Abstract
Despite the significant reduction of both morbidity and mortality after the introduction of many vaccines against COVID‐19, recent reports indicated a worsening skin conditions in particular patients with psoriasis. We extracted the data of 51 patients from 19 papers. The mean age was 56.9 (SD = 16.2) years, with a male prevalence 45%. Of the 51 cases, vaccine types at which psoriasis flare occurred were as the following: Pfizer vaccine (30), AstraZeneca (9), Moderna (8), Coronavac (2) Covishield (1), and Covaxin (1). Exacerbation was common in the second dose of Pfizer, AstraZeneca, Moderna, and Covishield vaccines. Moreover, the onset of psoriasis exacerbation was shorter after the second dose of Pfizer (mean = 12.8 [SD = 15.2]) and AstraZeneca (mean = 7.4 [SD = 3.6]) rather than the first dose of both vaccines, respectively (mean = 19.2 [SD = 21.3]) and (mean = 18.5 [SD = 10.7]).
Keywords: COVID‐19 vaccine, COVID‐19 vaccines, exacerbation, flare, psoriasis
1. INTRODUCTION
A close attention toward many skin conditions was devoted among the dermatologic society during the COIVD‐19 era. Not only for its cutaneous manifestations' in previously healthy individuals but also the outcomes of many patients with chronic skin conditions. 1 Despite the significant reduction of both morbidity and mortality after the introduction of many vaccines against COVID‐19, recent reports indicated a worsening skin conditions in particular patients with psoriasis. 2 , 3 , 4 In this report, we aimed to study the characteristics of psoriasis patients who experienced exacerbation of their comorbidity in relation to vaccine types.
2. METHOD
To get the relevant papers, a PRISMA guided search was conducted in five databases: PubMed (n = 43), Web of Science (n = 39), Virtual Health Library (n = 62), Scopus (n = 85), and Google Scholar (n = 889). We used the term “(psoriasis) AND (‘COVID‐19 vaccination’ OR ‘COVID 19 vaccination’ OR ‘COVID‐19 vaccine’ OR ‘COVID 19 vaccine’)” till June 18, 2022. We included all papers that reported exacerbation of psoriasis patients after COVID‐19 vaccination. We excluded reviews and conference abstracts. We extracted all the relevant information related to COVID‐19 vaccination (Table 1).
TABLE 1.
Characteristics of patients
| Reference ID | Country of patients | Age | Sex | Psoriasis type | Vaccine type | Exacerbation dose | Onset of exacerbation (days) | Management of exacerbation | Comorbid conditions |
|---|---|---|---|---|---|---|---|---|---|
| Bostan‐2021 | Turkey | 51 | Male | Plaque psoriasis | Pfizer | 1st dose | 60 | ‐ | Diabetes mellitus |
| 52 | Male | Plaque psoriasis | CoronaVac | 2nd dose | 30 | ‐ | ‐ | ||
| Fang‐2021 | Taiwan | 34 | Female | Psoriasis vulgaris | AstraZeneca | 1st dose | 7 | Topical betamethasone | ‐ |
| Infimate‐2022 | India | 21 | Male | Plaque psoriasis | COVAXIN | 1st dose | 4 | Acitretin | ‐ |
| Kabbani‐2022 | Belgium | 53 | Male | Plaque psoriasis | Pfizer | 1st and 2nd doses | 7 | Cyclosporine, topical steroids, acitretin and oral corticosteroids | Diabetes mellitus, hypertension, COPD |
| Koumaki −2022 | Greece | 34 | Female | Plaque psoriasis | Pfizer | 2nd dose | 10 | Secukinumab, topical emollients | Hashimoto and celiac disease |
| 61 | Male | Plaque psoriasis | AstraZeneca | 1st dose | 14 | Apremilast 30.IV methylprednisolone | Hypertension | ||
| 45 | Female | Plaque psoriasis | Pfizer | 2nd dose | 10 | Clobetasole propionate cream and calcipotriol/ betamethasone gel | Psoriatic arthritis | ||
| 56 | Female | Plaque psoriasis | Pfizer | 2nd dose | 2 | Adalimumab and Clobetasole propionate cream | Crohn's disease, COPD, dyslipidaemia | ||
| 53 | Female | Pustular psoriasis | Pfizer | 1st dose | 20 | Clobetasole propionate cream, hydroxyzine hydrochloride, IV methylprednisolone | Crohn's disease, arthralgia | ||
| 56 | Female | Plaque psoriasis | Pfizer | 2nd dose | 3 | Secukinumab | Arthralgia | ||
| 34 | Female | Plaque psoriasis | Pfizer | 2nd dose | 7 | Secukinumab | ‐ | ||
