Boosting the cutaneous chronicle of the COVID-19 vaccine: it's not over yet

Abstract

The initial UK rollout of the SARS-CoV-2 COVID-19 vaccine in 2020 sparked concerns regarding vaccine-related adverse reactions. Cutaneous pustular eruptions subsequent to COVID-19 vaccination have primarily manifested after the first to third doses, with the second dose being the norm [Karampinis E, Gravani A, Gidarokosta P et al. Pustular eruption following COVID-19 vaccination: a narrative case-based review. Vaccines (Basel) 2023; 11: 1298]. We report a distinctive case of new-onset generalized pustular psoriasis (GPP) following the sixth dose of a COVID-19 vaccine in a 77-year-old woman. Our patient presented with a widespread pustular eruption affecting 80% of her body, 3 days after receiving her COVID-19 VidPrevtyn Beta monovalent B.1.351 vaccine (Sanofi). This marked her sixth dose of a COVID-19 vaccine since 2021, with no history of allergy or reactions. Her vaccination history revealed exposure to five different types of vaccines from four different pharmaceutical companies. Notably, this was her first encounter with VidPrevtyn by Sanofi. A clinical diagnosis of GPP secondary to the COVID-19 booster was made, which was supported by histological findings on a punch biopsy. She was commenced on acitretin (10 mg daily) and intravenous piperacillin-tazobactam to cover for skin impetiginization. Initial skin improvement was slow, but antibiotic-induced pancytopenia and renal impairment precluded a switch to ciclosporin. Full-skin clearance was eventually achieved after a few months of acitretin 20 mg, but discontinuation resulted in a recurrence of symptoms. Consequently, the patient continues acitretin 10 mg daily, which is proving effective for control and is well tolerated. The patient was advised against future COVID-19 vaccination and to consider early antiviral treatment for COVID-19 infection if indicated. This case serves as a poignant reminder that despite a cumulative vaccination history, significant cutaneous adverse reactions following the COVID-19 vaccine persist. The Joint Committee on Vaccination and Immunisation advocates for 6-monthly COVID-19 booster vaccines in adults aged >= 75 years, with a seasonal booster recommended for those aged >= 65 years [UK Health Security Agency. COVID-19: the green book, chapter 14a. Available at: https://www.gov.uk/ government/publications/covid-19-the-green-bookchapter14a (last accessed 19 April 2024)]. As the landscape evolves with new variants and booster vaccines, there is an escalating potential for reactions, particularly after the first or second dose of the new booster vaccine. Furthermore, our case demonstrated a notable achievement in the effective management of vaccine-induced GPP with acitretin. It is imperative for clinicians to remain vigilant, recognizing that COVID-19 vaccination, while increasingly common, should not falsely reassure based on a negative history of numerous COVID vaccines in the past. Thoroughly assessing vaccination history is essential in clinical practice.