythroderma might have been exacerbated due to Pfizer-BioNTech BNT16B2b2 mRNA vaccine in this patient. Although psoriasis flare-up after COVID-19 vaccination was considered to be rare, patients with plaque, palmoplantar, guttate and pustular type psoriasis were reported to be flare-up after COVID-19 vaccine which were summarized in Table 1.1-8 In most studies, duration between the vaccination and the flare of psoriasis is between 1 and 14 days, but there are also studies reporting the duration between the vaccination and the flare of psoriasis longer than 14 days, as in our case.6, 7 Biologic agents may strongly reduce but not to completely undo the risk of psoriasis flare-up following vaccination. However, flare-up of psoriasis following COVID-19 vaccination have also been reported in the literature in patients undergoing biologics, as in our patient.7, 8 A study comparing the efficacy of secukinumab and ixekizumab in psoriasis patients showed higher rates of PASI-90 and PASI-100 responses at week 12 and 48 in the ixekizumab group as compared to secukinumab group.9 Similarly in our patient, the flare-up of psoriasis after COVID-19 vaccine resolved with switching secukinumab to ixekizumab. Although the exact pathogenesis of psoriasis exacerbation after vaccination remains unclear, one hypothesis is that viral components and vaccine adjuvants may lead to the induction of immune dysregulation. Another theory is that mRNA vaccines might trigger a significant increase in IL-6 production and induce recruitment of Th17 cells which play an important role in the pathogenesis of psoriasis.1 It may be speculated that the patient's previous COVID-19 infection may be a contributing factor to the immune dysregulation that was triggered by COVID-19 vaccination. PRED IXE Palmoplantar Psoriatic arthritis MTX PRED Top. cal/beta nbUVB To the best of our knowledge, this is the first case of exacerbation of psoriasis with erythroderma in a psoriatic patient after the first dose of COVID-19 Pfizer-BioNTech BNT16B2b2 mRNA vaccine. It is important for dermatologists to be aware that mRNA COVID-19 vaccine may be associated with the development of erythroderma in psoriasis patients. The authors have no conflict of interest to declare. Written informed consent for publication of medical images was taken from the patient. Data sharing not applicable to this article as no new data generated, or the article describes entirely theoretical research. Data sharing not applicable to this article as no new data generated, or the article describes entirely theoretical research.

COVID-19 vaccination was the main measure to overcome the pandemic. As with other drugs and vaccines, mild to moderate adverse events have been reported following vaccination. In addition, several cutaneous reactions have been described. In particular, there are several reports investigating de novo psoriasis or the exacerbation of psoriasis following COVID-19 vaccination. However, data on the possible pathogenetic mechanisms as well as comprehensive manuscripts on the topic are scant. Thus, the aim of our manuscript was to perform a review of the current literature on post-COVID-19 vaccination exacerbations and new-onset psoriasis in order to offer a wide perspective on this area and to point out possible pathogenetic mechanisms. Research on the current literature was performed following PRISMA guidelines. In total, 49 studies involving 134 patients developing new-onset psoriasis (n = 27, 20.1%) or psoriasis exacerbation (n = 107, 79.9%) were collected. Although cases of de novo psoriasis or a worsening of psoriasis have been reported following vaccination, all of the cases have been successfully treated while overall benefit-risk profile of COVID-19 vaccination does not justify vaccine hesitancy due to the risk of psoriasis being developed or worsening. Certainly, further studies are needed to identify possible pathogenetic mechanisms in order to identify "at-risk" patients. Finally, vaccination should not be discouraged.

Psoriasis is a chronic, immune-mediated inflammatory disease with heterogeneous clinical manifestations. Various trigger factors like infections and drugs are known to elicit or aggravate psoriasis. Previously, a possible association of vaccination and the new onset (particularly guttate lesions) or exacerbation of psoriasis has been reported.

