Pityriasis Rubra Pilaris Following Booster Dose of Mrna (pfizer– BioNTech ) COVID ‐19 Vaccine

Dermatologic TherapyEarly View e15791 LETTERFree Access Pityriasis rubra pilaris following booster dose of mRNA (Pfizer–BioNTech) COVID-19 vaccine Nika Hlaca, Nika Hlaca orcid.org/0000-0002-0517-5462 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this authorTina Zagar, Corresponding Author Tina Zagar tinazagar89@gmail.com orcid.org/0000-0002-0308-4057 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, Croatia Correspondence Tina Zagar, Department of dermatovenerology, Clinical Hospital Centre Rijeka and Faculty of Medicine, University of Rijeka, Croatia. Email: tinazagar89@gmail.comSearch for more papers by this authorMarija Kastelan, Marija Kastelan orcid.org/0000-0002-8318-8031 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this authorSandra Peternel, Sandra Peternel orcid.org/0000-0001-8590-0451 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this authorInes Brajac, Ines Brajac orcid.org/0000-0003-1491-7998 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this authorKatarina Dujmovic-Hasanbegovic, Katarina Dujmovic-Hasanbegovic Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this authorLarisa Prpic-Massari, Larisa Prpic-Massari orcid.org/0000-0003-3572-6197 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this author Nika Hlaca, Nika Hlaca orcid.org/0000-0002-0517-5462 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this authorTina Zagar, Corresponding Author Tina Zagar tinazagar89@gmail.com orcid.org/0000-0002-0308-4057 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, Croatia Correspondence Tina Zagar, Department of dermatovenerology, Clinical Hospital Centre Rijeka and Faculty of Medicine, University of Rijeka, Croatia. Email: tinazagar89@gmail.comSearch for more papers by this authorMarija Kastelan, Marija Kastelan orcid.org/0000-0002-8318-8031 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this authorSandra Peternel, Sandra Peternel orcid.org/0000-0001-8590-0451 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this authorInes Brajac, Ines Brajac orcid.org/0000-0003-1491-7998 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this authorKatarina Dujmovic-Hasanbegovic, Katarina Dujmovic-Hasanbegovic Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this authorLarisa Prpic-Massari, Larisa Prpic-Massari orcid.org/0000-0003-3572-6197 Department of Dermatovenerology, Clinical Hospital Centre Rijeka, Rijeka, Croatia Faculty of Medicine, University of Rijeka, Rijeka, CroatiaSearch for more papers by this author First published: 27 August 2022 https://doi.org/10.1111/dth.15791AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Dear Editor, Data on various cutaneous adverse events as a result of widespread SARS-CoV-2 vaccination is currently accumulating. However, data on cutaneous reactions following booster dose of COVID-19 vaccines are still limited.1, 2 Herein, we present a case of pityriasis rubra pilaris (PRP) following a booster dose of the BNT163b2 (Pfizer–BioNTech) mRNA COVID-19 vaccine. An 85-years-old woman presented to our department with pruritic, erythematous lesions on her scalp, spreading to the trunk and palms, appearing one week after the injection of the booster dose of the Pfizer-BioNTech COVID-19 vaccine. By contrast, the patient reported only mild local tenderness after administration of the first and second dose of the Pfizer-BioNTech COVID-19 vaccine. The patient didn't reveal other possible triggers such as recent infections, changes in her medications, or exposure to UV light preceding the skin eruption. Her medical history was positive for chronic pancreatitis, arrhythmia, and arterial hypertension, and these conditions were well-controlled over a long period. She had no personal or family history of skin diseases. On physical examination, she presented with scaly orange to red plaques on her trunk and waxy yellow palmar keratoderma (Figure 1A–C). Her legs, soles, and nails were not affected at the initial assessment. Our clinical diagnosis of PRP was confirmed by histopathological examination showing irregular epidermal hyperplasia with broad epidermal ridges, hyperkeratosis with alternating orthokeratosis and parakeratosis, follicular plugging and a sparse perivascular lymphocytic infiltrate in the superficial dermis (Figure 1D). The COVID-19 vaccination was the only detectable trigger. Therefore, we started treatment with acitretin 30 mg once daily, along with topical mometasone 0.1% ointment which resulted in complete regression of skin lesions 4 months later. FIGURE 1Open in figure viewerPowerPoint