Response to "New-onset pustular psoriasis in the setting of severe acute respiratory syndrome coronavirus 2 infection causing coronavirus disease 2019".

To the Editor: We read with interest the recent report of a new-onset of pustular psoriasis in the setting of SARS-COV-2 infection by Matthieu et al.1Mathieu R.J. Cobb C.B.C. Telang G.H. Firoz E.F. New-onset pustular psoriasis in the setting of severe acute respiratory syndrome coronavirus 2 infection causing coronavirus disease 2019.JAAD Case Rep. 2020; 6: 1360-1362Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Before the SARS-COV-2 pandemic context, a spectrum of respiratory viruses (RV) has been identified for the first time by our group as triggering factors of different psoriasis endotypes flares, including 3 generalized pustular psoriasis (GPP), 2 of which carryied homozygous IL36RN mutations.2Sbidian E. Madrange M. Viguier M. et al.Respiratory virus infection triggers acute psoriasis flares across different clinical subtypes and genetic backgrounds.Br J Dermatol. 2019; 181: 1304-1306Crossref PubMed Scopus (48) Google Scholar In our study, several RNA viruses, mainly Rhinovirus and Coronavirus were detected using multiplex polymerase-chain reaction on nasopharyngeal swabs. These observations support the contribution of viral triggers in predisposing specific genetic backgrounds in psoriasis pathogenesis. Regarding patients with Deficiency in Interleukin-36 receptor antagonist, it is worth emphasizing that the expression of IL-36γ and CXCL8 cytokines is enhanced in primary keratinocytes following exposure to poly-inosinic-polycytidilic acid, a Toll-Like-Receptor 3 agonist, which mimics respiratory virus double stranded RNA.3Marrakchi S. Guigue P. Renshaw B.R. et al.Interleukin-36-receptor antagonist deficiency and generalized pustular psoriasis.N Engl J Med. 2011; 365: 620-628Crossref PubMed Scopus (753) Google Scholar Furthermore, several studies reported a type-I interferon (IFN-I) signature in GPP and psoriasis vulgaris, with some correlation with a deregulation of the IL-36 pathway.4Catapano M. Vergnano M. Romano M. et al.IL-36 promotes systemic IFN-I responses in severe forms of psoriasis.J Invest Dermatol. 2020; 140: 816-826.e3Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar In addition, IL-36 inflammatory cytokines have been shown to be produced and released by bronchial epithelial cells after stimulation with dsRNA. Altogether, and taking into account the major role of the IFN-I pathway immune responses to RV, including toward SARS-COV-2,5Zhang Q. Bastard P. Liu Z. et al.Inborn errors of type I IFN immunity in patients with life-threatening COVID-19.Science. 2020; 370: eabd4570Crossref PubMed Scopus (1330) Google Scholar these data argue for an involvement of IL-36 and IFN-I pathways in RV infection-induced flares of psoriasis, and question the mechanistic links between respiratory and skin inflammatory effectors. Finally, the short time interval between RV infection and the onset of psoriasis flare-ups raises the challenge of immunosuppressive drug intervention in a context of ongoing viral infection, especially in the case of SARS-COV-2. This paradigm also applies to recently developed IL-36-blocking strategies, which appear appealing in GPP. The report by Matthieu et al brings up SARS-CoV2, among other RV, as a potent trigger of the skin immune system in GPP. Dissecting the immunogenotypic architecture underlying these models might not only help understand psoriasis pathophysiology, but also drive precision therapeutic approaches for the benefit of these patients. None disclosed. New-onset pustular psoriasis in the setting of severe acute respiratory syndrome coronavirus 2 infection causing coronavirus disease 2019JAAD Case ReportsVol. 6Issue 12PreviewPsoriasis is a chronic, immune-mediated disorder mainly affecting the skin and joints. The pathogenesis involves keratinocyte hyperproliferation, complex cytokine and interleukin (IL) interactions, polygenic predisposition, and known association with environmental triggers, including infections, medications, trauma, and stress.1 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), is associated with not only flares of psoriasis in patients with well-documented disease2-4 but also other cutaneous diseases. Full-Text PDF Open AccessReply to Assan et alJAAD Case ReportsVol. 11PreviewTo the Editor: We wish to thank Assan and colleagues for their insightful response to our recently published case report, “New-onset pustular psoriasis in the setting of severe acute respiratory syndrome coronavirus 2 infection causing coronavirus disease 2019.” We appreciate their research on the inflammatory pathways that may be implicated in pustular psoriasis. Our patient has since been seen in follow-up, and her skin has improved significantly with the use of topical betamethasone dipropionate augmented 0.05% ointment in addition to salicylic acid 2% ointment. Full-Text PDF Open Access