There has been a lot of data and recommendations published regarding psoriasis (PSO) and SARS-CoV-2, the virus that causes the COVID-19 illness, but after receiving calls from a few colleagues just this week looking for advice on how to navigate the vaccine and biologics for their patients, I decided to provide a quick and easy reference to aid in answering these questions.
I should mention that these are just recommendations, and each clinician should handle their patients’ questions on a case-by-case basis and engage in shared decision-making. Following the article, you will find a plethora of references available to you should you wish to investigate further. Many thanks to the knowledgeable and brilliant physicians who comprise the National Psoriasis Foundation COVID-19 Task Force; I have them to thank for their expertise and help in answering many of these questions.1,2
Can I expect my patients with PSO to have worse outcomes from infections with COVID-19?
The answer appears to be “no.” Most of the data support the notion that those with PSO and/or psoriatic arthritis (PsA) contract the virus at the same rate and have the same outcome as the general population. Those who have had poorer outcomes have generally had risk factors, and outcomes tend to fall in line with the high-risk general population. For example, underlying conditions and comorbidities, such as chronic heart, lung, or kidney disease; diabetes; obesity; or being of advanced age, are associated with poorer outcomes, regardless of whether a person has PSO. Keep in mind, however, that patients with PSO have a higher risk of having these underlying conditions, so this may warrant a conversation of caution with the patient. Regardless of risk factors, all patients should be reminded to take precautions to prevent infection and spread of SARS-CoV-2.
Should I continue my patients on their immunosuppressive therapies, such as methotrexate or TNF inhibitors, during the pandemic?
There have been several publications suggesting that therapies used for PSO/PsA do not negatively affect the outcomes from COVID-19. This appears to be consistent across other disease states that utilize these same medications, such as rheumatologic conditions and inflammatory bowel disease. In fact, there have been several registries and papers published supporting the notion that TNF inhibitors may offer a protective effect against morbidity and mortality from COVID-19.3,4 Even cyclosporine was not shown to increase the risk of COVID-19 infection in both PSO and atopic dermatitis.5 I have encouraged all of my patients to continue on their medications, and I have initiated both methotrexate and TNF inhibitors on newly diagnosed patients without hesitation. The same goes for the IL-17 and IL-23 classes of biologic therapies.
It should be noted that long-term oral corticosteroid use has been associated with worse COVID-19 illness outcomes, and use should be minimized if possible.6-8
If my patient on a biologic develops COVID-19, should I have them stop until they recover?
Due to limited data, this is a more difficult question to answer, and the decision should be made on a case-by-case basis. Currently, what follows is my approach based on what I have seen in the literature.
If my patient is low-risk and has little to no comorbidities, I have them monitor their signs and symptoms but keep them on their medication. Considering what we have learned about TNF inhibitors potentially being protective, and knowing that IL-17 and IL-23 biologics do not cause global immunosuppression, I allow my patients to continue their biologic. If the patient starts to deteriorate and they are on methotrexate, I have them discontinue until they have recovered.
I have all patients with high-risk comorbidities stop their methotrexate. In regard to biologics, this gets a little trickier, and it may be prudent to follow the prescribing information. If medications are stopped, I recommend my patients reinitiate when fully recovered. I encourage them to be in contact with their primary provider and go to the emergency room if their symptoms become serious and worrisome.
Should my patients get a COVID vaccine? Do they need to hold their biologic medication?
Yes, they should absolutely get vaccinated. All of the currently available vaccines are inactivated, which makes them safe even with biologic use. The most common question I have gotten is whether biologics will blunt the patient’s immune response, and there is a paucity of data regarding all vaccine effectiveness in biologic use. At this time, there is no data regarding SARS-Cov-2 vaccine effectiveness in our patients with PSO on immunomodulatory therapies.
In my literature search, it appears that methotrexate is the most controversial therapy, and it has been found in some cases to lower immune response to vaccines. If methotrexate can be held without causing a severe flare, it may be worth holding it until the vaccination series is complete.9,10 A review on immune response to vaccinations in patients with psoriasis on systemic therapies suggest holding methotrexate for 2 weeks after a vaccination.10
TNF inhibitors without concomitant use of methotrexate do not seem to impair the immune response to vaccines. This is also true for the IL-12/23, IL-17, and IL-23 inhibitors.9,10 Therefore, I have encouraged all of my patients to continue their biologic therapies and get the vaccination at any time of their injection schedule.
