Lawrence Green, MD is the section editor of the Psoriasis Centers of Excellence for The Dermatologist, clinical professor of dermatology at George Washington University School of Medicine in Washington, DC, and on the National Psoriasis Foundation Medical Board.
AAD. Managing your practice through the COVID-19 outbreak. https://www.aad.org/member/practice/managing/coronavirus
CDC. Information for healthcare professionals. https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html
NPF. NPF Medical Board COVID-19 Recommendations for Patients with Psoriatic Disease. https://www.psoriasis.org/advance/coronavirus
Melissa: There are many, many questions about the best way to manage patients with psoriasis during the coronavirus pandemic.
The Dermatologist spoke with Dr Lawrence Green with the George Washington School of Medicine about patients’ concerns, how to maintain a safe work environment if dermatologists choose to keep their practice open, and the current recommendations regarding patients on biologics, including anti‑TNF inhibitors.
If you have any additional questions for Dr Green that was not answered by this podcast, please submit them in the Feedback Box below. We will be sure to address them in an additional podcast.
Probably the most asked question right now is should patients be staying on their biologics and/or immunosuppressant therapies?
Dr Green: First and foremost, I think people need to listen to what their board‑certified dermatologist says.
As a board‑certified dermatologist, I cannot point to any broad data that say it’s safe or not to stay on a biologic or immunosuppressive therapy. So, I think the best way to look at it is to break down the biologics and immunosuppressants we use to treat severe psoriasis and look at what we know about them, and then make some inferences about whether they’d be safe to continue therapy or not.
So, let’s start with stopping all biologics in general, and then we’ll go more specific. If someone stops a biologic over months...for a few weeks, that’s not an issue. If they stop for months, and the psoriasis becomes severe again, then they’re more in an inflamed state. There’s a stress on the body from all the inflammation going on through the body and comorbidities are possibly occurring, so that person, you’d think, would be very susceptible to getting a COVID infection because their body’s stressed because of the severe psoriasis.
So, for that reason, as a generalization, someone who has severe psoriasis who’s doing well with biologics, the alternative of stopping for a number of months and becoming severe again, that’s not a good alternative.
So, for that, in general, I would try and keep patients on biologics if at all possible, who are well‑controlled, who we know have severe psoriasis. Now, stopping for a few weeks, like I said, is a different story, but let’s look at, from biologic to biologic.
Let’s start with the TNF inhibitors. Those are potentially the most likely to suppress the immune system broadly than the other types of biologics we use to treat psoriasis. Now, there’s some evidence that having the anti‑TNF can help fight a pneumonia. I don’t know about viral pneumonia for COVID, but I think that is lost in the more important notion that TNFs are a little more broadly immunosuppressive.
So, if there’s any biologic class where you would think about switching someone on to something else, that would be the class I would think of switching to someone who’s very worried about and is very potentially exposed to COVID infection.
But that said, if they’re doing well, and they can stay away, and social distancing, and stay away from big gatherings, and the patient’s doing well, I would think it would be OK to continue the anti‑TNFs, albeit that I would discuss, if the patient is very worried, switching from the anti‑TNF to another class.
So, let’s talk about another class of biologics, ustekinumab. That’s in its own class, because that’s an IL‑12/23. Now, there is evidence that we need IL‑12 to fight viral infections, so theoretically, if you take away IL‑12, the patient could be more susceptible to COVID‑19 infection. It’s not proven, it’s just hypothesis, but that’s something to think about.
If someone is using Stelara and has a risk for exposure to COVID‑19, would we want to think about switching them? But that said, there is no evidence that that will happen. We’re just looking at hypothetical situations.
I think the anti‑IL‑17 and the anti‑IL‑23 inhibitors really, of all the biologics, those are the safest in the face of COVID‑19 infection, and that’s what I would switch people to who are taking the TNF or Stelara, if they’re at all worried.
Now again, switching is a lot of work, and if a patient is stable and able to follow CDC guidelines and are not in an endemic area where there are a lot of people who are infected with the COVID‑19 virus around them, again, I wouldn’t recommend switching someone who’s stable.
