COVID-19 infection leading to acute pustular dermatoses.

Viral infections, including SARS-CoV-2, the virus that causes COVID-19 infection, have been implicated in the development of pustular dermatoses, including generalized pustular psoriasis (GPP) and acute generalized exanthematous pustulosis (AGEP). We performed a literature review of existing cases of GPP and AGEP associated with COVID-19 infection and/or treatment reported over a period of 12 months. We summarize the clinical characteristics of these cases and report an additional six new cases of GPP and AGEP. Seven patients with COVID-19 infection were diagnosed with new-onset or exacerbated GPP, and 33 patients were diagnosed with AGEP. In 55% of the cases, no concomitant potential culprit drug trigger was identified. We present this review of cases of COVID-associated acute pustular dermatoses to further contribute to the spectrum of cutaneous eruption associated with SARS-CoV-2 infection.

A review of disease burden and clinical management for generalized pustular psoriasis in China.

INTRODUCTION: Generalized pustular psoriasis (GPP) is a rare, severe, immune-mediated and potentially life-threatening skin disease. The rarity, differential diagnoses, relapsing nature, skin and systemic symptoms, complications and limited therapeutic approaches for this disease pose a clinical and psychological burden on patients and their families. AREAS COVERED: Epidemiologic data of GPP in Chinese patients, including the disease prevalence and age of disease onset, as well as epidemiologic data in global populations were reviewed. Multiple proinflammatory cytokines are involved in the disease development and clinical presentation of GPP and the interleukin (IL)-36-mediated signaling pathway play a central role. Furthermore, loss-of-function mutations in IL-36 RN (encoding the IL-36 receptor antagonist) are associated with GPP, suggesting a potential drug target for developing a disease-specific therapeutic approach. Biologic agents, including IL-36 R targeted agents, are promising treatment options, especially as existing conventional therapies are inadequate. Chinese guidelines for the diagnosis and treatment of psoriasis recommend systemic and topical treatment options for GPP and disease complications, as well as for GPP during pregnancy and juvenile GPP. EXPERT OPINION: This review summarizes the epidemiology, pathogenesis, clinical characteristics, disease burden and management of patients with GPP in China, and also describes future treatment targets and related clinical trials.

ACUTE HEPATITIS AND RASH LINKED THROUGH EPSTEIN-BARR VIRUS

Epstein-Barr virus (EBV) hepatitis is well established, and most cases involves asymptomatic liver enzyme abnormalities. Albeit rare, viruses such as EBV have been reported to induce generalized pustular psoriasis (GPP);and exanthems such as GPP have been associated with acute hepatitis. This case describes a unique case of cholestatic hepatitis due to EBV, followed by a diffuse pustular rash suggestive of GPP. After complete resolution of the cholestatic hepatitis, the patient returned over a year later with concurrent hepatitis and diffuse pustular rash. Case: An obese 26 year-old African-American female presented to the hospital on three separate occasions over a 15 month span with slightly varying symptoms. At the index hospitalization she presented with fatigue and jaundice. Liver chemistries revlead a mixed pattern liver injury, see Table 1. Extensive serological evaluation was unremarkable, though antinuclear antibody and anti-smooth muscle antibody were mildly and non-specifically elevated, but IgG was normal. A liver biopsy was performed revealing portal and lobular inflammation with predominantly lymphocytic moderate micro-vesicular steatosis (Figure 1). EBV PCR returned positive at 20,737 IU/mL yielding a diagnoses of EBV-induced hepatitis. She returned to the hospital one week later due to a diffuse pruritic and painful rash. She had scleral icterus and diffuse erythematous plaques with tiny pustules dispersed over the body sparing the palms, soles, and mucosal surfaces. Laboratory values were overall improved as noted in Table 1. Punch biopsy of the right arm was suggestive of EBV induced GPP. She rapidly stabilized and was discharged the following day with triamcinolone 0.1% ointment. The patient had an uneventful convalescence and liver chemistries returned to normal. Approximately 15 months after her initial hospitalization, she presented with both recurrent hepatitis and a pustular, pruritic, erythematous rash with perioral and periorbital swelling. She denied taking any new medications or supplements. Labs revealed recurrent, though now primarily cholestatic liver injury, see Table 1. Results of a repeat thorough serological evaluation were negative, including for EBV-PCR and COVID-19. Abdominal ultrasound revealed a 16 cm hepatic length. Pustules, spongiosis, and edema were found on repeat skin biopsy, suggestive of GPP. She recovered quickly with systemic steroids. Awareness of GPP induced hepatitis can guide a judicious assessment of abnormal liver chemistries. Furthermore, unnecessary healthcare utilization can be avoided by providing appropriate and timely pharmacotherapy (i.e., corticosteroid taper) for on demand flares. (Figure Presented) (Table Presented) (Figure Presented)

A severe case of Trichophyton rubrum-caused dermatomycosis exacerbated after COVID-19 vaccination that had to be differentiated from pustular psoriasis.

