A report describes a case of a 63-year-old man who presented with generalized itchy skin lesions. He reported the onset of rash 5 months before, which appeared initially as erythematous, painful and itchy papules over the bilateral lower limbs and gradually progressed to include the whole body sparing the neck and face. He also described the association of the lesions with intermittent attacks of severe pruritus that lasted for approximately 30 minutes. 

Interestingly, the patient noted the occurrence of symptoms 2 weeks following the first dose of the Pfizer-BioNTech vaccine. However, he denied the occurrence of any new skin lesions or worsening of previous lesions with subsequent booster doses of the same vaccine. 

His medical history was negative for similar skin manifestations concerning food, medications or animal contact. He gave a history of type 2 diabetes mellitus for 30 years, for which he took oral antiglycemic medications with a recent hemoglobin A1c of 9. 

He gave a negative history of atopy or other pruritic skin conditions and showed normal levels of thyroid-stimulating hormone (TSH), liver function tests (LFTs) and estimated glomerular filtration rate (eGFR). He did not have a history of any psychiatric conditions or cognitive decline. He used several over-the-counter moisturizing creams, topical herbal treatments and honey to relieve the itchiness and rash without any positive outcomes. His rashes were severe enough to cause disturbance in his sleep pattern and quality; without interfering with his daily activities. Examination revealed erythematous and brown papulonodular lesions along with varying degrees of hemorrhagic crusting, erosions and ulceration. Lesions were widespread and involved extensor upper and lower extremities and appeared symmetrically over the upper back with a classic butterfly distribution. 

Histopathology of the active lesion showed irregular acanthosis, hypergranulosis and elongated rete ridges consistent with chronic picking and scratching of the skin. Based on clinical and histopathological findings, the patient received the diagnosis of prurigo nodularis. 

He received topical steroids and emollients, including QV cream and petroleum jelly, along with oral antihistamines for initial treatment. The extent of involvement prompted the physicians to schedule him for narrowband ultraviolet B phototherapy as well. 

Source: Barnawi G, Alghamdi FS, Almuqati AS, et al. Prurigo nodularis eruption triggered by SARS-CoV-2 vaccine. Cureus. 2022;14(10):e29914.