First Onset of Pityriasis Rubra Pilaris following SARS-CoV-2 Booster Vaccination: Case Report and Review of the Literature

Abstract

There is increasing evidence of adverse events associated with the use of COVID-19 vaccines. Here, we report a case of the SARS-CoV-2-vaccination-related onset of pityriasis rubra pilaris (PRP) and provide an analysis of previously reported cases in the medical literature. A 67-year-old male presented with a 1-year history of histopathologically proven PRP that first developed 14 days after receiving a COVID-19 booster vaccination. Skin symptoms improved under ustekinumab medication after unsuccessful previous treatment approaches using systemic corticosteroids, brodalumab, and risankizumab. Among the published cases of post-COVID vaccination PRP, 12 (75%) males and 4 (25%) females were reported. The median age of the reported patients was 59 years. In 10 out of 16 patients (62.5%), PRP was diagnosed after the first vaccine dose, in 4 (25%) after the second dose, and in 2 of 15 patients (12.5%) after the third dose. The median time between COVID-19 vaccination and the onset of PRP was 9.5 days (range: 3–60 days). The majority of patients required systemic treatment, including systemic retinoids and methotrexate. PRP might be a rare adverse event after COVID-19 vaccination, particularly affecting older males. Even though most reported patients with COVID-19-vaccination-related PRP could be successfully treated with PRP standard medications, therapy refractory cases may also occur. Thus, clinicians must be aware of this rare but potentially severe complication.

Clinical characteristics of patients with pityriasis rubra pilaris following SARS‐CoV‐2 vaccination

“…COVID-19 vaccine-induced PRP usually occurred about 10 days after vaccination, whereas there was a wide range from 3 to 60 days. [1][2][3][4][5] The vaccines applied were as follows: 8/20 (40%) cases with vector-based vaccines (Vaxzevria, Covishield/AstraZeneca), 8/20 (40%) cases with mRNA-based vaccines (Comirnaty/Pfizer-BioNTech, Spikevax/Moderna) and 4/20 (20%) cases with an inactivated vaccine (CoronaVac/ Sinovac). In most patients, systemic treatment consisted of retinoids.…”

“…5,9 Information regarding reexposition to SARS-CoV vaccines was provided only in five cases, whereas PRP exacerbation was observed in two of these patients. 5 In conclusion, the patients history, the temporal relationship in most cases and the fact that PRP is a rare condition suggest a causal relationship between COVID-19 vaccination and the development of PRP. Clinicians should be aware of this relationship when considering the diagnosis of PRP.…”

“…Including the case of Zhang et al, 1 20 COVID-19 vaccine-induced PRP cases have been published so far (Figure 1). [1][2][3][4][5] Unlike classic adult-onset PRP, which is a rare autoinflammatory keratinising disease without gender preference, COVID-19 vaccine-induced PRP appears to be more likely in males (70% of cases, Table 1). By contrast, disease onset in patients with COVID-19 vaccineinduced PRP is around the 60s matching the expected age of disease onset of classic adult PRP.…”

“…In most patients, systemic treatment consisted of retinoids. [1][2][3][4][5] The latter represented first-choice therapies for PRP, even though the evidence for its use in PRP patients is relatively poor. In current and recent cases, however, interleukin 17 (IL-17), IL-23, and IL-23/12(p40) have also been administered with success in most cases.…”

“…The use of these biologics in PRP patients may be reasonable since it has recently been observed that the IL-17/IL-23 axis appears to play a significant role in the pathogenesis of PRP. 5,9 Information regarding reexposition to SARS-CoV vaccines was provided only in five cases, whereas PRP exacerbation was observed in two of these patients. 5 In conclusion, the patients history, the temporal relationship in most cases and the fact that PRP is a rare condition suggest a causal relationship between COVID-19 vaccination and the development of PRP.…”