The following are references not included in the above summary should you wish to take a deeper look into the data:
Outcomes in Patients with PSO and/or PsA who Develop COVID-19 Illness
- Vispi M, Corradin T, Peccianti C, et al. Psoriasis, biological drugs and coronavirus disease 2019: real life experience of two Italian provinces. Dermatol Rep. 2020;12(1):8642. doi:10.4081/dr.2020.8642
- Zen M, Fuzzi E, Astorri D, et al. SARS-CoV-2 infection in patients with autoimmune rheumatic diseases in northeast Italy: a cross-sectional study on 916 patients. J Autoimmun. 2020;112:102502. doi:10.1016/j.jaut.2020.102502
- Haberman R, Axelrad J, Chen A, et al. Covid-19 in immune-mediated inflammatory diseases — case series from New York. N Engl J Med. 2020;383(1):85-88. doi:10.1056/NEJMc2009567.
- Allocca M, Guidelli GM, Borroni RG, et al. Clinical course of COVID-19 in 41 patients with immune-mediated inflammatory diseases: experience from Humanitas Center, Milan. Pharmacol Res. 2020;160:105061. doi:10.1016/j.phrs.2020.105061
- Kutlu Ö, Metin A. Dermatological diseases presented before COVID-19: are patients with psoriasis and superficial fungal infections more vulnerable to the COVID-19? Dermatol Ther. 2020;33(4):e13509. doi:10.1111/dth.13509
- Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature. 2020;584(7821):430-436. doi:10.1038/s41586-020-2521-4
- Shahidi-Dadras M, Tabary M, Robati RM, Araghi F, Dadkhahfar S. Psoriasis and risk of the COVID-19: is there a role for angiotensin converting enzyme (ACE)? J Dermatolog Treat. Published June 30, 2020. doi:10.1080/09546634.2020.1782819
Effect of Systemic Treatments on COVID-19 Illness
- Pirro F, Caldarola G, Chiricozzi A, et al. The impact of COVID-19 pandemic in a cohort of Italian psoriatic patients treated with biological therapies. J Dermatolog Treat. Published August 4, 2020. doi:10.1080/09546634.2020.1800578
- Georgakopoulos JR, Mufti A, Vender R, Yeung J. Treatment discontinuation and rate of disease transmission in psoriasis patients receiving biologic therapy during the COVID-19 pandemic: a Canadian multicenter retrospective study. J Am Acad Dermatol. 2020;83(4):1212-1214. doi:10.1016/j.jaad.2020.07.021.
- Syed MN, Shin DB, Wan MT, Winthrop KL, Gelfand JM. The risk of respiratory tract infections in psoriasis patients treated with IL-23-pathway inhibiting biologics: a meta-estimate of pivotal trials relevant to decision-making during the COVID-19 pandemic. J Am Acad Dermatol. 2020;83(5):1523-1526. doi:10.1016/j.jaad.2020.06.1014.
- Wan MT, Shin DB, Winthrop KL, Gelfand JM. The risk of respiratory tract infections and symptoms in psoriasis patients treated with interleukin 17 pathway–inhibiting biologics: a meta-estimate of pivotal trials relevant to decision making during the COVID-19 pandemic. J Am Acad Dermatol. 2020;83(2):677-679. doi:10.1016/j.jaad.2020.05.035
- Fougerousse AC, Perrussel M, Bécherel PA. Systemic or biologic treatment in psoriasis patients does not increase the risk of a severe form of COVID-19. J Eur Acad Dermatol Venereol. Published online June 21, 2020. doi:10.1111/jdv.16761.