IntroductionThe COVID-19 vaccines have documented transient side effects, including injection site soreness, redness, headache, fatigue, and fever. In addition, there have been few reported long-term side effects, including Guillain-Barre, pericarditis, and cerebral venous sinus thrombosis. We present a rare case of severe insomnia as a long-term side effect following COVID-19 vaccination. Report of Cases: A 59-year-old female with a past medical history of well-controlled hypothyroidism and migraine presented to the sleep center with four months of insomnia. She had a history of COVID infection in November 2020 with only mild symptoms of sore throat and fatigue. The patient finished her two-shot series of the Moderna COVID-19 vaccine in April 2021. Immediately following the vaccination, the patient had severe trouble falling and staying asleep. Her insomnia was resistant to multiple medications including zolpidem Immediate-release(IR), Controlled-release(CR) formulas, zaleplon, eszopiclone, trazodone, melatonin, clonazepam, suvorexant, and lemborexant. However, magnetic resonance imaging (MRI) brain imaging only showed nonspecific white matter disease. She had no mood disorders or psychosocial stressors, and the patient had excellent sleep hygiene measures. However, insomnia caused severe impairment of her daily life activities to a point where she was almost seeking inpatient admission for her insomnia. During the COVID-19 pandemic, the effects on sleep have been significant, particularly insomnia. Prescriptions for sleep medications have increased. Many have attributed the rise of insomnia to pandemic-related stress, disturbance of circadian rhythm from home confinement, and worsening mental health.ConclusionTo our knowledge, there have not been documented side effects of insomnia on the COVID-19 vaccines, with some studies suggesting sleep deprivation reducing their effectiveness. As vaccination efforts continue worldwide, awareness of side effects from vaccines is paramount for clinicians facing the challenges in patient care.This case demonstrates that chronic insomnia can be a side effect of the COVID-19 vaccines. Therefore, further surveillance of patients and side effects from COVID-19 vaccination is warranted as insomnia can have significant clinical and psychosocial consequences.Support (If Any)

Background/AimsVaccination against coronavirus is a cornerstone in the fight against the COVID-19 pandemic. Although the safety and efficacy of vaccines was established prior to roll out, long-term data and reports of rare adverse reactions remain inadequate. Literature reviews revealed two cases of PMR-like syndrome, left elbow arthritis and a case of rheumatoid arthritis (RA) flare following COVID-19 vaccination. Additionally, a case of new onset RA and case of reactive arthritis was reported with COVID infection.MethodsWe present four patients with polymyalgia rheumatica (PMR) following COVID-19 vaccination. The clinical details of the four patients are outlined in the table: P061 Table 1Patient 1Patient 2Patient 3Patient 4Demographic data76-year-old Caucasian male68-year-old Caucasian male73-year-old African male65-year-old Caucasian maleType of COVID-19 vaccineAstraZenecaPfizerAstraZenecaAstraZenecaOnset of symptoms after the second dose of COVID-19 vaccinationWithin 1 weekWithin 2 weeksWithin 1 weekWithin 1 weekClinical symptoms-Inflammatory joint pain mainly in shoulders and hand with two hours morning stiffness -Bilateral knee and ankle swelling. -Significant restriction of self-care activities in daily living (ADL)-Severe shoulder pain and morning stiffness -Hand pain affecting ADL-Widespread painful joints affecting the neck, pelvic girdle, and hands -Significant restriction of self-care activities-Sudden onset of pain and stiffness of both shoulders and pelvic girdle -Requiring a walking stick. -Significant morning stiffnessClinical signs- Limited shoulder abduction -Tenderness over PIP and MCP without synovitis- Limitation of shoulder movement-Limitation of shoulder movement-Limitation of both shoulder movementAutoimmune profile (RF, CCP, ANA, ANCA and protein electrophoresis)NegativeNegativeNegativeNegativeFull blood countHaemoglobin (Hb) 125 g/l and white blood cells (WBCs) 17 10 × 9/1Hb 147 g/l and WBCs 11.5 10× 9/1Hb 160 g/l WBCs 14 10× 9/1Hb 124 g/l and WBCs 9.8 10× 9/1CRP at the onset of symptoms96 mg/l61 mg/l105 mg/l161 mg/lPrednisolone dose30 mg per day as there was no response to 15 mg and tapered as per PMR regime15 mg per day tapered as per PMR regime40 mg per day by A & E; and tapered as per PMR regime15 mg per day tapered as per PMR regimeUltrasound (US) revealed typical finding of bilateral sub deltoid bursitis and biceps tendonitis in the first patient and there was severe right sub deltoid bursitis with biceps tendonitis in the second patient. None of the patients had features to suggest malignancy, giant cell arteritis, seronegative spondyloarthropathies or connective tissue disease.ResultsAfter exclusion of other inflammatory causes of shoulder pain, they were diagnosed with PMR based on clinical judgement and high inflammatory marker at time of presentations, ultrasound findings and significant improvement with prednisolone.ConclusionPMR following COVID-19 vaccination is exceptional and cannot be proven. In these patients post vaccination chronology of events favours this diagnosis. It is known that immunological illness may start after viral infection or vaccination (hapten or immune stimulation). The patients have responded well to the prednisolone similar to typical PMR cases. We need further studies to look at possible link between COVID-19 vaccination and PMR.Disclosure M. Mohareb: None. A. Bharadwaj: None. A. Nandagudi: None.

