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Guttate Psoriasis Following COVID-19 Infection
Psoriasis is an inflammatory skin condition affecting 1% to 5% of the world population. 1 Guttate psoriasis is a subgroup of psoriasis that most commonly presents as raindroplike, erythematous, silvery, scaly papules. There have been limited reports of guttate psoriasis caused by rhinovirus and COVID-19 infection, but a PubMed search of articles indexed for MEDLINE using the term COVID-19 guttate psoriasis yielded only 3 documented cases of a psoriatic flare secondary to SARS-CoV-2 infection. 1-4 Herein, we detail a case in which a patient with mild SARS-CoV-2 infection who did not have a personal or family history of psoriasis experienced a moderate psoriatic flare 3 weeks after diagnosis of COVID-19.
Case Report
A 55-year-old woman was diagnosed with COVID-19 after SARS-CoV-2 RNA was detected from a nasopharyngeal swab. She reported moderate fatigue but no other symptoms. At the time of infection, she was not taking medications and reported neither a personal nor family history of psoriasis.
Three weeks after the COVID-19 diagnosis, she reported erythematous scaly papules only on the trunk and backs of the legs. Two months after the COVID-19 diagnosis, she was evaluated in our practice and diagnosed with guttate psoriasis. The patient refused biopsy. Physical examination revealed that the affected body surface area had increased to 5%; erythematous, silvery, scaly papules were found on the trunk, anterior and posterior legs, and lateral thighs (Figure). At the time of evaluation, she did not report joint pain or nail changes.
The patient was treated with triamcinolone acetonide cream 0.1% twice daily for 2 to 4 weeks. The guttate psoriasis resolved.
Comment
A sudden psoriatic flare can be linked to dysregulation of the innate immune response. Guttate psoriasis and generalized plaque-type psoriasis are postulated to have similar pathogenetic mechanisms, but guttate psoriasis is the only type of psoriasis that originates from viral infection. Initially, viral RNA will stimulate the toll-like receptor 3 protein, leading to increased production of the pathogenic cytokine IL-36γ and pathogenic chemokine CXCL8 (also known as IL-8), both of which are biomarkers for psoriasis.1 Specifically, IL-36γ and CXCL8 are known to further stimulate the proinflammatory cascade during the innate immune response displayed in guttate psoriasis.5,6
Our patient had a mild case of COVID-19, and she first reported the erythematous and scaly papules 3 weeks after infection. Dysregulation of proinflammatory cytokines must have started in the initial stages—within 7 days—of the viral infection. Guttate psoriasis arises within 3 weeks of infection with other viral and bacterial triggers, most commonly with streptococcal infections.1
Rodríguez et al7 described a phenomenon in which both SARS-CoV-2 and Middle East respiratory syndrome, both caused by a coronavirus, can lead to a reduction of type I interferon, which in turn leads to failure of control of viral replication during initial stages of a viral infection. This triggers an increase in proinflammatory cytokines and chemokines, including IL‐36γ and CXCL8. This pathologic mechanism might apply to SARS-CoV-2, as demonstrated in our patient’s sudden psoriatic flare 3 weeks after the COVID-19 diagnosis. However, further investigation and quantification of the putatively involved cytokines is necessary for confirmation.
Conclusion
Psoriasis, a chronic inflammatory skin condition, has been linked predominantly to genetic and environmental factors. Guttate psoriasis as a secondary reaction after streptococcal tonsillar and respiratory infections has been reported.1
Our case is the fourth documented case of guttate psoriasis secondary to COVID-19 infection.2-4 However, it is the second documented case of a patient with a diagnosis of guttate psoriasis secondary to COVID-19 infection who had neither a personal nor family history of psoriasis.
Because SARS-CoV-2 is a novel virus, the long-term effects of COVID-19 remain unclear. We report this case and its findings to introduce a novel clinical manifestation of SARS-CoV-2 infection.
