Home > SARS-CoV-2 vaccination management in patients with chronic plaque psoriasis

SARS-CoV-2 vaccination management in patients with chronic plaque psoriasis

Francesco Bellinato (email)× Francesco Bellinato (email)

Department of Medicine, Section of Dermatology and Venereology, University of Verona, Italy
Mattia Mazzariol (email)× Mattia Mazzariol (email)

Department of Medicine, Section of Dermatology and Venereology, University of Verona, Italy
Paolo Gisondi (email)× Paolo Gisondi (email)

Department of Medicine, Section of Dermatology and Venereology, University of Verona, Italy

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Since December 2020, large vaccination campaigns have been initiated all over the world, changing dramatically the course of the COVID-19 pandemic. As SARS‐CoV‐2 vaccines have become widely available, dermatologists need to face issues related to their safety and efficacy for patients with immune-mediated inflammatory diseases including those with psoriasis taking immunomodulatory treatments. According to different guideline including EuroGuiDerm Guideline, National Psoriasis Foundation and International Psoriasis Council recommendations, patients with psoriasis are candidate to SARS‐CoV‐2 vaccination whether they are on systemic drug treatment or not. Although randomized controlled trials of SARS‐CoV‐2 vaccines excluded such patients, current real-world data suggest that they are safe in patients with psoriasis undergoing immunomodulatory treatment. An open issue is whether patients on immunomodulatory treatments will mount a sufficient humoral and cellular immune response to the vaccine. In individuals receiving methotrexate or TNF-a inhibitors, impairment and waning in immunogenicity has been reported. Consequently, such patients might require testing to assess whether adequate immune responses are elicited after vaccination and booster vaccination are required to generate sufficient protection against SARS-CoV-2 infection.


In December 2019, in Wuhan (China), SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) was described for the first time [1]. This novel type of coronavirus spread rapidly through global population in few months with raising concern among public and health authorities worldwide until the World Health Organization (WHO) declared pandemic status on 11th March 2020 [2]. SARS-CoV-2 is the etiologic agent of Coronavirus disease 2019 (COVID-19), a condition characterized by a spectrum of symptoms, from mild (e.g., headache, cough, and fever) to severe manifestations and life-threatening events, such as acute respiratory distress syndrome (ARDS) and venous thromboembolisms, with an increased risk in chronically ill and immunologically compromised patients [3,4]. After 3 years of pandemic the number of deaths related to COVID-19 is 6.88 million out of a total of more than 761 million confirmed cases [5]. From the beginning of the first outbreak, one of the most viable ways to counter this health, social and economic burden has been to develop a vaccine using the spike (S) protein of the virus as the main activator of the immune system. With huge efforts by governments and pharmaceutical industries, numerous vaccines have been developed with the aim to prevent viral infection or, in case of infection, avoid the most severe manifestations, to reduce hospitalizations, intensive care unit admissions and, consequently, the overloading of health systems worldwide. Therefore, the largest vaccination campaign in human history was launched and only 1 year after the first vaccine was approved more than 10 billion doses had already been administered in the world [6,7]. Different categories of vaccines have been designed using different technology platforms and several of them are globally in use: (1) inactivated viral vaccines, which contain pathogens altered in a way to prevent their replication, (2) protein subunit vaccines, composed of fragments of the original virus by recombinant technology, (3) viral vector (non-replicating) vaccines, employing a carrier virus such as an adenovirus, and (4) nucleic acid-based vaccines (mRNA- or DNA-based) which code for viral proteins and induce the cells themselves to synthesize the antigen [8]. To date World Health Organization (WHO) approved 11 vaccines: Covilo (Sinopharm-Bejing), Covaxin (Bharat Biotech), CoronaVac (Sinovac) (Inactivated virus-based); Nuvaxoid (Novavax), COVOVAX (Serum Institute of India) (Protein Subunit-based); Vaxzevria (Oxford/AstraZeneca), Covishield (Serum Institute of India), Convidecia (CanSino), Jcovden (Janssen) (Non-Replicating Viral Vector-based); Spikevax (Moderna), Comirnaty (Pfizer/BioNTech) (RNA-based) [9]. Most vaccines showed a significant reduction in cases of symptomatic COVID-19 and severe or critical disease compared with placebo, and little or no difference for serious adverse events [8]. The effectiveness was also demonstrated against COVID-19-related hospitalization, intensive care unit admission and death, not only in cases of full vaccination but also in those who have received partial vaccination, although to a lesser degree [10]. Data collected by Centres of Disease Control (CDC) showed that the number of Covid-19-related deaths in the U.S. was higher in the unvaccinated than in the vaccinated with similar results across vaccine types [6]. An increase in efficiency was also observed with booster dose administration compared to primary immunization [11]. As the mass vaccination campaign progressed, increasing numbers of post-vaccination adverse reactions were reported and several studies have found that this risk is greater for mRNA vaccines [12,13]. Expected adverse events related to the body's normal reactiveness were observed in conjunction with the administration of different types of vaccine, such as local reactions at injection site, like pain, redness and swelling, or signs of systemic response, like fever, headache, chills, myalgia and fatigue, which were, however, mild and transient, [8] developing within 1 to 2 days after vaccination and lasting 1 to 2 more days [14]. It is also important to consider the relevance of the “nocebo effect”, which led to significant frequency of adverse events even in placebo recipients, probably because of the many concerns in population regarding vaccines, their rapid development, and uncertain safety [15]. In addition to reactions at the injection site, other frequent patterns of skin manifestation were described, which were, however, self-limiting and not severe, mostly urticarial and morbilliform eruptions [16,17]. Other less common manifestations were pernio/chilblain, pityriasis rosea-like reactions, zoster, cosmetic filler reactions and herpes simplex exacerbations [16,17].The most important severe adverse events described in the literature are divided into four major organ-specific groups: immune-allergic (urticaria, angioedema, anaphylactic shock, autoimmune hepatitis, vasculitis), cardiovascular (myocarditis and pericarditis, acute coronary syndrome, pulmonary thromboembolism, hypertension crisis), hematologic (vaccine-induced thrombotic thrombocytopenia, diffuse intravascular coagulation, venous thromboembolism, immune thrombocytopenia) and neurologic events (Guillain-Barré syndrome, transverse myelitis, cerebrovascular attack, cerebral venous sinus thrombosis and Bell’s palsy) [18]. Episodes of myocarditis and pericarditis, which represent some of the main safety concerns in male young adults, appear to be more frequently Covid-associated than mRNA vaccine-associated, while thromboembolic events have been described particularly in young women with a pre-existing hypercoagulability state receiving adenoviral vector vaccines [18]. The link of causality is still under investigation for several of these adverse events [19]. Despite the low incidence of severe adverse events, SARS-Cov-2 vaccines are receiving careful surveillance by national and international programs, continuing to show a good safety and efficacy profile in several studies, including during pregnancy and in children [20]. Despite these few and rare risks associated with their administration, they continue to be recommended in the general population by the scientific communities because benefits still outweigh risks and remain the most effective strategy to facilitate the gradual transition from pandemic to endemic state [6].

