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Review
. 2023 Jul 29;11(8):1298.
doi: 10.3390/vaccines11081298.

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

Emmanouil Karampinis  1 , Agoritsa Gravani  1 , Polyxeni Gidarokosta  1 , Dimitrios Petros Bogdanos  2 , Angeliki-Viktoria Roussaki-Schulze  1 , Efterpi Zafiriou  1
Affiliations
Review

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

Emmanouil Karampinis et al. Vaccines (Basel). .

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.

Keywords: COVID-19; acute generalized exanthematous pustulosis; neutrophilic pustular eruption; pustular eruption; pustular psoriasis; vaccination.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Images (a–d): the patient presented with painful skin patches accompanied with pinhead-sized sterile pustules on erythematous base and desquamation, as well as Nikolski positive sign with the lesions mainly located on the back, upper arms, abdomen area, thighs, soles and palms. Images (e–h): the patient presents with an improved skin clinical image, with the clinical lesions resolved by the tenth day after anakinra initiation.
Figure 2
Figure 2
Histopathology of psoriatic lesions presenting with large Munro abscess and loss of granular layer and acanthosis.
Figure 3
Figure 3
Presentation of sex distribution (using chi-square test) among AGEP, neutrophilic pustular eruption and pustular psoriasis cases occurred after COVID-19 vaccination (M: Male, F: Female) (p = 0.69).
Figure 4
Figure 4
Presentation of age bars with 95% confidence interval (using t-test) amongst AGEP, neutrophilic pustular eruption and pustular psoriasis cases occurred after COVID-19 vaccination (p = 0.78).
Figure 5
Figure 5
Figure 5 Presentation of first vs. second dose of vaccination (using chi-square test) associated with AGEP, neutrophilic pustular eruption and pustular psoriasis cases (p = 0.68).
Figure 6
Figure 6
Presentation of vaccine distribution percentages amongst AGEP, neutrophilic pustular eruption and pustular psoriasis category cases.
See this image and copyright information in PMC

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