There has been a lot of data and recommendations published regarding psoriasis and SARS-CoV-2, the virus that causes the COVID-19 illness, but after receiving calls from a few colleagues 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. In the online posting of this article, you will find a plethora of references should you wish to investigate further. Many thanks to the knowledgeable and brilliant physicians who comprise the National Psoriasis Foundation (NPF) 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 psoriasis 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 psoriasis 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 psoriasis. Keep in mind, however, that patients with psoriasis 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 tumor necrosis factor (TNF) inhibitors, during the pandemic?
There have been several publications suggesting that therapies used for psoriasis/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 psoriasis 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 develops COVID-19, should I have them stop their systemic therapy 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. 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 associated with severe COVID-19 outcomes, 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 and active COVID-19 infection stop their methotrexate. While not an NPF recommendation, the American College of Rheumatology has recommended withholding methotrexate in patients with
active infection regardless of COVID-19 severity.9
Biologics are 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 care 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. 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 psoriasis 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.10-12 A review on immune response to vaccinations in patients with psoriasis on systemic therapies suggest holding methotrexate for 2 weeks after a vaccination.11
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.10,11 Therefore, I have encouraged all of my patients to continue their biologic therapies and to get the vaccine at any time in their injection schedule. We should communicate to patients that even if they are worried about their therapies impairing an immune response to a COVID-19 vaccine, some protection is better than none.
Dr Hawley is an associate clinical professor of dermatology at Michigan State University College of Osteopathic Medicine and medical director of The Derm Institute of West Michigan in Grand Rapids, MI.
Disclosure: The author reports no relevant financial relationships.
Editor’s Note: This article was originally published online in April 2021 at the-dermatologist.com. A full list of additional resources and evidence is available at bit.ly/PsoCOVID-FAQ.
References
1. 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
2. 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
3. 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
4. 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
5. 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
6. 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
7. 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
8. 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
9. Mikuls TR, Johnson SR, Fraenkel L, et al. American College of Rheumatology muidance for the mManagement of rheumatic disease in adult patients during the COVID-19 pandemic: version 3. Arthritis Rheumatol. 2021;73(2):e1-e12. doi:10.1002/art.41596
10. 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
11. 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
12. COVID-19 vaccine clinical guidance summary for patients with rheumatic and musculoskeletal diseases. American College of Rheumatology; April 28, 2021. Accessed May 11, 2021. https://www.rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-Guidance-Rheumatic-Diseases-Summary.pdf