Safety of SARS‐CoV‐2 vaccines in patients with chronic plaque psoriasis

As SARS‐CoV‐2 vaccines have become widely available, dermatologists needed to face their safety and efficacy in patients with immune-mediated inflammatory diseases, particularly those with psoriasis who take immunosuppressive/immunomodulatory treatments [21]. Drugs such as methotrexate, cyclosporine and biologics targeting tumour necrosis factor (TNF), interleukin (IL)-17, IL-12/23, IL-23 are highly effective in blocking the immune pathways of psoriasis, but also can increase the risk of certain infections and potentially reduce vaccine immunogenicity. Case reports of psoriasis flares following SARS‐CoV‐2 vaccination have been reported (Figure 1) leading to hesitancy and apprehension among patients and physicians [16,17,22-30]. Such flares were frequently described after the boost dose and the mean interval between vaccination and psoriasis flare was 9.3 days [16]. The pathogenetic mechanism behind psoriasis exacerbations has not fully understood. In mRNA vaccines, single-stranded RNA can activate toll-like receptors (TLR), the inflammasome and the production of type I interferons, which are known to flare autoimmune disease. Similarly, double stranded DNA in adenoviral vector vaccines induce type I interferons production via TLR9 [16]. However, a more recent self-controlled case series analysis reported that vaccination against SARS‐CoV‐2 was not statistically associated with risk for psoriasis flare. The adjusted incidence rate ratio (IRR) of psoriasis flare was 0.96 (95%CI 0.80-1.14) 21 days after vaccination [31].

