New-onset and flares of psoriasis after COVID-19 infection or vaccination successfully treated with biologics: a case series

Dear Editor,

As a result of the severe inflammatory response observed after SARS-CoV-2 infections and vaccination, there has been a concern for patients affected by chronic immune-mediated diseases, including dermatological conditions (1–3). Aside from the fact that COVID-19 can present with various cutaneous manifestations, two reactions were distinguished: flares of preexisting dermatoses and new onset of immune-mediated dermatological disorders.

Psoriasis, as a chronic immune-mediated disease, can be exacerbated or appear de novo following concomitant infections. Several reports (4,5) have been published regarding psoriasis flares after COVID-19 vaccination or infection. Currently, no standardized guidelines have been proposed to address the treatment of these cases of psoriasis specifically, but biologics have shown effectiveness in several case reports (6).

We present 28 bio-naïve patients who exhibited flares or new onsets of psoriasis after COVID-19 infection and/or vaccination, all treated with biologics and followed for at least 16 weeks.

All patients received biological treatment according to the Italian guidelines for managing psoriasis (7). The effectiveness of biological treatments was defined by assessing PASI (Psoriasis Area and Severity Index) at baseline and week 16.

We also analyzed our psoriasis database to identify patients on treatment with a biologic drug who experienced a severe psoriasis flare after COVID-19 infection/vaccination, defined as a PASI score ≥ 10 in patients with preexisting mild psoriasis. Only one patient was identified.

Nineteen patients were males (67.86%), and the mean age was 52.61 years, with a standard deviation (SD) of 16.23. Twenty-five patients (89.29%) experienced a severe flare of psoriasis, having previously received the first diagnosis of mild psoriasis a mean of 21.57 years (SD 16.93) before. Among these 25 patients, 16 (64%) experienced the flare after COVID-19 vaccination, while the other 9 (36%) experienced a psoriasis exacerbation after infection from SARS-CoV2.

Regarding the three patients who experienced a new onset of psoriasis, two of them came to our Dermatology Department with moderate plaque psoriasis, the first presenting after COVID-19 infection and the second after the third dose of the Pfizer/BioNTech vaccine. The third patient had severe palmoplantar pustular psoriasis, along with genital plaque psoriasis, which developed after the second shot of the Pfizer/BioNTech vaccine.

Before starting the biological therapy, the mean PASI score was 13.65 (SD 8.15). All included patients were previously unsuccessfully treated with conventional systemic drugs or had a contraindication to the treatment with those. According to patients’ and disease characteristics, they all started an interleukin (IL) inhibitor after testing negative for viral hepatitis, HIV and tuberculosis tests. Anti-IL-23 drugs were the most prescribed (20 patients), with risankizumab being the most chosen treatment of this class (12), followed by guselkumab and tildrakizumab (4 patients each). Six patients received an IL-17 inhibitor (three secukinumab, one ixekizumab, one brodalumab and one bimekizumab). Finally, two patients received ustekinumab, an anti-IL-12/23 drug.

After 16 weeks of treatment, the mean PASI of our population decreased to 0.77 (SD 1.24), with 25 patients (89.29%) achieving PASI75, 21 (75%) PASI90 and 16 (57.14%) reaching a complete skin clearance (PASI100). An absolute PASI of 2 or less was achieved by 27 patients (96.43%). Notably, the only patient with a PASI > 2 still achieved a PASI 90 response at week 16, starting from a baseline PASI of 20. At week 16, no adverse events were reported, and all patients are still on treatment to date. The demographic and clinical characteristics of our population are shown in Table 1.

Table 1. Demographic and clinical characteristics of our 28 patients.

