COVID-19: A New Etiology for Guttate Psoriasis

Kathryn Harrison, MMS, PA-C

Abstract
Objective: To introduce a case report of a patient developing guttate psoriasis following a COVID-19 infection. The case report reviews the patient presentation, diagnosis, treatment plan, and reviews current literature. The overall goal of this case report is to inform medical providers that COVID-19 may cause guttate psoriasis. This is important because guttate psoriasis can be induced by streptococcus bacterial infections and less commonly viral infections. A comprehensive literature search using the key words “guttate psoriasis and COVID-19 infection,” “guttate psoriasis post viral infection,” and “guttate psoriasis and COVID-19 vaccination,” was conducted using databases including Google Scholar, PubMed, and ScienceDirect.

Introduction
Guttate psoriasis can be induced by a COVID-19 viral infection. Typically, guttate psoriasis presents due to an immune system reaction to a prior streptococcal infection in patients who have a chromosome six genetic mutation.1 Specifically, patients who are HLA-Cw*0602 positive have the highest risk of developing guttate psoriasis.2 This case is unique because an insufficient number of reports describe guttate psoriasis post COVID-19 infection.

Case Description
A 31-year-old white man presented with a chief complaint of a rash on his scalp, trunk, and extremities. The patient described the rash as small red spots, slightly scaly, and pruritic. The patient was not taking any prescription medications or over-the-counter supplements and had no known drug allergies. Important past history to note included mild generalized plaque psoriasis on extensor surfaces including his elbows, forearms, and knees. It resolved with topical clobetasol cream and had been clear for several months. Eighteen days prior to the onset of the rash, the patient tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A (polymerase chain reaction) PCR nasopharyngeal swab test confirmed a COVID-19 infection. Both rapid strep test and throat culture were taken with negative results. After making a full recovery from the COVID-19 infection, the patient scheduled an appointment for a dermatology consultation for his rash. Clinical examination revealed multiple erythematous tear-drop shaped papules present on the patient’s scalp, trunk, and extremities. Palms, soles, and genital areas were clear. The clinical diagnosis of guttate psoriasis was established and treatment was initiated with clobetasol 0.05% cream and calcipotriene 0.005% cream. Important to note there were no plaque psoriasis skin lesions on his extensor surfaces as he had previously, thus excluded the possibility of a generalized plaque psoriasis flare. The patient had significant improvement after two months of topical therapy.

Discussion
Gutta means “drop” in Latin, referring to the clinical presentation of small, red, scaly drop-shaped spots on the skin from scalp, face, trunk, and extremities.1 In most cases, the diagnosis of guttate psoriasis is made clinically. If clinical diagnosis is uncertain, a shave biopsy may be performed to confirm with a dermatopathologist. Histologic findings of guttate psoriasis include hyperplasia in the epidermis and small areas of parakeratosis with absence of the granular layer.2 In the dermis, capillary dilation and a lymphocytic and macrophage infiltrate are present.2 Several infectious organisms have been reported in the literature that cause guttate psoriasis, streptococcus being the most common. See Table 1 for a complete list of infectious organisms that have been identified. Treatment for guttate psoriasis includes targeted therapy for the underlying cause. Oral antibiotics are prescribed if the patient had a prior streptococcus infection and was not treated. Topical steroids, topical vitamin D analogs, narrow band ultraviolet B (UVB) phototherapy, and tonsillectomy are also potential treatment options.

A comprehensive literature search was performed using the key words “guttate psoriasis and COVID-19 infection,” “guttate psoriasis post viral infection,” and “guttate psoriasis and COVID-19 vaccination,” across multiple databases including Google Scholar, PubMed, and ScienceDirect. The literature review revealed two case reports of guttate psoriasis after a COVID-19 infection in 2020 and 2021. Gananandan et al reported the case of a 38-year-old man who presented with a COVID-19 infection and developed guttate psoriasis six days later. The patient was screened for streptococcus infection with an antistreptolysin O titer and results were negative at <200 IU/mL.3 This case report purports to be the first published report of guttate psoriasis secondary to COVID-19 infection.

Rouai et al published a case report of a 25-year-old male patient who presented with COVID-19 and had a full recovery in 10 days. Five days after recovery, he developed widespread guttate psoriasis on the trunk, limbs, and genitals.4 The diagnosis was confirmed with a skin biopsy. The researchers discuss COVID-19 viral infection and emotional stress from isolation during his illness as two possible causes for his guttate psoriasis.4

Before the COVID-19 pandemic, Sbidian et al published a 25-patient study that was completed between February 2011 and November 2018. Researchers tracked cases of psoriasis flares following respiratory tract infections and collected nasopharyngeal swabs for 16 viral pathogens and four bacteria.5 The results revealed that the most common viral cause of guttate psoriasis was rhinovirus, enterovirus with nine testing positive.5 The less common were parainfluenza 1 or 3, meta pneumovirus, coronavirus HKu1, coronavirus 0c43, and influenza B.5 These findings are relevant to this report because other strains of coronaviruses have been shown to cause guttate psoriasis.

Young et al reviewed the most commonly seen skin manifestations of COVID-19 infections. The manifestations included a morbilliform rash, urticaria, vesicular eruption, acral lesions known as “COVID Toes,” livedoid eruptions, and other cutaneous eruptions.6 Some of these skin eruptions have been observed prior to the typical COVID-19 infection symptoms and some are seen after symptoms develop.6 These findings are pertinent to the case report because guttate psoriasis is not listed as a known skin manifestation during a COVID-19 infection. Based on the literature, one can infer that guttate psoriasis is only seen after a COVID-19 infection and not before as a prodrome or concurrent symptom.