Figure 1. Numerous guttate plaques of psoriasis on the back (A) and right elbow (B) of a 45-year-old patient triggered 2 weeks after administration of the booster of an mRNA vaccine

Regarding the safety of SARS‐CoV‐2 vaccination in psoriatic patients on biologics, current real-world data suggest that adverse effects are comparable to those observed in healthy individuals, even if prospective randomized controlled trials excluded such patients for the current available vaccines, particularly the now widely used mRNA vaccine BNT162b2 [21]. For example, a study on 436 psoriatic patients treated with biologics (78 of whom underwent SARS‐CoV‐2 vaccination) reported no vaccination-related adverse effects [32]. In another study on 369 patients with psoriasis receiving anti-IL-17 and 23 agents who underwent SARS‐CoV‐2 vaccination, no serious vaccination-related adverse events were reported, while about a third developed mild adverse events (such as injection site pain, fever, fatigue, and muscle pain) that resolved within 48 hours [33]. In a study involving 505 patients with IMID treated with methotrexate, glucocorticoids, biologics and 203 healthy controls, no significant difference in frequency of adverse events between patients with IMID and controls was found [34]. A survey involving 325 patients with IMID treated with disease modifying anti-rheumatic drugs and biologics, most reactions were local and transient like those reported in vaccine trials, no series allergic reactions were reported [35]. Conversely, in a cohort study involving 127 patients with IMID and 97 controls receiving ChAdOx1-S vaccine, those with psoriasis were more likely to experience vaccine-related adverse effects than controls (72 vs 57%) [36]. In conclusion, there is no evidence that patients with psoriasis receiving biologics are at greater risk of harm from SARS‐CoV‐2 vaccination.

Efficacy of SARS‐CoV‐2 vaccines in patients with chronic plaque psoriasis

An open question is whether patients with psoriasis receiving biologics or other immunomodulatory treatments can mount an adequate immune response to the SARS‐CoV‐2 vaccine. In vaccine-induced host protection against SARS-CoV2 a complex interaction between innate, humoral, and cellular immunity occurs. In prospective cohort studies different assessment of humoral and cellular response after SARS-CoV2 vaccination has been evaluated, including total antibody titres, neutralizing activity and T-cell mediated immunogenicity as measured by interferon-gamma releasing assay (IGRA), as summarized in Table 1. Earlier studies on vaccination against pneumococcus, meningococcus, influenza, or tetanus showed that treatment with TNF-a inhibitors, IL‐12/23 inhibitors and IL‐17 inhibitors is not associated with lower antibody response [37]. In contrast, a decreased humoral immune response to SARS‐CoV‐2 vaccines in patients with immune-mediated inflammatory diseases was reported after the first dose [38]. As an example, among 120 patients with immune-mediated inflammatory diseases (including 107 with psoriasis) who received either mRNA or viral vector-based vaccines, 15% of participants receiving immunomodulatory drugs, particularly methotrexate, did not develop detectable concentrations of antibodies [38]. In the study by Mahil et al. involving 87 patients with psoriasis (treated with methotrexate, TNF-a and IL-17 and IL-23 inhibitors) and 17 healthy controls after a single BNT162b2 vaccine dose, seroconversion rates were found to be lower in patients receiving immunosuppressants than controls (78%, 95%CI 67-87 vs 100%, 95%CI 80-100), with the lowest rate in those receiving methotrexate (47%, 95%CI 21-73) [39]. However, neutralizing activity against wild-type SARS-CoV-2 was similar in those receiving targeted biologics and controls (median 50% inhibitory dilution 269 [141–418 interquartile range] vs 317 [213–487 interquartile range]). Similarly, cellular immune responses were induced in all groups [39]. Immune responses 14 days following the second dose was also evaluated by Mahil et al. in a cohort of patients with psoriasis receiving methotrexate, TNF-a inhibitors, IL-17 and IL-23 inhibitors versus healthy controls. All patients demonstrated either detectable spike-specific antibodies and similar neutralizing antibody titres. By contrast, a lower proportion of participants on methotrexate (62%, 95% CI 32-86) and targeted biologics (74%, 95%CI 60-85; p=0.38) had detectable T-cell responses following the second vaccine dose, compared with controls (100%, 95%CI 77-100; p=0·022), but there was no difference in the magnitude of T-cell responses between patients receiving methotrexate, targeted biologics and controls [40]. In summary, functional humoral immunity at 28 days after a single dose was impaired by methotrexate but not by biologics, whereas cellular responses were preserved in all patients. The functional consequences of these findings are unknown. Cristaudo A. et al. also investigated the humoral response to the BNT162b2 vaccine in 48 psoriatic patients on biologics (combined with methotrexate in three patients) and found no statistically significant difference in the antibody response of psoriatic patients versus controls (geometric mean of concentration four weeks post booster was 262.05 vs 259.06 AU/mL, p=0.658) [41]. However, patients also receiving methotrexate had lower antibody titres than those on biologic monotherapy (P = 0.001). A prospective cohort study by Chanprapaph et al. assessed the humoral and cellular immune response in patients with immune-mediated dermatological diseases, including 57 patients affected by psoriasis, at 28 days after second dose of ChAdOx1-S COVID-19 vaccine [36]. They found that patients with psoriasis, regardless of treatment with methotrexate or biologic agents, were comparable to healthy controls, with a seroconversion and positive IGRA rate of 87.7% and 80.7%, respectively. Of note patients with psoriasis had higher rates of discordancy between humoral and cellular immune response (17.5% vs 10%) [36]. Another prospective study comparing humoral responses 28 days following two doses of BNT162b2 (Pfizer/BioNTech vaccine) in 32 patients with psoriasis receiving biologic monotherapy versus 22 healthy controls showed no difference in the rate of seroconversion, but significantly lower titres were observed in patients with psoriasis treated with biologic monotherapy (1024.4 ± 870.3 vs. 3055.8 ± 2450.9, P < 0.001). There were no significant differences between the biologic treatment groups. The authors concluded that these lower titres suggest the need for the recommended booster shot [42].Cellular immunity is important for long term immunity particularly in patients on continuous treatment with immunomodulators. Kvist-Hansen et al. investigated the long term humoral and cellular immunity after mRNA COVID-19 vaccination in 123 patients with psoriasis versus 226 healthy controls. They found that the proportion of IgG responders was lower 6 months after vaccination in patients receiving anti TNF-a treatment compared to controls. Anti-TNF-a treatment was associated with lower IgG levels (beta=-0.82 95%CI -1.38 to -0.25). The median neutralization index was lower in the anti-TNF-a group compared to controls. The cellular response was found numerically lowest in the anti-TNF-a group as well. These findings suggests that anti TNF-a agents have faster waning of immunity to mRNA-based vaccination [43]. Data from a cohort of 194 patients with axial spondylarthritis and psoriatic arthritis confirmed that TNF-a inhibitors attenuate immunogenicity to the inactivated CoronaVac vaccine. After three doses of vaccine, anti-TNF-a drugs were still associated with impaired seropositivity and neutralizing antibodies (p<0.005) [44].The three-dose antibody response of COVID-19 mRNA vaccine in psoriasis patients treated with biologic drugs is a further ongoing issue. In a prospective cohort study involving forty-five psoriatic patients on biologic treatment a significant increase in antibody titres after each dose of vaccine compared with baseline was found, with no significant differences between patients and controls. Methotrexate used in combination with biologics has been shown to negatively influence the antibody response to the vaccine [45].


