New Onset of Severe Plaque Psoriasis Following COVID-19 Vaccination: A Case Report

Introduction

Psoriasis is a chronic immune-mediated cutaneous inflammatory disease. Triggers of psoriasis included infection, stress, trauma, alcohol consumption and drug. A possible association of vaccination with the new onset or exacerbation of psoriasis has been reported.¹ Here, to our knowledge, we reported a rare case of new-onset severe plaque psoriasis after COVID-19 vaccination.

Case Report

A 63-year-old woman presented with widespread erythema and plaques for 2 months, which occurred a day after the second dose of COVID-19 vaccination (SARS-Cov-2 Vaccine, inactivated, Beijing Institute of Biological Products Company, Beijing, China). The lesions began on her face and neck and spread to her trunk and extremities. Physical examination revealed diffuse erythematous plaques on her face, trunk and limbs (body surface area 72%, Psoriasis Area Severity Index 30.4, Figure 1A and B). Blood tests showed a normal blood count and she denied family history of psoriasis or any other putative triggers, such as drugs, previous infections and trauma. Based on these findings, she was diagnosed as acute plaque psoriasis triggered by COVID-19 vaccination. She was treated with secukinumab 150 mg per week because her weight was less than 60 kg. Her lesions responded well to the treatment of secukinumab after a month with significant improvement of scaly plaques on her back and extremities, leaving only some residual erythema and hyperpigmented patches (Figure 1C and D).

Figure 1 Clinical manifestation of the patient. (A) Multiple erythematous papules and plaques on the trunk. (B) Diffuse erythematous plaques on bilateral thighs. (C and D) Hyperpigmented patches and erythema on her back and limbs after secukinumab 150 mg per week.

Discussion

With COVID-19 mass vaccination, cutaneous reactions to COVID-19 vaccines described are increasing.² In a registry-based study including 414 cases by McMahon et al,³ injection site reactions, swelling, urticaria, erythromelalgia and flares of psoriasis after COVID-19 vaccination were reported. New onset or exacerbations of psoriasis following vaccination have been described in other different types of vaccines, including influenza, Bacillus Calmette-Guerin, tetanus-diphtheria, and pneumococcal polysaccharide vaccines.⁴ Recently, new onset or exacerbations of psoriasis associated with COVID-19 vaccines have been reported, including guttate psoriasis and acute generalized pustular psoriasis.⁵ Wei et al¹ reported six patients who experienced an exacerbation of known psoriasis and one patient with new-onset psoriasis following COVID-19 vaccination. Six of them presented with symptoms after the second dose of the vaccine. In our patient, psoriasis lesions occurred following the second dose of COVID-19 vaccination. And the lack of any other trigger factors (no infections or new medication) strongly suggests a causal association. However, most vaccination-related psoriasis were guttate variants and acute generalized pustular psoriasis.⁵ New-onset severe plaque psoriasis due to COVID-19 vaccines was scarce.

Psoriasis is an immune-mediated disorder characterized by Th1 and Th17 cells cytokines and a predominance of CD4⁺ T cells in the dermis. The onset of psoriasis can be induced by various medications, infections, vaccines and other triggers.⁶ Tumour necrosis factor (TNF)-α and interferon (IFN)-γ are two potent pro-inflammatory cytokines which can trigger inflammatory cascades in psoriasis.⁷ The mechanisms of new-onset psoriasis after vaccination are unknown. It has been elicited that IL-2, IL-12, TNF-α and IFN-γ produced by CD4+ T cells were increased after COVID-19 vaccination.⁸ IL-6-induce Th17 subset of CD4+ T cells in COVID-19 immunopathology and vaccine-induced immune enhancement was highlighted by recent studies.⁹ Therefore, it was speculated that COVID-19 vaccines may lead to activation of inflammatory pathways and thereby triggered psoriasis. However, further investigations are required.

As COVID-19 vaccination and booster vaccine shots continue worldwide in the future, it is necessary for dermatologists to be aware of the possibility of new-onset psoriasis secondary to COVID-19 vaccines. We should pay close attention to the possible adverse effects of COVID-19 vaccines and counteract the worsening of patient’s clinical condition.