We present a case of deep dermatomycosis caused by Trichophyton rubrum that developed after administration of SARS-CoV-2 BNT162b2 vaccination. A 75-year-old man was vaccinated with SARS-CoV-2 on day 0 and day 23. From day 25, pustules began to appear. A skin biopsy was performed. Tissue culture revealed the presence of Trichophyton rubrum. The patient was treated with topical luliconazole and 100 mg/day oral fosravuconazole for 84 days, after which the symptoms resolved.

Unmasking pustular psoriasis subsequent to COVID-19

Various cutaneous manifestations have recently appeared within context of 2019 novel coronavirus diseases (COVID-19). Currently, outbreaks of psoriasis were reported during COVID-19. We reported a case of a 32-year-old woman with COVID-19 who presented with pustular psoriasis. She was treated with oral prednisolone, hydroxyzine and topical clobetasol. The two-week follow-up revealed that her lesions were desquamating and that she was in a favorable situation. The current report will highlight specific skin manifestations of COVID-19, allowing clinicians to further confirm our suspicions.

Flare-up of generalized pustular psoriasis combined with systemic capillary leak syndrome after coronavirus disease 2019 mRNA vaccination.

Generalized pustular psoriasis (GPP) is characterized by acute flare-ups induced by various factors, but few reports have described GPP onset or flare-up induced by vaccination. To our knowledge, only three such cases following coronavirus disease 2019 (COVID-19) vaccination have been reported. We herein report a case of GPP flare-up after COVID-19 mRNA vaccination. A 65-year-old man with GPP controlled by infliximab presented with widespread pustular erythema, fever, and malaise following his second COVID-19 mRNA vaccination. A skin eruption was apparent at the injection site. He also exhibited systemic capillary leak syndrome (SCLS), which responded rapidly to secukinumab and systemic corticosteroids. Two biopsies, one of which was of the injection site, revealed not only findings typical of GPP, but also a dermal mixed-cell infiltration with eosinophils, and microthrombi in the small dermal vessels. The latter findings have been observed in cutaneous lesions induced by both COVID-19 infection and vaccination. This is the first case of a GPP flare-up accompanied by SCLS induced by a COVID-19 mRNA vaccine. Also, this is the first flare-up induced by the second vaccine dose, and the first such report including detailed histological data, including for the injection site.

Pustular psoriasis flare-up in a patient with COVID-19.

INTRODUCTION: The various cutaneous manifestations have lately appeared in the setting of COVID-19. Psoriasis flare-ups have been reported during a COVID-19 infection. CASE PRESENTATION: We present a case of a 32-year-old woman with COVID-19 who presented with generalized pustular psoriasis. She received oral prednisolone, hydroxyzine, and topical clobetasol. The patient received follow-up two weeks later and found that her lesions were favorably desquamating. METHODS: The PubMed, SCOPUS, and ISI Web of Science databases were thoroughly searched for English studies reporting psoriasis flare-ups following SARS-CoV-2 infection. Ten case reports/series were included after screening. CONCLUSIONS: Our case report brings awareness to clinicians for the possible cutaneous manifestation of COVID-19, which should be considered part of the differential diagnoses.

Acrodermatitis Continua of Hallopeau Evolving into Generalized Pustular Psoriasis Following COVID-19: A Case Report of a Successful Treatment with Infliximab in Combination with Acitretin.

The global pandemic of coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is emerging. Various cutaneous manifestations have been observed in patients with SARS-CoV-2 infection, yet exacerbations of psoriasis have been reported sporadically. Acrodermatitis continua of Hallopeau (ACH) is an uncommon, sterile pustular dermatosis involving one or more digits. In some rare cases, ACH may evolve into generalized pustular psoriasis (GPP), which is a severe, and potentially life-threatening, form of psoriasis that manifests itself with widespread eruptions of pustules. We describe the first case of a patient in whom ACH abruptly progressed into GPP during COVID-19. A combination of infliximab and acitretin was used allowing swift clinical improvement.

Colchicine in Dermatology: Rediscovering an Old Drug with Novel Uses.

Colchicine is an anti-inflammatory agent which has been used for decades in the treatment of gout. The drug has a number of dermatological indications like Psoriasis, Sweet's syndrome, aphthosis, Behcet's disease, erythema nodosum, leukocytoclastic vasculitis and is consistently effective in neutrophilic disorders. Thought it is an affordable with minimal side effects, It has remained underutilized. However, it has novel uses and is being considered in COVID-19 due to its action on IL-1ß and IL-6. This article presents a concise and up-to-date review focusing on its mechanisms of action and indications.