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CORRESPONDENCE Table of Contents  
Ahead of print publication
A case of new-onset palmoplantar pustulosis following mRNA COVID-19 vaccination

1 Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
2 Department of Dermatology, National Taiwan University Hospital; Department of Dermatology, National Taiwan University College of Medicine, Taipei, Taiwan

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Date of Submission04-Jan-2023
Date of Decision02-Mar-2023
Date of Acceptance28-Mar-2023
Date of Web Publication25-May-2023

How to cite this URL:
Hsu YSO, Tsai TF. A case of new-onset palmoplantar pustulosis following mRNA COVID-19 vaccination. Dermatol Sin [Epub ahead of print] [cited 2023 May 28]. Available from: https://www.dermsinica.org/preprintarticle.asp?id=377566

Dear Editor,

Palmoplantar pustulosis is a chronic inflammatory disease with recurrent episodes of sterile pustules predominantly involving the palms and soles.[1],[2] Although it is sometimes regarded as a variant of psoriasis, many argue that it is a separate entity. There have been reports of both new onset and exacerbation of various types of psoriasis following mRNA COVID-19 vaccinations,[3],[4] but palmoplantar pustulosis psoriasis (PPP) is rarely reported.[5] Here, we present a case of new-onset palmoplantar pustulosis following the Pfizer–BioNTech COVID-19 vaccine who also experienced an exacerbation upon subsequent vaccine rechallenge.

Our patient is a 54-year-old woman who suffered from pruritic oozing skin lesions on her soles 2 weeks after receiving her second COVID-19 vaccine, the Pfizer–BioNTech vaccine. She was initially treated as eczema with limited improvement for 3 months. Upon presentation to our department, large erythematous irregularly-bordered plaques with thick yellow sheets of scale studded with vesicles and pustules on the soles and palms were noted [Figure 1]a, [Figure 1]b, [Figure 1]c. Potassium hydroxide examination excluded dermatophyte infection. A few ill-defined scaly patches were also present on the dorsum of the feet. Otherwise, there was no other extra-palmoplantar skin involvement, arthritis, or a family history of psoriasis. The lesions were refractory to clobetasol propionate ointment. Skin biopsy was performed, revealing psoriasiform hyperplasia, mild spongiosis, and several foci of pustules in the subcorneal and corneal layers [Figure 1]d. A perivascular infiltrate of lymphocytes and neutrophils was present in the dermis. Based on the clinical and histopathologic features, the diagnosis of palmoplantar pustulosis was made. After discussion, the patient was treated with self-paid ixekizumab (160 mg), followed by two doses of biweekly ixekizumab (80 mg) due to its fast-onset time and acceptable price. Improvement was noted after 2 months [Figure 2]a, [Figure 2]c, and [Figure 2]e. Therefore, the patient decided to receive the booster Pfizer–BioNTech COVID-19 vaccine. Exacerbation of PPP was observed 10 days after she received the booster [Figure 2]b, [Figure 2]d, and [Figure 2]f, which was documented by the photos taken 1 day before and 13 days after vaccination. The patient was ultimately treated with ixekizumab and cyclosporine and obtained satisfactory disease control.
Figure 1: Several irregularly-bordered plaques with thick yellow scales studded with vesicles and pustules were seen on the soles (a-c), Skin biopsy demonstrated findings consistent with palmoplantar pustulosis (d).

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Figure 2: The patient's soles 1 day before (a, c and e) and 13 days after (b, d and f) the booster Pfizer-BioNTech COVID-19 vaccine.

