Pustular Eruption following COVID-19 Vaccination: A Narrative Case-Based Review

Abstract

From the beginning of public vaccinations until the relaxation of COVID-19 measures, many case reports, case series and case–control studies have been published indicating cutaneous side effects of COVID-19 vaccination. Post-vaccination pustular eruption was reported as well, with a challenging differential diagnosis between pustular psoriasis, AGEP (acute generalized exanthematous pustulosis) and neutrophil pustular eruptions. We report a case of 56-year-old woman presented with acute generalized pustular flare up culminated 5 days after the second dose of BNT162b2(Pfizer) vaccination. She was diagnosed with pustular psoriasis flare and due to the regulating role of IL-1 in pustular psoriasis and in the cytokine storm observed in cases of COVID-19 postvaccination inflammation; we decided to treat the patient with an IL-1 antagonist, subcutaneous anakinra (100 mg daily) along with acitretin. One week later, after anakinra withdrawal, she presented a pustular psoriasis flare and a 7-day anakinra re-administration led to a satisfactory improvement in the skin lesions. We also reviewed the medical literature and found 28 case reports with pustular eruption after the COVID-19 vaccination. We compared the patients reported, regarding sex, age, number of doses, post-vaccination period and vaccine brand, and compared those results with our patient. Finally, as indicated by our case and other cases with similarly treated pustular eruptions. targeted therapy to this cytokine imbalance such as anakinra (IL-1) antagonist can improve the clinical course of the patient.

Plaque Psoriasis Exacerbation and COVID-19 Vaccination: Assessing the Characteristics of the Flare and the Exposome Parameters

“…The evidence supporting the cytokine production theory is reinforced by the protective effect of biological therapy against flares. Additionally, the utilization of biological modalities that inhibit cytokine production and action [ 59 ], including treatments, like Anakinra (anti-IL1), can be used for managing mild to severe psoriasis exacerbations [ 68 ]. However, there are no data on cytokine modifications after COVID-19 vaccinations in psoriasis patients to comprehend cytokine regulation after vaccination in this specific population, and most studies depend on findings on other COVID-19 vaccination related adverse effects, such as myocarditis [ 3 ].…”

Clinicopathological characteristics of cutaneous complications following COVID‐19 vaccination: A case series

“…Most AGEP patients were males (four out of six) aged 27–74. Some cases happened 1 day after the vaccination, while others occurred after weeks 19 …”

Psoriasis and exposome: Unveiling the inner and the external contributors of psoriasis disease

“…In case of viral hepatitis and HIV infection, common pathophysiology links have been reported such as the overproduction of TNF-α in HCV and changes in the constitution of lymphocyte subpopulations [66]. Psoriasis exacerbations and new onsets as well as new subtype psoriasis occurrences (such as pustular form in a patient with plaque psoriasis [67]) have been documented in case of COVID-19 infections and post-COVID-19 vaccinations [68]. The etiology proposed was the hyperinflammation state in both cases.…”

“…Also, the treatment status of psoriasis patients can defend against the psoriasis-provoking actions of some exposome factors. For example, patients under biologic treatment showed less frequent episodes of psoriasis flare-up following COVID-19 vaccination [67].…”