Generalized pustulosis following Covid 19 vaccination in a patient in treatment with adalimumab

Abstract

Dear Editors,

Adalimumab is a tumor necrosis factor (TNF)-α inhibitor commonly used for multiple autoimmune diseases. Paradoxical cutaneous reactions under anti-TNF-α drugs have been described in the literature, predominantly linked to adalimumab.1 Although this adverse effect is widely known, mechanisms underlying its induction, as well as possible risk factors, are still unknown.

Here we report a case of papulopustular psoriasis induced by a second dose of Covid vaccine in a patient treated with adalimumab. The patient was a 52-year-old woman with history of HLA B27(–) spondylarthritis. No personal or family history of psoriasis was reported. During the previous 9 months she had been in treatment with adalimumab (40 mg) subcutaneously every 2 weeks. No other treatment was initiated during this period. However, she had received the second Covid vaccine the previous week (1st dose: Janssen, 2nd dose: Moderna). The patient presented with an abruptly developed generalized papulopustular reaction that had initiated as a palmoplantar pustulosis (Figure 1). A biopsy was performed and revealed generalized pustulosis (Figure 2). Adalimumab was discontinued and daily topical application of clobetasol propionate 0.05% plus urea 20% resulted in progressive improvement of the lesions. However, although clinical improvement was noted after the use of topical corticosteroids, the patient did not present with complete remission of the lesions.