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PPP is a relatively rare disease compared to psoriasis vulgaris, but it is more common in Asians, especially among the Japanese. Triggers and comorbidities such as local infection, metal allergy, thyroid disease, and smoking are frequent in patients with PPP.[1],[2] Interestingly, our patient is a female smoker with untreated hypothyroidism and recurrent tonsillitis without prior skin diseases who developed PPP only after receiving COVID-19 vaccination. Perhaps, the existing risk factors were insufficient and that a “second hit,” i.e. vaccination, possibly led to PPP development. Furthermore, the exacerbation of PPP observed after “rechallenging” our patient with the booster vaccine purported the relationship. Based on the Naranjo Adverse Drug Reaction (ADR) Probability Scale, 4 points were assigned to the Pfizer–BioNTech COVID-19 vaccine, indicating possible ADR.[6]

In the current list of dermatoses possibly induced by COVID-19 vaccination, aggravation or new onset of psoriasis has been frequently reported.[3],[4] Among the patients of new-onset psoriasis, the majority presented with plaque psoriasis, followed by guttate psoriasis and generalized pustular psoriasis.[4] In contrast, there has only been one reported case of relapsed palmoplantar pustulosis after COVID-19 vaccination.[5] The induction of proinflammatory cytokines, including the interferon-gamma (IFN-γ) response,[7] following COVID-19 vaccinations are believed to contribute to the pathogenesis of various dermatoses. Since patients suffering from PPP are also observed to have elevated blood levels of pro-inflammatory cytokines including tumor necrosis factor-alpha, interleukin (IL)-17, IL-22, and IFN-γ,[8] the proinflammatory signals brought by COVID-19 vaccination may potentiate the onset of PPP in risk groups.

Here, we presented a case of new-onset palmoplantar pustulosis following COVID-19 vaccination with exacerbation following rechallenge. Although the currently reported cases are few in number, PPP might be added to the growing list of dermatoses possibly induced by COVID-19 vaccination. Further studies are warranted to elucidate the mechanism, in which vaccination may induce PPP.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Data availability statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Financial support and sponsorship


Conflicts of interest

  1. Prof. T. F. Tsai has conducted clinical trials or received honoraria for serving as a consultant for AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, GSK-Stiefel, Janssen-Cilag, Novartis, Pfizer, and Sun Phrama.
  2. Prof. T. F. Tsai, an editorial board member at Dermatologica Sinica, had no role in the peer review process of or decision to publish this article.
  3. Dr. Y.S.O. Hsu declared no conflicts of interest in writing this paper.

  References Top

Murakami M, Terui T. Palmoplantar pustulosis: Current understanding of disease definition and pathomechanism. J Dermatol Sci 2020;98:13-9.  Back to cited text no. 1
Huang CM, Tsai TF. Clinical characteristics, genetics, comorbidities and treatment of palmoplantar pustulosis: A retrospective analysis of 66 cases in a single center in Taiwan. J Dermatol 2020;47:1046-9.  Back to cited text no. 2
Chao JP, Tsai TF. Psoriasis flare following ChAdOx1-S/nCoV-19 vaccination in patients with psoriasis under biologic treatment. Dermatol Sin 2021;39:208-9.  Back to cited text no. 3
  [Full text]  
Wu PC, Huang IH, Wang CW, Tsai CC, Chung WH, Chen CB. New onset and exacerbations of psoriasis following COVID-19 vaccines: A systematic review. Am J Clin Dermatol 2022;23:775-99.  Back to cited text no. 4
Katsuie S, Nakamura K, Ogawa E, Arakura F, Okuyama R. Relapse of palmoplantar pustulosis following COVID-19 vaccination. Cureus 2022;14:e28604.  Back to cited text no. 5
Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239-45.  Back to cited text no. 6
Lee TH, Nam M, Seo JD, Kim H, Kim HR, Hur M, et al. Evaluation of cellular responses to ChAdOx1-nCoV-19 and BNT162b2 vaccinations. Ann Lab Med 2023;43:290-4.  Back to cited text no. 7
Murakami M, Hagforsen E, Morhenn V, Ishida-Yamamoto A, Iizuka H. Patients with palmoplantar pustulosis have increased IL-17 and IL-22 levels both in the lesion and serum. Exp Dermatol 2011;20:845-7.  Back to cited text no. 8

Correspondence Address:
Tsen-Fang Tsai,
Department of Dermatology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 10002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ds.DS-D-23-00004


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