Onset of Palmoplantar Pustulosis After COVID-19 Vaccination

A 46-year-old woman with a 20 pack-years history of smoking presented to an outpatient primary care clinic for evaluation of a recurrent painless rash on her palms and the soles of her feet. The rash had been present for 3 months prior to outpatient presentation but was initially noticed by the patient 2 weeks after receiving the first dose in the Moderna mRNA COVID-19 vaccine primary series.

History. The rash began as fluid filled lesions with drainage upon disruption of the surface approximately 2 weeks after receiving the first vaccine. The rash on her palms then worsened 4 weeks later, after receiving the second dose of the Moderna mRNA COVID-19 vaccine primary series. Her symptoms improved intermittently over the course of months but remained largely unchanged (Figures 1 and 2).

Figures 1 & 2. Erythematous pustular eruption on the bilateral soles, which worsened after receiving the second dose of the Moderna COVID-19 vaccine.

The patient reported pruritus but denied any fevers, pain, numbness, mucosal lesions, or upper respiratory symptoms. She denied the use of any new products, any history of a similar rash, or anyone in the home with similar symptoms. She works at an assembly line and wears gloves occasionally but denied being exposed to new chemicals or products. Her family history was significant for psoriasis and type I diabetes.

Approximately 3 months after the development of the rash, the patient’s primary care physician reported discrete red macules and deep-seated pustules on the bilateral plantar feet and palms. The patient reported minimal improvement with the use of over-the-counter cortisone or petrolatum, thus betamethasone dipropionate 0.05% cream was initiated.

Diagnostic testing. The patient was advised to return for a culture to rule out infectious causes. However, this was never completed. The patient was also referred to a dermatology specialist for evaluation of palmoplantar pustulosis.

At her visit with the dermatology specialist approximately 9 months after first developing the rash, the patient reported a lack of improvement with the betamethasone dipropionate cream. The patient had worsening symptoms on her palms and soles after receiving a Moderna mRNA booster vaccine about 7 weeks prior to presentation to the dermatologist (Figures 3 & 4). On examination, the palms and soles had resolving hyperpigmented macules with a few scattered pustules. No immunofluorescence or histopathology was obtained.