Generalized pustular psoriasis is a possibly serious condition that can be triggered by various factors. Previous studies show a slight likelihood of disease exacerbation subsequent to COVID-19 vaccination. Here, we present the first (to the best of our knowledge) case of pustular psoriasis flare after each one of the two shots of the BBIBP-CorV (Sinopharm) vaccine despite adalimumab treatment.

© 2023 The Author(s). Published by S. Karger AG, Basel

BBIBP-CorV (Sinopharm) is an inactivated vaccine candidate with potent protection against SARS-CoV-2 [1]. Previous evidence shows there is minimal concern that patients with an immune-mediated inflammatory disease are at any greater risk of harm from COVID-19 vaccination compared to healthy controls [2], although there are studies reporting psoriasis flare-ups following Oxford-AstraZeneca COVID-19 [3], CoronaVac COVID-19 vaccination [4], and Pfizer-BioNTech BNT16B2b2 COVID-19 mRNA vaccine [5]. Here, we describe a pustular psoriasis patient with adalimumab treatment who developed an erythrodermic and pustular flare after both the first and second doses of BBIBP-CorV vaccine. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see www.karger.com/doi/10.1159/000530074).

A 53-year-old man presented twice to the emergency department with psoriasis flare-up after both the first and second shots of the BBIBP-CorV vaccine. The patient had been suffering from pustular psoriasis for 20 years and did not mention any other previous medical history. He had daily use of folic acid 1 mg and Calcium-vitamin D tablets. He was under treatment with Cinnora® (adalimumab) 40 mg once every 2 weeks and mentioned daily use of Neotigason 25 mg, which had been discontinued 2 months prior to the first Sinopharm shot. The patient received his first dose of BBIBP-CorV vaccine on November 19th and experienced bilateral erythema and pustular lesions on the axilla in the following 4 days. The lesions completely resolved with the use of topical clobetasol at first, and then triamcinolone acetonide and zinc sulfate solution. Three days after receiving the second dose of BBIBP-CorV vaccine on December 6th, he noticed erythema and pustules on the inguinal area and lower abdomen, which rapidly extended to other body parts accompanied by fever (Fig. 1Fig. 2.–3). The patient was admitted and the physical examination revealed 39°C fever with generalized erythema and pustules. He had no respiratory symptoms associated with COVID-19 infection. Initial laboratory findings demonstrated leukocytosis (WBC: 33,600/µL) and high titers of CRP (CRP = 43). The COVID-19 PCR test was negative.

a–c Diffuse erythematous scaly plaques with coalescing pustules and intact skin areas on the trunk.

Diffuse scaly areas on right arm.

Diffuse erythematous scaly plaques intact skin areas on the lower limbs.

He was diagnosed with generalized pustular psoriasis exacerbation associated with Sinopharm administration and was managed with Neotigason 25 mg/D and a short course of systemic steroids. It is of note that our patient had experienced several pustular psoriasis flares following colds and other infections prior to these two episodes. The patterns of the episodes associated with COVID-19 vaccination were completely similar to previous flares. According to analogous presentation of the flares and previous diagnosis of pustular psoriasis confirmed by biopsy, the reported reactions were considered pustular psoriasis and were differentiated from acute generalized exanthematous pustulosis.

Like other immune-mediated disorders, psoriasis patients are more prone to severe infections due to both immunosuppressive treatments and the inflammatory nature of the disease per se. The evidence indicates a higher risk of infections with adalimumab and infliximab compared with non-methotrexate and non-biological treatments [6]. Hence, implementing a suitable vaccination protocol in daily clinical practice for patients with autoimmune inflammatory diseases seems more important than the general population [7]. Given the current evidence, there is the slightest concern that patients with immune-mediated inflammatory diseases show more side effects from COVID-19 vaccination than healthy individuals. For the most part, the benefits of avoiding severe COVID-19 infection through vaccination are more than the theoretical risks of these vaccines [2].

On the other hand, some reports show psoriasis flare-up or new-onset psoriasis development after vaccination. Munguia et al. [8] reported four cases of psoriasis exacerbation following influenza vaccination with H1N1, H3N2, and B influenza strains. A generalized pustular psoriasis flare-up associated with CoronaVac administration was reported by Onsun et al. [4]. Elamin et al. [3] presented a new case of generalized pustular psoriasis after Oxford-AstraZeneca Vaccine. Psoriasis flare-up following the first and second dose of Pfizer vaccine was reported by Perna and Krajewski, respectively [5, 9]. Two patients with palmoplantar psoriasis after Pfizer vaccine administration were also reported by Piccolo et al. [10]. Other pustular skin conditions have been reported following COVID vaccines [11]; it is of upmost importance to investigate the relationship between immunological responses driven by COVID vaccination and their common pathways to the development of cutaneous pustulosis.

Studies on psoriasis exacerbation after BCG and influenza vaccines suggest that IL-6 is produced in the immunization process and later promotes the development of Th1 and Th17 cells [12, 13]. These cells trigger the release of downstream cytokines that cause the epidermal changes in psoriasis [14, 15].

It is noticeable that vaccination may not provide enough protection against COVID-19 in psoriatic people with systemic treatments, and booster shots are required to achieve the desired immunity. Alternatively, these treatments, particularly anti-TNF-α biologics, minimize the risk of exacerbations following vaccine administration. Patients using topical or the ones with no treatments are more susceptible to start an inflammatory process on their own [12]. There are no previous reports on psoriasis flare-up after COVID-19 vaccination in patients under adalimumab treatment. This is the first study implying that there is a possibility of psoriasis exacerbation after vaccination in patients who had several previous flare-ups following infections, despite using anti-TNF-α treatments. It is essential to be aware of the probable side effects of COVID-19 vaccination and determine what other triggers may predispose these patients to develop new-onset psoriasis or flare-up following vaccination.

This research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. Our patient has given a written informed consent to publish his case and images. This study was reviewed and approved by the Tehran University of Medical Sciences Research Ethics Committee (Code: IR.TUMS.MEDICINE.REC.1401.177).

The authors have no conflicts of interest to declare.

No funding was received for this study.

Kamran Balighi conceived and developed the presented idea. Hatam Rokhafrouz proceeded the data. Dorsa Dayani wrote the manuscript with input from all authors. Kamran Balighi was in charge of overall direction and planning.

All data generated during this study are included in this article and its supplementary material files. Further inquiries can be directed to the corresponding author.

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