Age: 50.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Oral discomfort, Pain, Pain in extremity, Pityriasis rubra pilaris, Pruritus
Clinical narrative: Patient developed Pityriasis rubra pilaris (PRP) type 1 - three days after first vaccination.  Condition worsened after 2nd shot.  7.27.21 - Allergy Immunology appointment:  ALLERGY/IMMUNOLOGY NEW PATIENT VISIT  Assessment/Plan: Patient is a 51 y.o. male who presents today for the following concerns: Reaction to COVID vaccine: he has new diagnosis of guttate psoriasis that started several days after the first dose of the Pfizer SARS-CoV-2 vaccine, possibly worsened after getting the second injection. This vaccine mimics a viral infection and has caused flaring of symptoms in patients with underlying autoimmune disease (like rashes and joint pains in patients with lupus or RA). These are typically mild and respond to steroids. The long lived symptoms are concerning for new onset disease. Certainly the inflammatory response to the vaccine could have "tipped" the disease process to become active. However, at this point, the disease is an autoimmune condition and is not "caused" by the vaccine. This is not an allergy. There is not test to show a correlation between the vaccine and this condition. It likely will flare if he gets another vaccine, would hold on further boosters for now until disease is under control. Recommend continued management per dermatology. Chief Complaint: reaction to COVID vaccine   History of Present Illness:  Patient is a 51 y.o. male with PMH significant for hypothyroidism, allergic rhinitis who presents today with concerns for reaction to COVID vaccine.  He got the Pfizer SARS-CoV-2 vaccine on 3/31/21. He felt it through his neck that day. He was a little tired, no fever.  A few days later, he started getting spots. His lips started burning when he was out roller skating. He got red spots on his chest, arms, legs, back. He had flaring on hands, feet. They hurt. It was very itchy. His skin was dry, not sweating. He had a hard time sleeping due to feet pain, tips of fingers hurt.  He was told to take Benadryl, ibuprofen.  He got the second one and he thinks symptoms slowly increased more after that. He saw a dermatologist. He was put on some steroid creams. He was put on light therapy. He was told he had guttate psoriasis. He did not have psoriasis prior to this vaccine.   10.29.21 - Dermatology visit: Plan:  Results c/w PRP vs eczematous process vs treated/guttate psoriasis. Given clinical appearance and history of eruption, we favor diagnosis of PRP at this time and agree with your dermatologist. For now, we recommend continuing plan as detailed at last visit: continue cyclosporine as prescribed by your dermatologist. Continue topical steroids as needed. Continue follow up with your dermatologist for treatment. There is room to increase his dose of cyclosporine if he has not noticed improvement in his current dose, and this should be discussed with his dermatologist if his rash is not improving. If patient would alternatively like to transfer care to dermatology we are happy to see him for follow up in 2-3 months. If he is interested in returning for follow up, please help him schedule follow up appointment. - Clinical staff to relay results and plan.    Electronically signed by PA-C at 12/01/2021 7:58 AM    ASSESSMENT AND PLAN: Rash of the face, trunk, and extremities - biopsy c/w PRP. We will obtain outside biopsy results for internal review. ROI form signed by patient and will be faxed to Dermatologist.  - Continue cyclosporine 250 mg daily as prescribed by dermatologist. - For future consideration: increasing dose of cyclosporine, acitretin, MTX, isotretinoin, or biologic. - We recommended a mild soap and to avoid anti-bacterial soaps which may be too irritating.  - The patient should also use fragrance-free, color-free laundry detergents and avoid dryer sheets which can be irritating.  - The patient?s skin should be well-moisturized, using a recommended moisturizer multiple times a day as needed.  - Continue triamcinolone 0.1% ointment (trunk, arms, and legs) to be applied twice daily to affected areas for two weeks and then tapered to weekends only.  - Prescribed triamcinolone 0.025% ointment (face and body folds) to be applied twice daily to affected areas for two weeks and then tapered to weekends only.  - Continue clobetasol 0.05% ointment (palms and soles) to be applied twice daily to affected areas for two weeks and then tapered to weekends only.  - Side effects of topical steroids were reviewed with the patient including skin atrophy, striae, telangectasias and tachyphylaxis.