A case of pityriasis rubra pilaris following AstraZeneca COVID-19 vaccine

Abstract

IntroductionThe COVID-19 vaccination rollout is well underway. While common cutaneous side effects primarily pertain to transient injection site reactions,1Wei T.S. Tam Y.C. Pang S.M. Cutaneous reactions to COVID-19 vaccines: a review.JAAD Int. 2022; 7: 178-186https://doi.org/10.1016/j.jdin.2022.01.011Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar rare cutaneous side effects continue to be reported. Here we describe a case of pityriasis rubra pilaris (PRP) following administration of the AstraZeneca COVID-19 vaccine.Case reportA 65-year-old Caucasian man presented to the emergency department with erythroderma associated with palmoplantar keratoderma 8 weeks following the first dose of the AstraZeneca ChAdOx1 nCoV-19 Vaxzevria (AZ) vaccine.The condition began with scattered erythematous plaques over his face 2 days following administration of the AZ vaccine. This condition spread to his chest over the next 3 weeks. Biopsies revealed mild spongiosis, parakeratosis, and a perivascular lymphocytic infiltrate with sparse necrotic keratinocytes. Direct immunofluorescence test result was negative. This presentation was managed as a nonspecific vaccine-related reaction, and the patient was commenced on prednisolone and topical corticosteroids. He had not commenced any new medications, and his long-standing medications, including perindopril, amlodipine, and atorvastatin, were ceased. He had no coryzal symptoms suggestive of an infective prodrome. There was no personal or family history of skin disorders.Despite treatment, the eruption spread in a cephalocaudal manner over the subsequent weeks, leading to his presentation at the emergency department 8 weeks following initial vaccine exposure. On examination, he had erythroderma characterized by erythematous-to-orange scaly plaques with islands of sparing, follicular keratotic red-brown papules over both thighs, and waxy red-orange palmoplantar keratoderma with fissuring of the soles (Fig 1). He had splinter hemorrhages and mild onycholysis of his fingernails. The eruption spared his scalp. There was no oral, ocular, or genital mucosal involvement and no lymphadenopathy.Initial biopsies performed on admission revealed nonspecific features, including focal mild spongiosis and a mild-to-moderate papillary dermal perivascular lymphoplasmacytic inflammatory infiltrate. Due to subsequent high clinical suspicion for PRP, repeat biopsies were performed. Histopathology revealed epidermal thickening with mild psoriasiform hyperplasia, broad rete ridges, and thick suprapapillary plates. There was a prominent granular layer and alternating orthokeratosis and parakeratosis in a horizontal and vertical direction (Fig 2). There were no spongiotic or lichenoid changes and few scattered eosinophils. No atypical lymphocytes or epidermotropism were present. A complete blood cell count, kidney and liver function tests, and lipid profile studies were unremarkable, as was serology for HIV and hepatitis B and C.Fig 2Pityriasis rubra pilaris (PRP) histopathology. Skin biopsy revealed mild psoriasiform hyperplasia and a “checkerboard” pattern typical of PRP, with alternating orthokeratosis and parakeratosis in both the horizontal and vertical directions (A and B, hematoxylin-eosin stain; original magnifications: A, ×10; B, ×40).View Large Image Figure ViewerDownload Hi-res image Download (PPT)The clinical features and histopathology were consistent with a diagnosis of PRP. Given the temporal relationship and lack of known preceding infection or new medication, the proposed trigger for this eruption was the AZ vaccine. Acitretin 25 mg daily was commenced with topical corticosteroids and wet dressings with partial relief of symptoms.DiscussionTo date, 5 known cases of post-COVID-19 vaccination PRP have been reported, following administration of AstraZeneca Vaxzevria,2Lladó I. Butrón B. Sampedro-Ruiz R. Fraga J. de Argila D. Pityriasis rubra pilaris after Vaxzevria COVID-19 vaccine.J Eur Acad Dermatol Venereol. 