- Sbidian E, Madrange M, Viguier M, et al. Respiratory virus infection triggers acute psoriasis flares across different clinical subtypes and genetic backgrounds. Br J Dermatol. 2019;181:1304-1306. doi:10.1111/bjd.18203
- Gananandan K, Sacks B, Ewing I. Guttate psoriasis secondary to COVID-19. BMJ Case Rep. 2020;13:e237367. doi:10.1136/bcr-2020-237367
- Rouai M, Rabhi F, Mansouri N, et al. New-onset guttate psoriasis secondary to COVID-19. Clin Case Rep. 2021;9:e04542. doi:10.1002/ccr3.4542
- Agarwal A, Tripathy T, Kar BR. Guttate flare in a patient with chronic plaque psoriasis following COVID-19 infection: a case report. J Cosmet Dermatol. 2021;20:3064-3065. doi:10.1111/jocd.14396
- Madonna S, Girolomoni G, Dinarello CA, et al. The significance of IL-36 hyperactivation and IL-36R targeting in psoriasis. Int J Mol Sci. 2019;20:3318. doi:10.3390/ijms20133318
- Nedoszytko B, Sokołowska-Wojdyło M, Ruckemann-Dziurdzin´ska K, et al. Chemokines and cytokines network in the pathogenesis of the inflammatory skin diseases: atopic dermatitis, psoriasis and skin mastocytosis. Postepy Dermatol Alergol. 2014;31:84-91. doi:10.5114/pdia.2014.40920
- Rodríguez Y, Novelli L, Rojas M, et al. Autoinflammatory and autoimmune conditions at the crossroad of COVID-19. J Autoimmun. 2020;114:102506. doi:10.1016/j.jaut.2020.102506
Psoriasis is an inflammatory skin condition affecting 1% to 5% of the world population. 1 Guttate psoriasis is a subgroup of psoriasis that most commonly presents as raindroplike, erythematous, silvery, scaly papules. There have been limited reports of guttate psoriasis caused by rhinovirus and COVID-19 infection, but a PubMed search of articles indexed for MEDLINE using the term COVID-19 guttate psoriasis yielded only 3 documented cases of a psoriatic flare secondary to SARS-CoV-2 infection. 1-4 Herein, we detail a case in which a patient with mild SARS-CoV-2 infection who did not have a personal or family history of psoriasis experienced a moderate psoriatic flare 3 weeks after diagnosis of COVID-19.
Case Report
A 55-year-old woman was diagnosed with COVID-19 after SARS-CoV-2 RNA was detected from a nasopharyngeal swab. She reported moderate fatigue but no other symptoms. At the time of infection, she was not taking medications and reported neither a personal nor family history of psoriasis.
Three weeks after the COVID-19 diagnosis, she reported erythematous scaly papules only on the trunk and backs of the legs. Two months after the COVID-19 diagnosis, she was evaluated in our practice and diagnosed with guttate psoriasis. The patient refused biopsy. Physical examination revealed that the affected body surface area had increased to 5%; erythematous, silvery, scaly papules were found on the trunk, anterior and posterior legs, and lateral thighs (Figure). At the time of evaluation, she did not report joint pain or nail changes.
The patient was treated with triamcinolone acetonide cream 0.1% twice daily for 2 to 4 weeks. The guttate psoriasis resolved.
Comment
A sudden psoriatic flare can be linked to dysregulation of the innate immune response. Guttate psoriasis and generalized plaque-type psoriasis are postulated to have similar pathogenetic mechanisms, but guttate psoriasis is the only type of psoriasis that originates from viral infection. Initially, viral RNA will stimulate the toll-like receptor 3 protein, leading to increased production of the pathogenic cytokine IL-36γ and pathogenic chemokine CXCL8 (also known as IL-8), both of which are biomarkers for psoriasis.1 Specifically, IL-36γ and CXCL8 are known to further stimulate the proinflammatory cascade during the innate immune response displayed in guttate psoriasis.5,6
Our patient had a mild case of COVID-19, and she first reported the erythematous and scaly papules 3 weeks after infection. Dysregulation of proinflammatory cytokines must have started in the initial stages—within 7 days—of the viral infection. Guttate psoriasis arises within 3 weeks of infection with other viral and bacterial triggers, most commonly with streptococcal infections.1
Rodríguez et al7 described a phenomenon in which both SARS-CoV-2 and Middle East respiratory syndrome, both caused by a coronavirus, can lead to a reduction of type I interferon, which in turn leads to failure of control of viral replication during initial stages of a viral infection. This triggers an increase in proinflammatory cytokines and chemokines, including IL‐36γ and CXCL8. This pathologic mechanism might apply to SARS-CoV-2, as demonstrated in our patient’s sudden psoriatic flare 3 weeks after the COVID-19 diagnosis. However, further investigation and quantification of the putatively involved cytokines is necessary for confirmation.