SARS-CoV-2 vaccination management in chronic plaque psoriasis is a clinically relevant issue. According to different guideline/recommendations including EuroGuiDerm, National Psoriasis Foundation and International Psoriasis Council, patients with psoriasis are candidate to SARS‐CoV‐2 vaccination whether they are on systemic drug treatment or not. Psoriasis is not a contraindication to vaccination [46,47]. In fact, the advantages of avoiding severe COVID-19 through vaccination is much greater than the theoretical risk of its adverse events. The American College of Rheumatology, recommended to withhold methotrexate 1 week after each dose of vaccine for patients with well-controlled disease [48]. This recommendation is based on data from influenza and pneumococcal vaccines showing that methotrexate, but not target therapies, impair humoral responses [49].Although several studies support the safety and efficacy of SARS‐CoV‐2 vaccination, a considerable population still expresses vaccine hesitancy, including those affected by psoriasis. Age, gender, lack of trust in science, and concerns of safety and efficacy represent determinants for vaccine hesitancy. According to the global patient‐reported PsoProtectMe survey, up to 8% of patients with psoriasis have vaccine hesitancy [51]. A recent systematic review recommends strategizing the campaign for booster doses by identifying and evaluating the reasons for such hesitancy and by appropriate communication [50].In conclusion, current data suggests that SARS‐CoV‐2 vaccines appear safe in patients with psoriasis undergoing immunomodulatory treatment. In some individuals receiving methotrexate or TNF-a inhibitors, waning in immunogenicity of the vaccine could occur. Consequently, such patients might require testing to assess whether adequate immune responses are elicited after vaccination and whether booster vaccination is required to generate sufficient protection against SARS-CoV-2 infection. Further studies are needed to assess the long-term impact of the different classes of biologics on humoral and cellular immunogenicity [21].


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