# Pustular psoriasis flare following COVID-19 infection: a case report and literature review

## TL;DR

A woman with a history of psoriasis developed severe pustular psoriasis after recovering from COVID-19, which was treated successfully with corticosteroids and other medications.

## Contribution

The paper presents a novel case of generalized pustular psoriasis triggered by SARS-CoV-2 infection and reviews related cases to highlight immune mechanisms.

## Key findings

- A 46-year-old woman developed GPP 11 days after recovering from COVID-19 pneumonia.
- Infection-related GPP flares showed longer latency and higher corticosteroid use compared to vaccine-related cases.
- Both SARS-CoV-2 infection and vaccination may activate the IL-36 axis via innate immune signaling.

## Abstract

Generalized pustular psoriasis (GPP) is a rare, potentially life-threatening inflammatory disease characterized by neutrophilic pustules and systemic inflammation. We report a case of severe GPP triggered by SARS-CoV-2 infection in a 46-year-old woman with a long history of psoriasis. Eleven days after recovery from COVID-19 pneumonia, she developed widespread pustules and fever. Histopathology revealed subcorneal spongiform pustules and dermal neutrophilic infiltration consistent with GPP. Systemic corticosteroids followed by etretinate and deucravacitinib achieved complete remission. A literature review identified 11 infection- and 10 vaccine-related GPP cases. Compared with vaccine-associated cases, infection-related flares showed longer latency and higher corticosteroid use. Mechanistically, both SARS-CoV-2 infection and vaccination may be associated with IL-36 axis activation, potentially via spike protein–driven, Toll-like receptor–mediated innate immune signaling. This case highlights that distinct immune kinetics may underlie infection- and vaccine-related GPP, while supporting a putative role of IL-36–driven inflammation in COVID-19–associated disease exacerbation.