Sex: M
Vaccine: COVID19
Symptoms: Body surface area, Physical examination, Psoriasis
Clinical narrative: patient who experienced exacerbation of psoriasis after receiving the BNT162b2 vaccine; This is a literature report.  A 65-years-old male patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection, Batch/Lot number: unknown, Expiration date: unknown), via an unspecified route of administration, administered at an unspecified anatomical location on an unspecified date, as DOSE 1, SINGLE for COVID-19 immunization. The patient's medical history included hepatocellular carcinoma from an unknown date and unknown if ongoing 1 week and psoriasis from an unknown date and unknown if ongoing since childhood. The patient's concomitant medications were not reported. The patient previously took nivolumab for hepatocellular carcinoma, apremilast for psoriasis, calcipotriene for psoriasis and clobetasol for psoriasis. On an unspecified date the patient experienced patient who experienced exacerbation of psoriasis after receiving the bnt162b2 vaccine. The patient received infusions of nivolumab, a PD-1 inhibitor, for hepatocellular carcinoma for 9 months, which were discontinued 3 months prior to this psoriatic flare due to an excellent treatment response. Although not ideally controlled in the setting of nivolumab therapy, his psoriasis was stable on apremilast and topical calcipotriene and clobetasol and became less active after cessation of immunotherapy. The patient was previously seen in clinic 1 day prior to his vaccine appointment to discuss better management options for his psoriasis. Physical exam revealed very thin plaques involving about 10 percent of the body surface area (BSA), which was the patient's baseline. The patient returned 3 weeks later with significantly worse pruritus and scattered plaques that had increased in BSA, erythema, and scale (Figure 1). He reported the symptoms began 1 week after getting the BNT162b2 vaccine and denied any other possible triggers, including changes in medications, discontinuation of his psoriasis treatment, or symptoms of and known exposure to SARS-CoV-2. A skin biopsy was not performed as the lesions clinically appeared similar to previous flares. Considering the drastic change in the severity of his psoriasis within a matter of weeks and no other known reportable causes, the acute worsening of his skin disease appeared to be provoked by the BNT162b2 vaccine. The patient received the second vaccine dose and followed up 3 weeks later. He did not experience further aggravation of his flare. Infections are a known trigger of psoriasis with various morphologies, including plaque psoriasis, guttate psoriasis, and pustular psoriasis, reported following numerous viral and bacterial infections.1 Furthermore, exacerbations have been observed after various immunizations, including the influenza, Bacillus Calmette-Guerin (BCG), tetanus-diphtheria, and pneumococcal polysaccharide vaccines, in settings when other provoking factors were excluded. The mechanisms underlying these responses may rely on induction of interleukin 6 (IL-6), which stimulates T helper 17 (Th17) cells to produce IL-22, the cytokine that plays a key role in keratinocyte proliferation characteristic of psoriasis.2 Additionally, accounts of exacerbations in the plaque, guttate, and pustular forms have been observed days to weeks following infection with SARS-CoV-2.3-6 Our patient had previously been treated with nivolumab, which is also known to trigger and exacerbate psoriasis; however, this medication was discontinued 3 months prior to this flare with some subsequent improvement in his psoriasis.7 Furthermore, influenza vaccination during active immunotherapy treatment for cancer appears to result in higher rates of vaccine-mediated immunologic side effects.8 Consequently, it is unknown if prior treatment with PD-1 inhibitor immunotherapy predisposed our patient to a vaccinemediated autoimmune disease flare. The patient underwent lab tests and procedures which included body surface area which showed increased, physical examination which showed revealed very thin plaques involving about 10 percent of Physical exam revealed very thin plaques involving about 10 percent of the body surface area (BSA), which was the patient's baseline, physical examination which showed the patient returned 3 weeks later with significan (The patient returned 3 weeks later with significantly worse pruritus and scattered plaques that had increased in BSA, erythema, and scale), physical examination which showed lesions clinically appeared similar to previous (lesions clinically appeared similar to previous flares) on an unspecified date. FIGURE 1 Erythematous scaly plaques throughout the chest, abdomen, back, and extremities. Therapeutic measures were taken as a result of patient who experienced exacerbation of psoriasis after receiving the bnt162b2 vaccine. The outcome of the event was unknown.; Sender's Comments: Based on the current available information and the plausible drug-event temporal association, a possible contributory role of the suspect product BNT162B2 to the development of event exacerbation of psoriasis  cannot be totally excluded.   The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.