Patients who have any variant of psoriasis are recommended to receive the COVID-19 vaccine based on the National Psoriasis Foundation and the Psoriasis and Psoriatic Arthritis Alliance guidelines.8 The overall morbidity and mortality rates of a COVID-19 infection in the psoriasis and psoriatic arthritis patient population is similar to that of the general public.11 However, patients with psoriasis have higher rates of comorbidities, including obesity; diabetes; and chronic heart, lung, or renal disease.11 These comorbidities are associated with a more severe course of COVID-19 infection.
Sotiriou et al wrote a letter to the editor regarding 14 cases of the COVID-19 vaccination causing a psoriasis exacerbation in the Greek population. The three vaccines administered were Moderna, Pfizer, and AstraZeneca. Of the 14 cases, 13 had a plaque psoriasis flare and one had a guttate psoriasis flare.9 Nine of the patients had prior existing mild psoriasis and the other five had no prior history.9 There was no statistical difference between vaccine type and psoriasis flare.9 Patients’ psoriasis flares were treated with topical calcipotriol/betamethasone, systemic agents, or psoralen, and ultraviolet A radiation (PUVA) phototherapy.9 The researcher’s final recommendation is advising patients who are afflicted with psoriasis to be vaccinated against COVID-19 thereby lowering their risk of developing a psoriasis exacerbation, especially the guttate variant.9

Lehmann et al reported the case of a 79-year-old female patient presenting with a psoriasiform rash that began 10 days after receiving the first dose the COVID-19 vaccine Comirnaty made by BioNTech (Freiburgstrasse, Bern, Switzerland).10 The patient had no prior history of psoriasis. On exam, she presented with erythematous papules and scaly plaques on her arms, thighs, back, and scalp.10 A skin biopsy was performed, and the histopathology confirmed the diagnosis of guttate psoriasis. The patient was treated with topical clobetasol ointment once daily and minimal improvement was noted.10 She received the second dose of Comirnaty and experienced a flare. Secondary treatment was initiated with topical calcipotriol and betamethasone ointment along with UVB phototherapy.10 The researchers concluded this case “strongly suggests” a causal association between the COVID-19 vaccine and guttate psoriasis.10
Health care providers should be aware that guttate psoriasis can be triggered by the COVID-19 vaccine, however, research currently shows that this reaction occurs infrequently and should not deter patients from getting vaccinated.11

In conclusion, based upon the case report and literature review, the risk of developing new-onset guttate psoriasis after a COVID-19 infection is possible, however quite uncommon. Health care providers should screen patients for past history of a COVID-19 infection when seeing patients with a chief complaint of a rash, especially with a guttate psoriasis morphology. Early recognition of guttate psoriasis is essential to initiate treatment and improve patient quality of life including both the physical appearance and mental health component of living with a skin disease. Treatment provides symptom relief for pruritus and cosmetic improvement of erythematous scaly papules. Reassurance to patients that guttate psoriasis is not contagious is imperative so they can get back to normal activities of daily living. To date, this is the third case report and further studies are needed to assess the variable skin manifestations of COVID-19.

References:

1. Lehrer M. Guttate Psoriasis. U.S. National Library of Medicine Web site. https://medlineplus.gov/ency/article/000822.htm Published April 16, 2019. Accessed October 14, 2021.
2. Altman K. Guttate Psoriasis. eMedicine Web site. https://emedicine.medscape.com/article/1107850-overviewPublished October 16, 2020. Accessed October 14, 2021.
3. Gananandan K, Sacks B, Ewing I. Guttate psoriasis secondary to COVID-19. BMJ Case Reports. 2020; 13(8). Accessed October 27, 2021. https://casereports.bmj.com/content/13/8/e237367
4. Rouai M, Rabhi F, Mansouri N, Kahena J, Dhaoui R.New-onset guttate psoriasis secondary to COVID-19. Clinical Case Reports 2021; 9(7). July 28, 2021. Accessed October 24, 2021. https://onlinelibrary.wiley.com/doi/10.1002/ccr3.4542
5. 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(6):1304-1306. doi:10.1111/bjd.18203. Accessed October 24, 2021.
6. Young S, Fernandez A. Skin manifestations of COVID-19. Clevel Clin J Med. https://www.ccjm.org/content/early/2020/05/18/ccjm.87a.ccc031 Accessed October 24, 2021.
7. Stanway A. Guttate Psoriasis. DermNet NZWeb site. https://dermnetnz.org/topics/guttate-psoriasis October 2021. Accessed October 14, 2021.
8. Kandola A. What to know about COVID-19 vaccines and psoriasis. Medical News Today Web site. https://www.medicalnewstoday.com/articles/psoriasis-and-covid-vaccine September 21, 2021. Accessed October 14, 2021.
9. Sotiriou E, Tsentemeidou A, Bakirtzi K, Lallas A, Ioannides D, Vakirlis E. Psoriasis exacerbation after COVID-19 vaccination: a report of 14 cases from a single centre. J Eur Acad Dermatol. August 7, 2021. Accessed October 24, 2021. https://doi.org/10.1111/jdv.17582
10. Lehmann M, Schorno P, Hunger RE, Heidemeyer K, Feldmeyer L, Yawalkar N. New onset of mainly guttate psoriasis after COVID-19 vaccination: a case report. J Eur Acad Dermatol. July 26, 2021. https://onlinelibrary.wiley.com/doi/full/10.1111/jdv.17561 Accessed November 11, 2021.
11. COVID-19 Task Force Guidance Statements. National Psoriasis Foundation. https://www.psoriasis.org/covid-19-task-force-guidance-statements/ Updated January 25, 2021. Accessed November 17, 2021.

Kathryn Harrison, MMS, PA-C, is from A. T. Still University Doctor of Medical Science Program in Mesa, Arizona.

Disclosures: The author has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article.