But if you want to switch an IL‑17, I’m sure IL‑23 inhibitor, I think are the safest. Those are the least immune‑suppressive. It’s a very targeted immune‑suppression, and I would continue those patients who are worried about COVID‑19 infection with those agents.
Now, if someone is...definitely has a COVID‑19 infection or feels a fever, not even known if they’re exposed, they haven’t been tested yet, and they have a fever, and they have symptoms of a COVID‑19 infection, stop the biologic.
Because a few weeks off a biologic while you’re figuring out whether you have a COVID‑19 infection or not is not going to harm the patient. The psoriasis is not going to bounce back very quickly. It takes months for it to bounce back, so I think that’s a good assumption to make as well.
Melissa: What about patients on apremilast or methotrexate?
Dr Green: So, people on other immunosuppressive agents like apremilast or methotrexate, we again have no information on what to do, so I can just go based on theory, not fact.
I would keep someone using apremilast if they’re not exposed to someone with a COVID‑19 infection. That is a general medication that suppresses the immune system a little bit, but it’s not known to suppress the immune system significantly like some of the other immunosuppressants like cyclosporine or prednisone and medications like that.
So, unless someone, again, is in an endemically‑exposed area, there’s a lot of COVID‑19 infection, they have been in contact with people who have COVID‑19, I would certainly recommend continuing apremilast.
The nice thing about apremilast, too, is it has a relatively short half‑life, so if you want to discontinue it for a little bit, you can go right back up and start it again without having any of it remain in you. And like, some of the biologics have a much longer half‑life, so if you take it, and you have exposure, you can’t take it back. With apremilast, it, the short half‑life means that it’s out of you within several days of taking it, so there’s no problem with starting and stopping it as you need if you think you have may have had exposure for a little bit, and then you can go right back to it.
And then also, of course, there’s no there’s no development of antibodies by starting and stopping it frequently like you could have with a biologic, which render it less effective. So apremilast, we don’t know, but I would think it’s safe.
Methotrexate is a little more difficult. That’s, in my opinion, a bit more suppressive than apremilast, and I don’t really know what to say about someone who’s taking methotrexate.
The nice thing, though, about methotrexate, though, is it does have a short half‑life as well, so if you stop it, it’s going to be out of your system pretty quickly, so it won’t have any lasting effects, so you would theoretically have your regular, if you want to call it regular, immune system back to fight any potential COVID‑19, uh, exposure or infection.
Melissa: Last week, there was conflicting information regarding the use of ibuprofen among patients with coronavirus. What are your recommendations for those taking ibuprofen or a non‑steroid anti‑inflammatory drugs?
Dr Green: Right. There are anecdotal reports out there that taking non‑steroidal anti‑inflammatory medications can make people who have active COVID‑19 infection worse. There are anecdotal reports.
I would recommend people take acetaminophen or Tylenol instead of non‑steroidals, but we have no proof that’s accurate. So, for people with psoriatic arthritis who are taking a non‑steroidal anti‑inflammatories, I would continue to take them unless you actually know that you have a COVID‑19 infection or suspect you have a COVID‑19 infection.
Those also have short half‑lives, so stopping them, they will be out of your system relatively quickly.
Melissa: Another more general question is, are patients with psoriasis at risk for COVID‑19? I know a lot of the comorbidities like cardiovascular disease increases the risk, but, like, do we know if the skin disease itself does?
Dr Green: We don’t know if the skin disease that people have, psoriasis specifically, because you have a...you’re have an increase for COVID‑19 infection. My guess would be that the more severe it is, the more you’re at risk, because the more your body’s in a chronically inflamed state, you know.
There’s more psoriasis, untreated psoriasis you have, the more stress you have on the body. And when you have a stress on the body, your body’s immune system can’t work as well, can’t fight things off as well. So, I think it would put you at a disadvantage.
So that’s why I think when it comes to biologics, going back to that, when it comes to biologics, continuation versus stopping that and worrying about COVID‑19 infection, I think it’s important to continue the biologics, because having severe psoriasis, I think puts you more at risk, in my opinion. More at risk for COVID‑19 than taking a biologic and not having psoriasis.
Melissa: What recommendations do you have for addressing patients who are calling in concerned about getting COVID‑19 or thinking they might have it?