| 61 | Female | Pustular psoriasis | Pfizer | 2nd dose | 4 | IV methylprednisolone, hydroxyzine hydrochloride, subcatuneous methotrxate and IV infliximab | Rheumatoid arthritis, hypothyroidism | ||
| 66 | Female | Plaque psoriasis | Pfizer | 1st dose | 20 | Ustekinumab, topical isoconazole and diflucortolone valerate cream | Psoriatic arthritis, type 2 diabetes, essential hypertension, dyslipidaemia | ||
| 67 | Female | Plaque psoriasis | Pfizer | 2nd dose | 20 | Oral prednisolone, topical clobetasol propionate cream | Psoriatic arthritis | ||
| 56 | Male | Plaque psoriasis | Pfizer | 2nd dose | 20 | Topical calcipotriol and betamethasone foam | Acute coronary disease | ||
| 51 | Male | Plaque psoriasis | Pfizer | 2nd dose | 25 | Topical calcipotriol and betamethasone gel | Psoriatic arthritis | ||
| Durmaz‐2021 | Turkey | 64 | Male | Psoriasis vulgaris | Pfizer | 3rd dose | 42 | ‐ | Epilepsy |
| 64 | Male | ‐ | Pfizer | 2nd dose | 7 | ‐ | ‐ | ||
| 25 | Female | Pustular psoriasis | Pfizer | 1st dose | 3 | ‐ | ‐ | ||
| Nagrani‐2021 | India | 56 | Female | ‐ | Covishield | 2nd dose | 2 | Apremilast, antihistamines and emollients. | ‐ |
| Lopez‐2022 | Mexico | 58 | Male | ‐ | Pfizer | 2nd dose | 4 | wet wraps with triamcinolone to lower extremities, triamcinolone 0.1% ointment over body, and hydroxyzine for itching | Hypertension, osteomyelitis and hepatitis C |
| Mieczkowska‐2022 | USA | 65 | Male | ‐ | Pfizer | 1st dose | 7 | ‐ | ‐ |
| Onsun‐2021 | Turkey | 72 | Male | Plaque psoriasis | CoronaVac | 1st dose | 4 | Acitretin and IV infliximab | ‐ |
| Pavia‐2022 | Italy | 24 | Female | Plaque psoriasis | Pfizer | 2nd dose | 10 | Risankizumab with two subcutaneous injections and daptomycin | ‐ |
| Ohmura‐2022 | Japan | 30 | Male | Plaque psoriasis | Moderna | 2nd dose | 1 | Ixekizumab | ‐ |
| Yatsuzuka‐2021 | Japan | 65 | Male | Pustular psoriasis | Pfizer | 2nd dose | 12 | Secukinumab | ‐ |
| Pesque‐2022 | Spain | 30 | Female | Plaque psoriasis | Moderna | 1st dose | 10 | Topical steroids and topical calcipotriol | ‐ |
| Phuan‐2021 | Singapore | 80 | Female | ‐ | Pfizer | 3rd dose | 3 | Cyclosporine and topical steroids | ‐ |
| Quattrini‐2021 | Italy | 83 | Female | Palmoplantar psoriasis | Pfizer | 2nd dose | 2 | Oral prednisone and methotrexate | ‐ |
| Sotiriou‐2021 | Greece | 69 | Female | Plaque psoriasis | AstraZeneca | 2nd dose | 8 | Phototherapy | ‐ |
| 82 | Female | Plaque psoriasis | Moderna | 2nd dose | 10 | Topical calcipotriol/betamethasone | ‐ | ||
| 62 | Female | Plaque psoriasis | Pfizer | 2nd dose | 6 | Topical calcipotriol/betamethasone | ‐ | ||
| 73 | Male | Plaque psoriasis | Pfizer | 2nd dose | 7 | Topical calcipotriol/betamethasone | ‐ | ||
| 66 | Male | Plaque psoriasis | AstraZeneca | 1st dose | 22 | Risankizumab | ‐ | ||
| 62 | Female | Plaque psoriasis | AstraZeneca | 2nd dose | 13 | Apremilast | ‐ | ||
| 78 | Female | Plaque psoriasis | Pfizer | 2nd dose | 5 | Topical calcipotriol/betamethasone | ‐ | ||
| 64 | Female | Plaque psoriasis | AstraZeneca | 2nd dose | 6 | Phototherapy | ‐ | ||
| 69 | Male | Plaque psoriasis | AstraZeneca | 1st dose | 32 | Phototherapy | ‐ | ||
| 83 | Male | Plaque psoriasis | Pfizer | 2nd dose | 9 | Topical calcipotriol/betamethasone | ‐ | ||
| 61 | Female | Plaque psoriasis | AstraZeneca | 2nd dose | 3 | Phototherapy | ‐ | ||
| 49 | Male | Plaque psoriasis | Pfizer | 2nd dose | 10 | Ixekizumab | ‐ | ||
| 55 | Female | Plaque psoriasis | Pfizer | 2nd dose | 7 | Cyclosporine | ‐ | ||
| 64 | Female | Plaque psoriasis | AstraZeneca | 2nd dose | 7 | Guselkumab | ‐ | ||
| Perna‐2021 | USA | 40 | Male | Plaque psoriasis | Pfizer | 1st dose | 5 | Infliximab | obesity, hypertension and depression/anxiety |
| Wei‐2022 | USA | 76 | Male | ‐ | Moderna | 2nd dose | 62 | Apremilast, phototherapy | ‐ |
| 69 | Male | ‐ | Moderna | 2nd dose | 21 | Apremilast, tildrakizumab | ‐ | ||
| 68 | Female | ‐ | Moderna | 2nd dose | 6 | Risankizumab | ‐ | ||
| 67 | Male | ‐ | Moderna | 2nd dose | 60 | Tildrakizumab, clobetasol | ‐ | ||
| 52 | Female | ‐ | Moderna | 1st and 2nd doses | 7 | Risankizumab, clobetasol, mometasone, triamcinolone | ‐ | ||