- Wang CJ, Truong AK. COVID-19 infection on IL-23 inhibition. Dermatol Ther. Published online July 14, 2020. doi:10.1111/dth.13893
- Queiro Silva R, Armesto S, González Vela C, Naharro Fernández C, González-Gay MA. COVID-19 patients with psoriasis and psoriatic arthritis on biologic immunosuppressant therapy vs apremilast in North Spain. Dermatol Ther. 2020;33(6):e13961. doi:10.1111/dth.13961
- Olisova OY, Anpilogova EM, Svistunova DA. Apremilast as a potential treatment option for COVID-19: no symptoms of infection in a psoriatic patient. Dermatol Ther. 2020;33(4):e13668. doi:10.1111/dth.13668
- Valenti M, Facheris P, Pavia G, et al. Non-complicated evolution of COVID-19 infection in a patient with psoriasis and psoriatic arthritis during treatment with adalimumab. Dermatol Ther. 2020;33(4):e13708. doi:10.1111/dth.13708
- Benhadou F, Del Marmol V. Improvement of SARS-CoV-2 symptoms following guselkumab injection in a psoriatic patient. J Eur Acad Dermatol Venereol. 2020;34(8):e363-e364. doi:10.1111/jdv.16590
- Gisondi P, Facheris P, Dapavo P, et al. The impact of the COVID-19 pandemic on patients with chronic plaque psoriasis being treated with biological therapy: the Northern Italy experience. Br J Dermatol. 2020;183(2):373-374. doi: 10.1111/bjd.19158
- Facheris P, Valenti M, Pavia G, et al. Complicated coronavirus disease 2019 (COVID-19) in a psoriatic patient treated with ixekizumab. Int J Dermatol. 2020;59(8):e267-e268. doi:10.1111/ijd.15008
- Messina F, Piaserico S. SARS-CoV-2 infection in a psoriatic patient treated with IL-23 inhibitor. J Eur Acad Dermatol Venereol. 2020;34(6):e254-e255. doi:10.1111/jdv.16468
- Gelfand JM, Armstrong AW, Bell S, et al. National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease during the pandemic: version 1. J Am Acad Dermatol. 2020;83(6):1704-1716. doi:10.1016/j.jaad.2020.09.001
- Gelfand JM, Armstrong AW, Bell S, et al. National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease during the pandemic: version 2—advances in psoriatic disease management, COVID-19 vaccines, and COVID-19 treatments. J Am Acad Dermatol. Published online January 7, 2021. doi:10.1016/j.jaaad.2020.12.058
- Chen XY, Yan BX, Man XY. TNFα inhibitor may be effective for severe COVID-19: learning from toxic epidermal necrolysis. Ther Adv Respir Dis. 2020;14:1753466620926800. doi:10.1177/1753466620926800
- Robinson PC, Liew DFL, Liew JW, et al. The potential for repurposing anti-TNF as a therapy for the treatment of COVID-19. Med (NY). 2020;1(1):90-102. doi:10.1016/j.medj.2020.11.005
- Di Lernia V, Goldust M, Feliciani C. Covid-19 infection in psoriasis patients treated with cyclosporin. Dermatol Ther. 2020;33(4):e13739. doi:10.1111/dth.13739
- Gianfrancesco M, Yazdany J, Robinson PC. Epidemiology and outcomes of novel coronavirus 2019 in patients with immune-mediated inflammatory diseases. Curr Opin Rheumatol. 2020;32(5):434-440. doi:10.1097/BOR.0000000000000725
- Gianfrancesco M, Hyrich KL, Al-Adely S, et al; COVID-19 Global Rheumatology Alliance. Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis. 2020;79(7):859-866. doi:10.1136/annrheumdis-2020-217871
- Brenner EJ, Ungaro RC, Gearry RB, et al. Corticosteroids, but not TNF antagonists, are associated with adverse COVID-19 outcomes in patients with inflammatory bowel diseases: results from an international registry. Gastroenterology. 2020;159(2):481–491.e3. doi:10.1053/j.gastro.2020.05.032
- McMahan ZH, Bingham CO 3rd. Effects of biological and non-biological immunomodulatory therapies on the immunogenicity of vaccines in patients with rheumatic diseases. Arthritis Res Ther. 2014;16(6):506. doi:10.1186/s13075-014-0506-0
- Chiricozzi A, Gisondi P, Bellinato F, Girolomoni G. Immune response to vaccination in patients with psoriasis treated with systemic therapies. Vaccines (Basel). 2020;8(4):769. doi:10.3390/vaccines8040769