Dr Green: So, if people who are calling me, and many patients have called me and asked whether they think they should be continuing biologic therapy. They’re stable, their psoriasis is doing well with the biologic, and they have a history of severe psoriasis, I recommend they’re stay on the current biologic.
Like I said, for people who think they’re in an exposed area, but haven’t been exposed, maybe you would want to switch from the anti‑TNF to an anti‑IL‑17 or ‑23, but that’s a lot of work, and the patient has to realize that, but if that’s what they want, I think that’s fine as well.
But in general, I recommend they stay on the biologic unless they think they have exposure. If they have exposure or they’re worried about exposure, they can temporarily stop the biologic for a few weeks to determine if they have exposure or a COVID‑19 infection. If they don’t, certainly go back to the biologic.
People who are chronically exposed to COVID‑19 are always at risk. They have to make a decision. I think those people should stay on a biologic unless they start feeling symptoms of COVID‑19 infection or general flu‑like symptoms to begin with.
But I would hope, however, those who are using biologics are not at high risk and are not going to places where they have a lot of potential exposure to COVID‑19.
I think these people should, anyone who’s using a biologic, just like anyone with any comorbidity condition, and psoriasis you can think of as a comorbidity condition in a way, they should stay away as much as possible and follow our government’s guidelines: social distancing, stay away from large gatherings, frequent handwashing, etc.
Melissa: What are your recommendations for maintaining a safe work environment for staff, providers, and patients?
Dr Green: That’s really up to the board‑certified dermatologist and what they’re most comfortable with, as well as the employees, I think, of the dermatologist. There’s some dermatologists I know who are shutting down, and not taking any chances.
A lot of dermatologists are using telemedicine if that’s possible. And I don’t know if you know, but the government has temporarily suspended HIPPA regulations in the use of telemedicine during this COVID‑19 crisis.
Dermatologists, and physicians in general, are now permitted for the time being, to use non‑HIPPA‑compliant technology to provide telemedicine to patients. So, in the past, where you have to have a telemedicine‑certified platform in order to provide telemedicine consultations, that’s not in place right now.
If you just want to FaceTime someone or Skype someone, that can be a telemedicine visit that can be billed according to recently released government guidelines. So that’s one thing some dermatologists are doing, if that can work in their office.
Some dermatologists are still seeing patients, but at a reduced rate. They’re making sure the waiting room is virtually empty so that there are no other people in the waiting room at the same time. They are offering hand sanitizer or having patients wash their hands.
I know in my office we’re asking people when they check in if they have felt flu‑like symptoms or traveled anywhere recently, or any fevers, or had anyone or known anyone who had the COVID‑19 virus. So, we ask that. If the answer’s yes to any of those, we ask them to reschedule.
And then, of course, when we bring patients back, we’re always wearing masks and gowns for the protection of the patient more so than ourselves. So those are things that some dermatologists are doing.
Melissa: Do you have any specific resources dermatologists can use to keep up with the latest information from government organizations?
Dr Green: The CDC is, you know, of course revising regulations daily. I suggest that we look to the AAD website, aad.org, because the AAD has a task force dedicated to providing guidance to the AAD members during this crisis. Please check the AAD website for update.
The National Psoriasis Foundation is issuing guidelines for use of biologics in patients at this time. So those are resources to look for. Some of the ideas I’ve mentioned to you, what other dermatologists are doing in about seeing patients, it’s all coming from AAD recommendations.
Melissa: What other important points should we remember during this time?
Dr Green: Well, I think it’s important that we follow basic techniques, and we remind our patients to wash their hands frequently, and, you know, and to moisturize on our end, to moisturize after they wash their hands, because the CDC’s recommending frequent handwashing, frequent hand‑sanitizing. Those are so drying.
We have to make sure our patients also carry moisturizers around. I recommend cream or petrolatum‑based moisturizers at all times to keep their hands fresh so they’re not overly dried out by all this handwashing.
Melissa: Thank you, Dr Green, and thank you for listening. Again, if you have any additional questions, please submit them in the Feedback Box below, and we’ll be sure to answer them in additional podcasts.