New Onset and Exacerbations of Psoriasis Following COVID-19 Vaccines

A Systematic Review

Po-Chien Wu; I-Hsin Huang; Chuang-Wei Wang; Cheng-Chang Tsai; Wen-Hung Chung; Chun-Bing Chen

Disclosures

Am J Clin Dermatol. 2022;23(6):775-799. 

In This Article

Abstract and Introduction

Abstract

Background: Vaccination has been promoted to control viral transmission in response to the coronavirus disease 2019 (COVID-19) pandemic. Cases of new-onset or exacerbation of psoriasis, an immune-mediated inflammatory disease, were reported following COVID-19 vaccination. However, a comprehensive review examining the association between COVID-19 vaccination and the occurrence or exacerbation of psoriasis has yet to be performed.

Objective: The aim of this systematic review is to investigate the demographics, clinical variables, and outcomes associated with psoriasis following COVID-19 vaccination.

Methods: A systematic literature search was conducted using the PubMed, Embase, Web of Science, and Cochrane databases from database inception to April 25, 2022. The review included studies with relevant terms, including 'psoriasis,' 'psoriasis vulgaris,' 'guttate psoriasis,' 'pustular psoriasis,' 'palmoplantar pustulosis,' 'psoriatic erythroderma,' 'psoriatic arthritis,' 'COVID-19,' and 'vaccine.' We included all studies reporting at least one patient who developed new-onset psoriasis or experienced a psoriasis flare following at least one dose of any COVID-19 vaccine. A flare was defined as the worsening of disease conditions after vaccination according to the study by Gregoire et al. The appraisal tool described by Murad et al. was used to assess the quality of case reports and series, whereas the National Institute of Health quality assessment tool was used to assess observational studies.

Results: The initial search yielded 367 results, including 7 studies reporting new-onset psoriasis, 32 studies reporting psoriasis flares, and 4 studies reporting both. The most commonly observed psoriasis subtype was plaque-type psoriasis. mRNA vaccines, including those produced by Moderna and BioNTech/Pfizer, were frequently associated with subsequent psoriasis episodes. First, second, and third vaccine doses were associated with psoriasis incidents, with the second dose most frequently associated with psoriasis flares. Delayed onset was observed, ranging from 2 to 21 days in the new-onset group and from 1 to 90 days in the flare group. Most patients experienced favorable outcomes, with improvement or resolution occurring within 3 days to 4 months.

Conclusions: Both new-onset psoriasis and psoriasis flares were reported as cutaneous adverse events following COVID-19 vaccination. Psoriatic patients may require regular follow-up before and after COVID-19 vaccination.

Trial Registration: Review registration number PROSPERO database: CRD42022304157.

Introduction

Globally, the novel coronavirus disease 2019 (COVID-19) pandemic has drastically impacted general health and the economy. Vaccines have been developed to protect against infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), representing one of the most reliable methods for controlling viral transmission.[1] Commonly used vaccines developed for COVID-19 include mRNA vaccines, such as Comirnaty® (BioNTech/Pfizer; BNT162b2) and Spikevax® (Moderna; mRNA-1273), which encode the full-length SARS-CoV-2 spike protein; chimpanzee adenovirus vector vaccine, such as Covishield® (AstraZeneca; AZD1222/ChAdOx1); and inactivated viral protein vaccines, such as CoronaVac (Sinovac). COVID-19 vaccines have achieved wide coverage, with 60.8% of the global population having received at least one vaccine dose as of January 2022.[1,2] Increasing reports have described cutaneous adverse events (CAEs) related to COVID-19 vaccination, which have been considered to be vaccine-related new-onset cases or flares of pre-existing dermatoses.[1,3–5] Various CAEs have been documented following vaccination, including injection-site reactions, morbilliform rash, urticaria, pityriasis rosea, psoriasis, and bullous pemphigoid.[6–14]

Psoriasis is a commonly occurring inflammatory disease that affects 0.5−11.4% of the adult population worldwide and involves a complex pathogenic mechanism linked to several immune cells and cytokines, including tumor necrosis factors, interleukin (IL)-17, IL-22, and IL-23.[15–18] Various psoriasis subtypes have been defined, including plaque, guttate, pustular, and nail psoriasis and psoriatic arthritis (PsA).[19] The safety and efficacy of COVID-19 vaccines have been demonstrated among psoriasis patients treated with systemic therapies,[20–23] and consensus guidelines have been established regarding the vaccination timing of individuals treated with systemic immunomodulatory medications to optimize the vaccine response.[24,25] However, increasing reports describe the development of new-onset psoriasis or psoriasis exacerbations with an increase in the total population of vaccinated individuals.[26] Patients who experience psoriatic events following vaccination, regardless of any prior history of diagnosis or treatment, can present with diverse clinical manifestations.[27–29] To our knowledge, no comprehensive review has examined the issues surrounding COVID-19 vaccination-related psoriasis. We conducted this systematic review to provide an overview of the demographic and clinical factors and outcomes associated with psoriasis episodes following COVID-19 vaccination.

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