2021; 35: e833-e835https://doi.org/10.1111/jdv.17542Crossref PubMed Scopus (9) Google Scholar AstraZeneca Covishield,3Sahni M.K. Roy K. Asati D.P. Khurana U. An old entity, a new trigger: post COVID-19 vaccine pityriasis rubra pilaris.Int J Risk Saf Med. 2021; 32: 261-264https://doi.org/10.3233/JRS-210048Crossref PubMed Scopus (11) Google Scholar Pfizer-BioNTech BNT163b24Hunjan M.K. Roberts C. Karim S. Hague J. Pityriasis rubra pilaris-like eruption following administration of the BNT163b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 188-190https://doi.org/10.1111/ced.14878Crossref PubMed Scopus (11) Google Scholar and BNT162,5Sechi A. Pierobon E. Pezzolo E. et al.Abrupt onset of Sweet syndrome, pityriasis rubra pilaris, pityriasis lichenoides et varioliformis acuta and erythema multiforme: unravelling a possible common trigger, the COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 437-440https://doi.org/10.1111/ced.14970Crossref PubMed Scopus (18) Google Scholar and Moderna 2019-nCoV Vaccine messenger RNA-12735Sechi A. Pierobon E. Pezzolo E. et al.Abrupt onset of Sweet syndrome, pityriasis rubra pilaris, pityriasis lichenoides et varioliformis acuta and erythema multiforme: unravelling a possible common trigger, the COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 437-440https://doi.org/10.1111/ced.14970Crossref PubMed Scopus (18) Google Scholar vaccines (Table I). We present a sixth case of COVID-19 vaccination-induced PRP. Prior to these reports associated with COVID-19 vaccination, only 4 known cases of vaccine-related PRP had been reported, following the measles-mumps-rubella vaccine,6Bennani B.N. Rouhou H.C. Waton J. et al.Pityriasis rubra pilaris after vaccination. Article in French.Ann Dermatol Venereol. 2011; 138: 753-756https://doi.org/10.1016/j.annder.2011.01.049Crossref PubMed Scopus (5) Google Scholar Vaxigrip Tetra,7Bitbol-Duneton V. Mikita M. Lebas D. Bularca S. Wiart T. Modiano P. Pityriasis rubra pilaris triggered by Tetragrip vaccine.Ann Dermatol Venerol. 2006; 133: S280-S281Google Scholar diphtheria-tetanus-pertussis vaccine,8Mohamed M. Belhadjali H. Hammedi F. Ben Meriem C. Zili J. Pityriasis rubra pilaris occurring after vaccination with diphtheria-pertussis-tetanus and oral poliovirus vaccines.Indian J Dermatol Venereol Leprol. 2015; 81: 618-620https://doi.org/10.4103/0378-6323.168326Crossref PubMed Scopus (8) Google Scholar,9Musette P. Senet P. Verola O. Dubertret L. A case of pityriasis rubra pilaris induced by DTPolio vaccination.Ann Dermatol Venerol. 1997; 124: S226Google Scholar and oral poliovirus vaccine.8Mohamed M. Belhadjali H. Hammedi F. Ben Meriem C. Zili J. Pityriasis rubra pilaris occurring after vaccination with diphtheria-pertussis-tetanus and oral poliovirus vaccines.Indian J Dermatol Venereol Leprol. 2015; 81: 618-620https://doi.org/10.4103/0378-6323.168326Crossref PubMed Scopus (8) Google ScholarTable IReported cases of pityriasis rubra pilaris following COVID-19 vaccination.Case reportPatient demographicsVaccine typeVaccine doseOnset of PRP following vaccineWada et al, 202265 y, manChAdOx1 nCoV-19 Vaxzevria1st2 dLlado et al, 20212Lladó I. Butrón B. Sampedro-Ruiz R. Fraga J. de Argila D. Pityriasis rubra pilaris after Vaxzevria COVID-19 vaccine.J Eur Acad Dermatol Venereol. 2021; 35: e833-e835https://doi.org/10.1111/jdv.17542Crossref PubMed Scopus (9) Google Scholar63 y, womanChAdOx1 nCoV-19 Vaxzevria1st11 dSahni et al, 20213Sahni M.K. Roy K. Asati D.P. Khurana U. An old entity, a new trigger: post COVID-19 vaccine pityriasis rubra pilaris.Int J Risk Saf Med. 2021; 32: 261-264https://doi.org/10.3233/JRS-210048Crossref PubMed Scopus (11) Google Scholar72 y, manChAdOx1 nCoV-19 Covishield1st, nil recurrence with 2nd dose3 wkHunjan et al, 20224Hunjan M.K. Roberts C. Karim S. Hague J. Pityriasis rubra pilaris-like eruption following administration of the BNT163b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 188-190https://doi.org/10.1111/ced.14878Crossref PubMed Scopus (11) Google Scholar51 y, manBNT163b2 (Pfizer-BioNTech)1st, worsened following 2nd3 dSechi et al, 20225Sechi A. Pierobon E. Pezzolo E. et al.Abrupt onset of Sweet syndrome, pityriasis rubra