Dear Editor, Psoriasis is a chronic inflammatory disease affecting 1% to 3% of the world's population1, 2 and results from the interaction between genetics and environmental factors such as stress, infections, and drugs, causing a T-cell-mediated response.1-3 Vaccination is an uncommon triggering factor for the flare-ups of several skin diseases,2, 4-6 and a potential association between vaccination and the onset or exacerbation of psoriasis has been previously documented.2, 5-7 In this letter, we report four new cases of psoriasis flare-ups after an influenza vaccination (Table 1). Topical corticosteroids Vitamin D analogs Oral acitretin Oral prednisone in slow de-escalation Topical corticosteroids The first patient was a 41-year-old man with chronic plaque psoriasis undergoing adalimumab therapy who developed a severe flare-up that required hospital admission 24 hours after an intramuscular Chiroflu influenza vaccination (Trivalent A/Victoria/2452/2019 H1N1, A/Hong Kong/2671/2019 H3N2, and B/Victoria/705/2018) (Figure 1). The patient clinically improved after treatment with subcutaneous guselkumab, topical corticosteroids, and emollients. The second patient was a 70-year-old woman with chronic psoriasis who was undergoing treatment with topical corticosteroids and vitamin D analogs. The patient was referred to our department from the emergency room because she had started to develop diffuse erythema and numerous plaques following an intramuscular Chiroflu influenza vaccination 7 days earlier (Figure 2). The patient was started on treatment with oral acitretin, oral prednisone in slow de-escalation, and topical methylprednisolone aceponate, showing marked improvement after 3 weeks. The third patient was a 55-year-old woman with severe chronic psoriasis treated with subcutaneous secukinumab (previously with etanercept, adalimumab, and ustekinumab) who developed a facial psoriasis plaque 24 hours after a subcutaneous Chiroflu influenza vaccination. The patient was treated with topical fluticasone, with complete resolution of the skin lesion in 2 weeks. The fourth patient was a 67-year-old woman with severe chronic psoriasis undergoing guselkumab therapy who developed a guttate psoriasis flare-up following a Chiroflu influenza vaccination 1 month earlier. The patient's biological therapy was changed to brodalumab, with improvement in the cutaneous lesions. New-onset or severe exacerbations of psoriasis following influenza vaccination are uncommon. Most reported vaccination-related psoriasis flare-ups have been classified as guttate and guttate/plaque variants.2, 4-7 We report four cases of psoriasis exacerbation following influenza vaccination with H1N1, H3N2, and B influenza strains. In our four patients, the close temporal relationship between the vaccination and the onset of the psoriasis flare-ups suggests a possible causal association.5 Although the etiological relationship between psoriasis and vaccination remains uncertain, it is known that the influenza vaccine generates T-helper (Th)1 and Th17 immunologic responses, which could represent a possible mechanism for vaccination-induced psoriasis.2 The immunologic reaction to the influenza vaccination might rely on the generation of interleukin (IL)-6 and IL-22, producing Th17 cells that play a key role in the development of the characteristic epidermal changes of psoriasis.5, 6, 8 In patients treated with IL-17 inhibitors, Th1 cells might be involved in the development of psoriasis flare-ups instead of Th17 cells. However, we found no differences in the clinical outcomes between the patient treated with secukinumab and the other patients. To date, “psoriasis vaccinalis” has also been described with Bacillus Calmette-Guerin, tetanus-diphtheria, and pneumococcal polysaccharide vaccines, including psoriasis-like eruptions and psoriatic arthropathy.8-11 The very low incidence of this condition and the favorable cost-effectiveness of the influenza vaccine should not change the immunization practice, especially for patients with psoriasis undergoing immunosuppressive and/or biological therapy.5, 6 Nevertheless, it is important to acknowledge vaccination as a triggering factor of psoriasis flare-ups, particularly in the COVID-19 era, given that we do not yet know whether COVID-19 vaccines will be a triggering factor for preexisting or new dermatological conditions, although it appears possible. Patients should therefore be carefully monitored once the COVID-19 immunization process begins. The authors declare no potential conflict of interest. All authors have contributed to the work. Marta Drake-Monfort, Susana Armesto, Marcos Antonio González-López, and Pablo Munguía-Calzada reported the four cases. Pablo Munguía-Calzada and Marcos Antonio González-López wrote the article. Leandra Reguero-del Cura and Ana Elisabet López-Sundh made the photographs, reviewed the bibliography, and performed the critical revision of the letter. The data that support the findings of this study are available from the corresponding author.

COVID-19 vaccines are globally administered and generally safe. However, rare cutaneous adverse effects have been reported. We report a 37-year-old woman who developed new-onset guttate psoriasis five days after receiving the Pfizer/BioNTech COVID-19 vaccine. Initial treatment with cyclosporine and topical calcipotriol/betamethasone showed limited efficacy necessitating a switch to methotrexate and NBUVB which resulted in improvement over 3 months. New-onset psoriasis following COVID-19 vaccination is primarily managed with topical treatments, with guttate psoriasis showing a better prognosis compared to other subtypes. This case underscores the need for individualized treatment approaches and highlights the importance of recognizing vaccine-associated psoriasis.