Conclusion
Psoriasis, a chronic inflammatory skin condition, has been linked predominantly to genetic and environmental factors. Guttate psoriasis as a secondary reaction after streptococcal tonsillar and respiratory infections has been reported.1
Our case is the fourth documented case of guttate psoriasis secondary to COVID-19 infection.2-4 However, it is the second documented case of a patient with a diagnosis of guttate psoriasis secondary to COVID-19 infection who had neither a personal nor family history of psoriasis.
Because SARS-CoV-2 is a novel virus, the long-term effects of COVID-19 remain unclear. We report this case and its findings to introduce a novel clinical manifestation of SARS-CoV-2 infection.
Psoriasis is an inflammatory skin condition affecting 1% to 5% of the world population. 1 Guttate psoriasis is a subgroup of psoriasis that most commonly presents as raindroplike, erythematous, silvery, scaly papules. There have been limited reports of guttate psoriasis caused by rhinovirus and COVID-19 infection, but a PubMed search of articles indexed for MEDLINE using the term COVID-19 guttate psoriasis yielded only 3 documented cases of a psoriatic flare secondary to SARS-CoV-2 infection. 1-4 Herein, we detail a case in which a patient with mild SARS-CoV-2 infection who did not have a personal or family history of psoriasis experienced a moderate psoriatic flare 3 weeks after diagnosis of COVID-19.
Case Report
A 55-year-old woman was diagnosed with COVID-19 after SARS-CoV-2 RNA was detected from a nasopharyngeal swab. She reported moderate fatigue but no other symptoms. At the time of infection, she was not taking medications and reported neither a personal nor family history of psoriasis.
Three weeks after the COVID-19 diagnosis, she reported erythematous scaly papules only on the trunk and backs of the legs. Two months after the COVID-19 diagnosis, she was evaluated in our practice and diagnosed with guttate psoriasis. The patient refused biopsy. Physical examination revealed that the affected body surface area had increased to 5%; erythematous, silvery, scaly papules were found on the trunk, anterior and posterior legs, and lateral thighs (Figure). At the time of evaluation, she did not report joint pain or nail changes.
The patient was treated with triamcinolone acetonide cream 0.1% twice daily for 2 to 4 weeks. The guttate psoriasis resolved.
Comment
A sudden psoriatic flare can be linked to dysregulation of the innate immune response. Guttate psoriasis and generalized plaque-type psoriasis are postulated to have similar pathogenetic mechanisms, but guttate psoriasis is the only type of psoriasis that originates from viral infection. Initially, viral RNA will stimulate the toll-like receptor 3 protein, leading to increased production of the pathogenic cytokine IL-36γ and pathogenic chemokine CXCL8 (also known as IL-8), both of which are biomarkers for psoriasis.1 Specifically, IL-36γ and CXCL8 are known to further stimulate the proinflammatory cascade during the innate immune response displayed in guttate psoriasis.5,6
Our patient had a mild case of COVID-19, and she first reported the erythematous and scaly papules 3 weeks after infection. Dysregulation of proinflammatory cytokines must have started in the initial stages—within 7 days—of the viral infection. Guttate psoriasis arises within 3 weeks of infection with other viral and bacterial triggers, most commonly with streptococcal infections.1
Rodríguez et al7 described a phenomenon in which both SARS-CoV-2 and Middle East respiratory syndrome, both caused by a coronavirus, can lead to a reduction of type I interferon, which in turn leads to failure of control of viral replication during initial stages of a viral infection. This triggers an increase in proinflammatory cytokines and chemokines, including IL‐36γ and CXCL8. This pathologic mechanism might apply to SARS-CoV-2, as demonstrated in our patient’s sudden psoriatic flare 3 weeks after the COVID-19 diagnosis. However, further investigation and quantification of the putatively involved cytokines is necessary for confirmation.
