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Survey Finds Patients with Psoriasis Think Stopping Biologic Is Appropriate During the Pandemic

A survey of patients with psoriasis found that a majority of respondents stated that they would stop their biologic or reduce their dosage during the pandemic, illustrating a critical need for dermatologists to discuss the relationship between COVID-19 and immunomodulating therapies with their patients.

Researchers from Wake Forest University (Winston-Salem, NC) recruited 1104 participants through Amazon Mechanical Turk to complete a REDCap survey regarding psoriasis and therapy use during the COVID-19 pandemic. Respondents answered a series of questions to assess their understanding of biologic use on a five-point scale (1 = no understanding; 5 = advanced understanding). A five-point scale was also used to assess respondent understanding of the effect of biologics on COVID-19 (1 = increased chance of worse outcomes; 5 = increased chance of better outcomes). Survey participants also answered questions regarding their sources of information on biologic use during the pandemic, sociodemographic characteristics, and medical terminology knowledge.

In total, 281 participants met inclusion criteria (psoriasis diagnosis, aged 18 years or older, biologic use for the treatment of psoriasis). These patients, on average, thought that biologics neither increased nor decreased the risk of worse outcomes from COVID-19 (2.76±1.02). However, a majority of patients stated either stopping or reducing the dosage of their biologic during the pandemic (n=160, 56.9%, and n=160, 56.9%, respectively).

Survey participants also noted receiving information regarding biologic safety during the pandemic from family and friends (n=145, 51.6%). Dermatologists were the second most-used source for information, but respondents noted dermatologists were perceived as the most accurate (n=76, 27%). Approximately one-third of respondents received information on biologic safety from social media (n=93, 33.1%).

“There is a need for dispersal of better, more synchronous information on biologic use during the [COVID-19] pandemic that perhaps leans on physician-vetted, peer-reviewed, published recommendations,” said the research group.

Dermatologists can point their patients with psoriasis towards resources such as the COVID-19 Task Force Guidance Statements from the National Psoriasis Foundation, available at

Pandher K, Porter CL, Patel HS, Huang WW, Feldman SR. Understanding views of patients on biologics for psoriasis amid the COVID‐19 pandemic. J Eur Acad Dermatol Venereol. Published online December 17, 2020. doi:10.1111/jdv.17091

Dr John Koo, director of the University of California, San Francisco, Psoriasis and Skin Treatment Center, explained in a video interview with The Dermatologist how he discusses perceived risks of severe COVID-19 infection and immunomodulatory therapies with his patients. Watch below!

Some things that make patients really worried—one is the possible misunderstanding that people with psoriasis have weak immune system. That is a belief that is held by many patients because they hear something about psoriasis and immune system, and unfortunately, a lot of the patients jumped to the conclusion that “oh, I must have weak immune system.” And that's not true, because psoriasis is a hyperimmune condition. The immune system is actually jazzed up. When your whole body is inflamed, you know, when your blood vessel is chock full of activated immune cells along with very high level of inflammatory mediator, your immune system is not weak—it's actually too much. And that's why we need to use medications like topical steroids or medications like cyclosporine, biologics—we try to bring the immune system down to normal level. You know, so, this pervasive misunderstanding that people who have psoriasis worry that their immune system is weak, I'm happy to correct them that no, their immune system is hyper. The second worry that I like to address, especially with regard to COVID-19, is that many patients are worried that their medications, many of which are labeled as immunosuppressant, that they worry that they might be more susceptible for catching this virus or that if they did get sick with COVID-19 that they may have even worse course of the disease because of the treatment. And this, with regard to their biological agent, there is no convincing evidence that biologic agents, which are the mainstay for most patients, make people more likely to catch virus or that make them sicker if they did get infected.

One thing that's another common misunderstanding that I find my patients have is, if I may use my hand, let's say this hand represents the normal immune system like you and I. Then this hand, my right hand over here—I don't know if it's right or left in your screen—this is the patient's immune system. You know, once again, they often think that immune system is weak, when in fact the immune system is hyper. Then why [do] we use the medications like biologic that is called immunosuppressant? Well, because we need to bring this hyper-immune system back to normal. But what we are not trying to do, not purposely, is to make the immune system weaker than normal. And this is where, once again, misunderstanding or lack of education on the part of the patients make them worry, now needlessly in my opinion, because they think that the medications like biological make them weaker. Yes, some of that happens, you know, for example, Humiara, the anti-TNF, it could make them weaker than average for like tuberculosis, but on the whole, that's not the purpose of biological agent. On the whole, it's actually to make it more like average, and that's especially true for the newer biologic agents, the ones that block interleukin 17. Now, the one that blocks interleukin 17, you might decrease a little bit for superficial fungus and yeast, but [with] interleukin 23, even that is pretty minimal.

You know, so, first thing that I need to do to make the patient feel more comfortable, one is to explain that the immune system is hyper, not immunosuppressed or too weak, and second is their treatment is designed to make them average, not weaker than average. Then when I explain those two, they feel a lot more comfortable.

Now, of course, FDA said that if somebody actually catch COVID-19, if they're actually infected with a virus, you do have to stop all these types of treatments, so we do that, but luckily, most people recover in couple of weeks, so we can restart the medication pretty promptly. You know, so, that doesn't seem to create as much of a problem, it's just that pervasive misunderstanding on those two points creates a lot of anxiety on the part of the patient.

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