pilaris, pityriasis lichenoides et varioliformis acuta and erythema multiforme: unravelling a possible common trigger, the COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 437-440https://doi.org/10.1111/ced.14970Crossref PubMed Scopus (18) Google Scholar82 y, womanPfizer-BioNTech BNT1621st7 dSechi et al, 20225Sechi A. Pierobon E. Pezzolo E. et al.Abrupt onset of Sweet syndrome, pityriasis rubra pilaris, pityriasis lichenoides et varioliformis acuta and erythema multiforme: unravelling a possible common trigger, the COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 437-440https://doi.org/10.1111/ced.14970Crossref PubMed Scopus (18) Google Scholar62 y, womanModerna 2019-nCoV Vaccine mRNA-12731st5 dd, days; mRNA, messenger RNA; PRP, pityriasis rubra pilaris; wk, weeks. Open table in a new tab The 6 patients reported to have PRP following COVID-19 vaccination were aged 51 to 82 years, reflecting the population that has so far received the majority of the vaccines. The time to onset of PRP ranges from 2 days to 3 weeks. Similar to the presentations described by Sahni et al,3Sahni M.K. Roy K. Asati D.P. Khurana U. An old entity, a new trigger: post COVID-19 vaccine pityriasis rubra pilaris.Int J Risk Saf Med. 2021; 32: 261-264https://doi.org/10.3233/JRS-210048Crossref PubMed Scopus (11) Google Scholar Hunjan et al,4Hunjan M.K. Roberts C. Karim S. Hague J. Pityriasis rubra pilaris-like eruption following administration of the BNT163b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 188-190https://doi.org/10.1111/ced.14878Crossref PubMed Scopus (11) Google Scholar and Sechi et al,5Sechi A. Pierobon E. Pezzolo E. et al.Abrupt onset of Sweet syndrome, pityriasis rubra pilaris, pityriasis lichenoides et varioliformis acuta and erythema multiforme: unravelling a possible common trigger, the COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 437-440https://doi.org/10.1111/ced.14970Crossref PubMed Scopus (18) Google Scholar our patient developed the typical, erythrodermic findings of classic adult-onset PRP. Llado et al2Lladó I. Butrón B. Sampedro-Ruiz R. Fraga J. de Argila D. Pityriasis rubra pilaris after Vaxzevria COVID-19 vaccine.J Eur Acad Dermatol Venereol. 2021; 35: e833-e835https://doi.org/10.1111/jdv.17542Crossref PubMed Scopus (9) Google Scholar described a case of circumscribed PRP, confined to the patient’s palmoplantar and extensor surfaces. Our patient experienced improvement in PRP symptoms over a 3-month period while receiving acitretin treatment. The cutaneous findings of the other cases also improved with acitretin,2Lladó I. Butrón B. Sampedro-Ruiz R. Fraga J. de Argila D. Pityriasis rubra pilaris after Vaxzevria COVID-19 vaccine.J Eur Acad Dermatol Venereol. 2021; 35: e833-e835https://doi.org/10.1111/jdv.17542Crossref PubMed Scopus (9) Google Scholar,4Hunjan M.K. Roberts C. Karim S. Hague J. Pityriasis rubra pilaris-like eruption following administration of the BNT163b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 188-190https://doi.org/10.1111/ced.14878Crossref PubMed Scopus (11) Google Scholar subcutaneous methotrexate,5Sechi A. Pierobon E. Pezzolo E. et al.Abrupt onset of Sweet syndrome, pityriasis rubra pilaris, pityriasis lichenoides et varioliformis acuta and erythema multiforme: unravelling a possible common trigger, the COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 437-440https://doi.org/10.1111/ced.14970Crossref PubMed Scopus (18) Google Scholar and oral and topical corticosteroids.3Sahni M.K. Roy K. Asati D.P. Khurana U. An old entity, a new trigger: post COVID-19 vaccine pityriasis rubra pilaris.Int J Risk Saf Med. 2021; 32: 261-264https://doi.org/10.3233/JRS-210048Crossref PubMed Scopus (11) Google Scholar,4Hunjan M.K. Roberts C. Karim S. Hague J. Pityriasis rubra pilaris-like eruption following administration of the BNT163b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 188-190https://doi.org/10.1111/ced.14878Crossref PubMed Scopus (11) Google Scholar The prognosis of COVID-19 vaccine-related PRP is unknown.In our case, the clinical progression of the eruption coincided with the histopathologic evolution. Initial biopsies demonstrated features suggestive of a drug eruption, despite the absence of an oral medication trigger. The onset of the rash 2 days after the COVID-19 vaccination and further progression following cessation of all oral medications supports a causal relationship. Ross et al10Ross N.A. Chung H.J. Li Q. Andrews J.P. Keller M.S. Uitto J. Epidemiologic, clinicopathologic, diagnostic, and management challenges of pityriasis rubra pilaris: a case series of 100 patients.JAMA Dermatol. 