Conclusion
Psoriasis, a chronic inflammatory skin condition, has been linked predominantly to genetic and environmental factors. Guttate psoriasis as a secondary reaction after streptococcal tonsillar and respiratory infections has been reported.1
Our case is the fourth documented case of guttate psoriasis secondary to COVID-19 infection.2-4 However, it is the second documented case of a patient with a diagnosis of guttate psoriasis secondary to COVID-19 infection who had neither a personal nor family history of psoriasis.
Because SARS-CoV-2 is a novel virus, the long-term effects of COVID-19 remain unclear. We report this case and its findings to introduce a novel clinical manifestation of SARS-CoV-2 infection.
- Sbidian E, Madrange M, Viguier M, et al. Respiratory virus infection triggers acute psoriasis flares across different clinical subtypes and genetic backgrounds. Br J Dermatol. 2019;181:1304-1306. doi:10.1111/bjd.18203
- Gananandan K, Sacks B, Ewing I. Guttate psoriasis secondary to COVID-19. BMJ Case Rep. 2020;13:e237367. doi:10.1136/bcr-2020-237367
- Rouai M, Rabhi F, Mansouri N, et al. New-onset guttate psoriasis secondary to COVID-19. Clin Case Rep. 2021;9:e04542. doi:10.1002/ccr3.4542
- Agarwal A, Tripathy T, Kar BR. Guttate flare in a patient with chronic plaque psoriasis following COVID-19 infection: a case report. J Cosmet Dermatol. 2021;20:3064-3065. doi:10.1111/jocd.14396
- Madonna S, Girolomoni G, Dinarello CA, et al. The significance of IL-36 hyperactivation and IL-36R targeting in psoriasis. Int J Mol Sci. 2019;20:3318. doi:10.3390/ijms20133318
- Nedoszytko B, Sokołowska-Wojdyło M, Ruckemann-Dziurdzin´ska K, et al. Chemokines and cytokines network in the pathogenesis of the inflammatory skin diseases: atopic dermatitis, psoriasis and skin mastocytosis. Postepy Dermatol Alergol. 2014;31:84-91. doi:10.5114/pdia.2014.40920
- Rodríguez Y, Novelli L, Rojas M, et al. Autoinflammatory and autoimmune conditions at the crossroad of COVID-19. J Autoimmun. 2020;114:102506. doi:10.1016/j.jaut.2020.102506
- Sbidian E, Madrange M, Viguier M, et al. Respiratory virus infection triggers acute psoriasis flares across different clinical subtypes and genetic backgrounds. Br J Dermatol. 2019;181:1304-1306. doi:10.1111/bjd.18203
- Gananandan K, Sacks B, Ewing I. Guttate psoriasis secondary to COVID-19. BMJ Case Rep. 2020;13:e237367. doi:10.1136/bcr-2020-237367
- Rouai M, Rabhi F, Mansouri N, et al. New-onset guttate psoriasis secondary to COVID-19. Clin Case Rep. 2021;9:e04542. doi:10.1002/ccr3.4542
- Agarwal A, Tripathy T, Kar BR. Guttate flare in a patient with chronic plaque psoriasis following COVID-19 infection: a case report. J Cosmet Dermatol. 2021;20:3064-3065. doi:10.1111/jocd.14396
- Madonna S, Girolomoni G, Dinarello CA, et al. The significance of IL-36 hyperactivation and IL-36R targeting in psoriasis. Int J Mol Sci. 2019;20:3318. doi:10.3390/ijms20133318
- Nedoszytko B, Sokołowska-Wojdyło M, Ruckemann-Dziurdzin´ska K, et al. Chemokines and cytokines network in the pathogenesis of the inflammatory skin diseases: atopic dermatitis, psoriasis and skin mastocytosis. Postepy Dermatol Alergol. 2014;31:84-91. doi:10.5114/pdia.2014.40920
- Rodríguez Y, Novelli L, Rojas M, et al. Autoinflammatory and autoimmune conditions at the crossroad of COVID-19. J Autoimmun. 2020;114:102506. doi:10.1016/j.jaut.2020.102506
Practice Points
- Guttate psoriasis is the only type of psoriasis that originates from viral infection.
- Dysregulation of proinflammatory cytokines during COVID-19 infection in our patient led to development of guttate psoriasis 3 weeks later.
