Psoriasis is a chronic, recurrent, immune-mediated inflammatory disease and it can be provoked or exacerbated by a variety of different environmental factors, particularly infections and drugs. In addition, a possible association between vaccination and the new onset and/or exacerbation of psoriasis has been reported by a number of different authors. The aim of this study is to investigate the effects of influenza vaccination on patients with psoriasis. Here, we report the findings from 43 patients suffering from psoriasis (clinical phenotypes as mixed guttate/plaque lesions, palmoplantar or scalp psoriasis) whose diseases had been triggered after influenza vaccination applied in the 2009-2010 season. The short time intervals between vaccination and psoriasis flares in our patients and the lack of other possible triggers suggest that influenza vaccinations may have provocative effects on psoriasis. However, further large and controlled studies need to be carried out to confirm this relationship.
Vaccination is a proven and well-established strategy for the prevention of infectious diseases in the general population and in patients with immune-mediated chronic inflammatory diseases. This group of patients has an increased risk of contracting complications of some vaccine-preventable infections due to the nature of the disease and immunomodulatory treatments [
Psoriasisis one of the world's most frequent chronic, recurrent, and inflammatory diseases, affecting around 2% of the population and is characterized by erythematous scaly plaques on the skin [
We collected cases that were on the onset of contracting psoriasis or where the disease had worsened, within 3 months following immunization with commercial influenza vaccines that were used in the 2009-2010 season. Trade names and the date of the applications were noted for all patients together with the historical and clinical features of the eruption. The diagnosis of psoriasis and its clinical phenotype classification were established for all patients after clinical and histopathological evaluations by an experienced dermatologist. Patients were asked whether they had used any other drug and/or vaccination prior to their eruption. Also, various factors including focal infections that may have a triggering effect on their psoriasis were investigated. Routine hematological and biochemical analysis, urinalysis, HIV and VDRL tests, throat and urine cultures, Water’s and thorax radiographs, and tooth examinations were performed. Patients were enrolled into our study group if no other trigger of psoriasis had been identified such as infection or intake of drugs.
Our observational clinical studyevaluated 43 psoriasis patients whose diseases had been triggered after receiving vaccinations for influenza. Patients had a history of using one of the two types of inactivated influenza vaccine trivalent types A and B (split virion). Among these, Vaxigrip Sanofi Pasteur, which contained three different strains of the influenza virus A/Brisbane/59/2007- (H1N1-) like strain, A/Brisbane/10/2007- (H3N2-) like strain, and B/Brisbane/60/2008-like strain with some adjuvants (e.g., ovalbumin, thimerosal, formaldehyde, and neomycin), was used in 34 of the patients (79.1% of the total sample); Fluarix GlaxoSmithKline Biologicals, which contained three different strains of the influenza virus A/Brisbane/59/2007, IVR-148 (H1N1), an A/Brisbane/10/2007-like virus A (H3N2), and B/Brisbane/60/2008 with some adjuvants (e.g., ovalbumin, formaldehyde, and gentamicin sulfate), were used in 9 of the patients (20.9% of the total sample).
Of the 43 patients (26 female, 17 male), 37 (86%) had mixed plaque type and guttate psoriasis, three of the patients (7%) suffered from palmoplantar psoriasis, and another three (7%) suffered from psoriasis on the scalp. There was an exacerbation of preexisting psoriasis after vaccination in 36 (83.7%) of them while it was the first induction of psoriasis in the remaining 7 (16.3%) patients. The latent period for the induction or exacerbation of psoriasis after vaccination was between 2 weeks and 2 months, but most patients contracted it within a period of 2 to 3 weeks. While 38 (88.4%) patients had a history of vaccination prior to their psoriasis without any other drug intake, the remaining five (11.6% of the sample) patients had a history of using some drugs but these were not identified as being responsible for the induction or exacerbation of psoriasis. The patients in our study group had no other vaccination experience in the past except the influenza vaccine and had no other triggering factors such as infections at the time they were enrolled into the study.
Although increased susceptibility to infection in patients with psoriasis remains a matter of debate, it should be emphasized that some special consideration should be given to vaccination strategies in psoriasis patients, especially in the current era of biological therapies [
Substantial advances have been achieved in understanding the genetics and pathomechanisms of psoriasis in recent years. It is considered to be a primarily Th1-type disease characterized by Th1 cytokines and a predominance of CD8+ cells in the epidermis and CD4+ cells in the dermis [
Over the years numerous reports have raised the suspicion of the safety of vaccines in autoimmunity and in persons already diagnosed with autoimmune conditions. Because of the popularity and the widespread use of influenza vaccine, its effects have been examined in many autoimmune conditions [
Our study has a number of limitations including the lack of a control group and follow-up evaluations which could prove causal correlation between vaccine and clinical manifestation. Despite these potential limitations, our observations may partially support the apparent association between influenza vaccination and the development of psoriasis. The fact that no other provoking factors were found in our patients promotes this relationship.
Although staphylococcal, streptococcal, measles, and varicella vaccines have also been applied previously in the treatment of psoriasis, an early report described two cases of psoriasis induced by BCG vaccination and influenza vaccination under the name of “psoriasis vaccinalis” [
Consequently, our data suggests that the H1N1 influenza vaccines, which were used in the 2009-2010 season, have the potential to trigger development of psoriasis. Therefore, it is important not only to know the protective potential of influenza vaccines but also to understand their potential to provoke psoriasis.
However, as previously suggested, although the administration of the influenza vaccine has been associated with psoriasis in some patients, their very low incidence and mild clinical course, combined with the general lack of high level of evidence, do not warrant an abandonment of the immunization practice considering the favorable cost-effectiveness ratio of the vaccine use. Therefore, we recommend the follow-up of such individuals and suggest further large-sized, controlled, and well-constructed clinical research studies going forward, which may confirm this relationship.
The authors declare that there is no conflict of interests regarding the publication of this paper.