2016; 152: 670-675https://doi.org/10.1001/jamadermatol.2016.0091Crossref PubMed Scopus (47) Google Scholar stated that the variable cutaneous findings of early PRP and a slower rate of eruption progression can contribute to delayed diagnosis, often necessitating multiple biopsies for histopathologic diagnosis, as was required for our patient. The histopathology of other reported COVID-vaccine-induced PRP cases also showed the typical “checkerboard” pattern of alternating orthokeratosis and parakeratosis.2Lladó I. Butrón B. Sampedro-Ruiz R. Fraga J. de Argila D. Pityriasis rubra pilaris after Vaxzevria COVID-19 vaccine.J Eur Acad Dermatol Venereol. 2021; 35: e833-e835https://doi.org/10.1111/jdv.17542Crossref PubMed Scopus (9) Google Scholar, 3Sahni M.K. Roy K. Asati D.P. Khurana U. An old entity, a new trigger: post COVID-19 vaccine pityriasis rubra pilaris.Int J Risk Saf Med. 2021; 32: 261-264https://doi.org/10.3233/JRS-210048Crossref PubMed Scopus (11) Google Scholar, 4Hunjan M.K. Roberts C. Karim S. Hague J. Pityriasis rubra pilaris-like eruption following administration of the BNT163b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 188-190https://doi.org/10.1111/ced.14878Crossref PubMed Scopus (11) Google Scholar, 5Sechi A. Pierobon E. Pezzolo E. et al.Abrupt onset of Sweet syndrome, pityriasis rubra pilaris, pityriasis lichenoides et varioliformis acuta and erythema multiforme: unravelling a possible common trigger, the COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 437-440https://doi.org/10.1111/ced.14970Crossref PubMed Scopus (18) Google Scholar From these reports, there seems to be no clear histopathologic difference between vaccine-induced PRP as compared to classical, idiopathic PRP.It remains unknown, whether subsequent doses of COVID-19 vaccination will cause worsening or recurrence of PRP. Sahni et al3Sahni M.K. Roy K. Asati D.P. Khurana U. An old entity, a new trigger: post COVID-19 vaccine pityriasis rubra pilaris.Int J Risk Saf Med. 2021; 32: 261-264https://doi.org/10.3233/JRS-210048Crossref PubMed Scopus (11) Google Scholar reported no recurrence following the second dose of the ChAdOx1 nCoV-19 Covishield vaccine; however, Hunjan et al4Hunjan M.K. Roberts C. Karim S. Hague J. Pityriasis rubra pilaris-like eruption following administration of the BNT163b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine.Clin Exp Dermatol. 2022; 47: 188-190https://doi.org/10.1111/ced.14878Crossref PubMed Scopus (11) Google Scholar described worsening of PRP following the second dose of the Pfizer-BioNTech BNT163b2 vaccine. We recommend avoiding the further doses of the same vaccine, with consideration to receive an alternative.The COVID-19 vaccines currently in use worldwide have been demonstrated to be extremely safe; however, rare side effects continue to be reported. Our case adds to the existing reports of PRP as a rare complication of COVID-19 vaccination. Early presentations of this eruption may not be associated with typical histologic findings and therefore repeat skin biopsies may be required for histopathologic confirmation of the diagnosis. IntroductionThe COVID-19 vaccination rollout is well underway. While common cutaneous side effects primarily pertain to transient injection site reactions,1Wei T.S. Tam Y.C. Pang S.M. Cutaneous reactions to COVID-19 vaccines: a review.JAAD Int. 2022; 7: 178-186https://doi.org/10.1016/j.jdin.2022.01.011Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar rare cutaneous side effects continue to be reported. Here we describe a case of pityriasis rubra pilaris (PRP) following administration of the AstraZeneca COVID-19 vaccine.