Age	Gender	Type of psoriasis	Onset	Duration of psoriasis (years)	Trigger	Type of vaccine	Dose of vaccine	Biologic	PASI baseline	PASI Week 16
38	F	Guttate	Severe Exacerbation	18	COVID Infection	NA	NA	Risankizumab	22	0
28	M	Guttate	Severe Exacerbation	10	COVID Infection	NA	NA	Risankizumab	18	0
42	M	Plaque	De Novo	2	COVID Infection	NA	NA	Risankizumab	14.7	0
40	F	Plaque	Severe Exacerbation	19	COVID Vaccine	BNT162b2	III	Tildrakizumab	10	0
50	M	Plaque	Severe Exacerbation	4	COVID Vaccine	BNT162b2	II	Tildrakizumab	10	3
25	M	Plaque	Severe Exacerbation	2	COVID Vaccine	BNT162b2	II	Ixekizumab	30	0
82	F	Plaque	De Novo	1	COVID Vaccine	BNT162b2	III	Secukinumab	14	0.6
40	F	Plaque	Severe Exacerbation	28	COVID Vaccine	mRNA-1273	III	Tildrakizumab	10	1
53	M	Plaque	Severe Exacerbation	21	COVID Vaccine	BNT162b2	II	Risankizumab	30	0
50	M	Plaque	Severe Exacerbation	32	COVID Vaccine	BNT162b2	II	Guselkumab	9.5	0
29	M	Pustular	De Novo	1	COVID Vaccine	BNT162b2	II	Guselkumab	2	0
38	M	Plaque	Severe Exacerbation	17	COVID Vaccine	BNT162b2	II	Risankizumab	10	0
62	F	Plaque	Severe Exacerbation	32	COVID Infection	NA	NA	Risankizumab	6	2
56	M	Plaque	Severe Exacerbation	8	COVID Vaccine	BNT162b2	I	Secukinumab	12	0
50	M	Plaque	Severe Exacerbation	32	COVID Vaccine	mRNA-1273	II	Brodalumab	30	0
78	M	Plaque	Severe Exacerbation	54	COVID Vaccine	BNT162b2	III	Risankizumab	24	1
67	F	Plaque	Severe Exacerbation	52	COVID Vaccine	BNT162b2	III	Risankizumab	21.6	0
59	M	Plaque	Severe Exacerbation	39	COVID Infection	NA	NA	Risankizumab	18	3
57	M	Guttate	Severe Exacerbation	20	COVID Vaccine	BNT162b2	II	Guselkumab	6	0
53	M	Plaque	Severe Exacerbation	8	COVID Vaccine	BNT162b2	II	Bimekizumab	8	1
61	M	Plaque	Severe Exacerbation	26	COVID Vaccine	mRNA-1273	II	Risankizumab	12	5
47	M	Guttate	Severe Exacerbation	4	COVID Infection	NA	NA	Risankizumab	10.5	1.5
84	F	Plaque	Severe Exacerbation	62	COVID Infection	NA	NA	ustekinumab	6	0
61	M	Plaque	Severe Exacerbation	8	COVID Infection	NA	NA	Risankizumab	12	0.4
72	F	Plaque	Severe Exacerbation	22	COVID Vaccine	BNT162b2	II	Ustekinumab	2	0
43	M	Plaque	Severe Exacerbation	25	COVID Infection	NA	NA	Secukinumab	20	2
76	M	Plaque	Severe Exacerbation	42	COVID Vaccine	BNT162b2	III	Guselkumab	10	0
34	F	Plaque	Severe Exacerbation	15	COVID Infection	NA	NA	Tildrakizumab	4	1

Abbreviations: PASI: psoriasis area and severity index; NA: not applicable.

Regarding patients on treatment with biologics in our Department, only one woman experienced a severe flare of psoriasis. She was on treatment with ustekinumab, which she suspended before receiving the first two doses of the Pfizer/BioNTech vaccine. She came to our attention with a flare of generalized pustular psoriasis, and she was switched to risankizumab, obtaining a PASI90 response at week 16. She is still on treatment to date, maintaining complete skin clearance. In our experience, mild worsening of plaque psoriasis following COVID-19 infection and/or vaccination has been reported by 12.34% of our patients receiving biological therapy. None of our patients have interrupted the biological treatment during and after the apex of the COVID-19 pandemic.

Both new onset and exacerbations of psoriasis following COVID-19 infection and vaccination have been reported. A recent systematic review evaluated seven studies reporting new-onset psoriasis, 32 studies reporting psoriasis flares, and four studies reporting both conditions (8). According to this review, most flares developed after mRNA vaccines (most commonly Pfizer/BioNTech). Most patients were treated using topical agents, while a few patients with psoriasis flares were managed with systemic treatment, including biologics (8).

In our experience, all patients achieved favorable responses. The high effectiveness rates we observed in our patients, regardless of the prescribed drug, could be due to the precocious start of the biological treatment as in an undergoing clinical trial (9). It is worth mentioning that none of our patients under biological treatment experienced a flare of psoriasis, with only one exception. A female patient experienced a GPP flare after receiving the II dose of the Pfizer/BioNTech vaccine and skipping the planned administration of ustekinumab (10). In this case, immediate treatment with risankizumab led to almost complete skin clearance in 16 weeks. According to most authors (11), patients treated with biologics should not discontinue the drug when receiving the COVID-19 vaccine. Moreover, anti-IL-23 and anti-IL-17 for plaque psoriasis should not be interrupted during a mild COVID-19 infection (12–14).

In conclusion, we described a case series of 28 patients who experienced de novo onset or flares of psoriasis after COVID-19 infection or vaccination. All these patients were successfully managed with anti-IL-17 or anti-IL-23 drugs, showing higher rates of clinical responses after 16 weeks compared with clinical trials and real-life studies. Our data support the use of biologics in patients with short disease duration and underline the safety of these treatments during the COVID-19 pandemic.

Ethical approval

Institutional review board approval was exempted as the study protocol did not deviate from standard clinical practice. All patients received biologics as in good clinical practice, in accordance with European guidelines. All included patients had provided written consent for retrospective study of data collected during routine clinical practice (demographics, clinical scores). The study was performed in accordance with the Helsinki Declaration of 1964 and its later amendments. Data collection and handling complied with applicable laws, regulations, and guidance regarding patient protection, including patient privacy.

Disclosure statement

L. Gargiulo has received research grants from Almirall. M. Valenti has been a consultant and/or speaker for Sanofi, Leo Pharma, Eli Lilly and Boehringer Ingelhei. A. Costanzo has served as an advisory board member, consultant and has received fees and speaker’s honoraria or has participated in clinical trials for Abbvie, Almirall, Biogen, LEO Pharma, Lilly, Janssen, Novartis, Pfizer, Sanofi Genzyme, and UCB-Pharma. A. Narcisi has served on advisory boards, received honoraria for lectures and research grants from Almirall, Abbvie, Leo Pharma, Celgene, Eli Lilly, Janssen, Novartis, Sanofi-Genzyme, Amgen and Boehringer Ingelheim. The other authors have nothing to disclose.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.