| 27 | Female | ‐ | Pfizer | 2nd dose | 90 | Clobetasol | ‐ |
3. RESULTS
We extracted the data of 51 patients from 19 papers (Table 1 and supplementary file, Data S1). The mean age was 56.9 (SD = 16.2) years, with a male prevalence 45%. The type of psoriasis was plaque (33), pustular (4), vulgaris (2), palmoplanter (1), and not reported (11). Of the 51 cases, vaccine types at which psoriasis flare occurred were as the following: Pfizer (30), followed by AstraZeneca (9), Moderna (8), Coronavac (2), Covishield (1), and Covaxin (1). Exacerbation was common in the second dose of Pfizer, AstraZeneca, Moderna, and Covishield vaccines (Figure 1). Moreover, the onset of psoriasis exacerbation was shorter after the second dose of Pfizer (mean = 12.8 [SD = 15.2]) and AstraZeneca (mean = 7.4 [SD = 3.6]) rather than the first dose of both vaccines, respectively (mean = 19.2 [SD = 21.3]) and (mean = 18.5 [SD = 10.7]).
FIGURE 1.
The distribution of the vaccine induced psoriasis flare. The vertical column indicated the number of patients while in the horizontal column indicated the vaccine type.
4. DISCUSSION
COVID‐19 vaccines exhibit several cutaneous manifestations including swelling erythema, rash, and urticaria. However, flaring of certain dermatological diseases occurred after vaccination as well. 5 Herein, we found that exacerbation of psoriasis condition after COVID‐19 vaccination mainly occurs after the second dose of four of the reported six vaccines as only one report indicated Covaxin induced‐psoriasis exacerbation after the first dose in addition to the similar prevalence of the first and the second dose in Coronavac‐induced psoriasis. It is worth noting that the psoriasis flare was reported after a mean of 12.8 and 7.4 days of Pfizer and AstraZeneca second dose, which is much lower than the onset of psoriasis flare in the first dose of both vaccines, which occurred after nearly 19 days in both vaccines.
Our understanding regarding the possible mechanisms for psoriasis exacerbation after COVID‐19 vaccines are still under investigation. However, certain hypotheses may be close to answer our concerns regarding this phenomenon such as the immunity suppression that was derived from the immunosuppressant drugs for the psoriasis treatment together with the activation of dendritic cells and the associated increase of the expressed cytokines which play a significant role in psoriasis development. 6
Currently, there are no specific guidelines about the best therapeutic modality for psoriasis flare after COVID‐19 vaccination. Despite that immunosuppressants—in particular steroids (either topical or systemic)—constituted the backbone of therapy in many of our included cases (Table 1). 4 , 7 , 8
Vaccination against COVID‐19 is of extreme importance in both the healthy individuals and those with comorbid conditions especially psoriasis. However, close monitoring of psoriasis patients after COVID‐19 vaccination is recommended for the avoidance of psoriasis exacerbation despite being a rare entity. Moreover, increasing the knowledge about the safety and efficacy of COVID‐19 vaccination in patients with psoriasis is remarkably needed.
AUTHOR CONTRIBUTIONS
Amr Ehab El‐Qushayri was responsible for the idea and the study design. Amr Ehab El‐Qushayri screened and extracted the data. Amr Ehab El‐Qushayri and Beatrice Nardone shared in the writing of the full text and approval of final version. All steps were supervised by Beatrice Nardone.
FUNDING INFORMATION
The authors received no funding for this study.
CONFLICT OF INTEREST
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Supporting information
Appendix S1: Supporting Information
El‐Qushayri AE, Nardone B. Psoriasis exacerbation after COVID‐19 vaccines: A brief report of the reported cases. Dermatologic Therapy. 2022;35(12):e15900. doi: 10.1111/dth.15900
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Appendix S1: Supporting Information
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.