Clinical and histopathological presentation of PRP. Red to orange scaly plaques on the back with orange waxy palmar keratoderma (A–C). A skin biopsy (D) showing irregular epidermal hyperplasia with broad rete ridges, hyperkeratosis with alternating orthokeratosis and parakeratosis and a sparse superficial perivascular lymphocytic infiltrate (H&E, 100× magnification). Inset shows additional section with follicular plugging (H&E, 200× magnification) PRP is a rare inflammatory papulosquamous dermatosis, that has recently been linked to the mutations in the caspase recruitment domain-containing protein 14 (CARD14).3 Infections, drugs, malignancies, and rarely vaccines, are all possible PRP triggers.3, 4 Previously, cases of PRP have been observed following vaccination with diphtheria, poliovirus and influenza vaccines.4 SARS-CoV-2 vaccines have recently been recognized as a potential trigger for PRP.5-9 Several cases of PRP have already been reported following the first two doses of SARS-CoV-2 vaccines, however this is the first case to describe PRP after homologous booster dose of Pfizer–BioNTech mRNA COVID-19 vaccine.5-9 Booster doses are given 6 months after the patient's primary vaccine series has been completed. A recent study on cutaneous reactions after booster doses of mRNA COVID-19 vaccines found that urticaria was the most common reaction, followed by local injection site reactions, erythromelalgia, and vesicular reactions.1, 2 In our case, the onset of PRP was 7 days, which is consistent with the study on cutaneous adverse reactions following SARS-CoV-2 vaccine booster.2 Interestingly, and in line with our findings, cutaneous reactions to booster doses might happen even in the absence of reactions to the first and second shots.1, 2 The vaccine-related PRP development may be induced by upregulation of inflammatory immunological pathways, or cross-reactivity between viral or adjuvant molecules and self-antigens.1, 8 It appears that in our patient, repeated exposure to the same mRNA vaccine stimulated the immune system, causing a cytokine imbalance that resulted in the development of PRP. This is, to the best of our knowledge, the first case of PRP following a booster dose of the novel BNT163b2 mRNA COVID-19 vaccine. Currently, cutaneous reactions following the booster dose represent only a small portion of the cutaneous reactions caused by COVID-19 vaccines.1, 2 Nonetheless, as a result of booster vaccination having the potential to trigger immune-mediated skin diseases, it is reasonable to expect more reports on vaccine-induced cutaneous adverse reactions in the future. Finally, our case demonstrates the possibility of developing a cutaneous reaction after receiving a booster dose of mRNA COVID-19 vaccine, even in the absence of a reaction to the first and second doses of the same SARS-CoV-2 vaccine. AUTHOR CONTRIBUTIONS Nika Hlaca conceived the original idea and wrote the original manuscript. Tina Zagar, Sandra Peternel, Katarina Dujmovic-Hasanbegovic and Ines Brajac performed literature research and contributed to the analysis of the data. Marija Kastelan and Larisa Prpic-Massari performed supervision, writing-review and editing. CONFLICT OF INTEREST The authors declare that they have no competing interests. DATA AVAILABILITY STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request. INFORMED CONSENT Informed consent was obtained from the patient for publication of this report. Open Research DATA AVAILABILITY STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request. REFERENCES 1Prasad S, McMahon DE, Tyagi A, et al. Cutaneous reactions following booster dose administration of COVID-19 mRNA vaccine: A first look from the American Academy of Dermatology/International League of Dermatologic Societies registry. JAAD Int. 2022; 8: 49- 51. CrossrefPubMedGoogle Scholar 2Avallone G, Cavallo F, Astrua C, et al. Cutaneous adverse reactions following SARS-CoV-2 vaccine booster dose: a real-life multicentre experience. J Eur Acad Dermatol Venereol. 2022 Jun 30. [Epub ahead of print]. doi:10.1111/jdv.18386 Wiley Online LibraryWeb of Science®Google Scholar 3Wang D, Chong VC, Chong WS, Oon HH. A Review on Pityriasis Rubra Pilaris. Am J Clin Dermatol. 2018; 19(3): 377- 390. CrossrefPubMedWeb of Science®Google Scholar 4Mohamed 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(6): 618- 620. CrossrefPubMedGoogle Scholar 5Hunjan MK, 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(1): 188- 190. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 6Lladó I, Butrón B, Sampedro-Ruiz R, Fraga J, de Argila D. 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