PracticalDermatology

Just weeks ago, the World Health Organization declared COVID-19 a global pandemic. The order to “shelter in place” for two weeks in California has now been in place for five weeks and is expected (as of this writing) to be in effect at least until May 15. Doctors and scientists continue to learn about the exact nature of the coronavirus, including how it spreads, how long people are considered contagious following exposure, and how to best measure immunity. The vast majority of deaths continue to occur in the elderly and those with underlying health conditions. In the dermatology community, many concerns have arrived, including the potential impact of the disease on patients with psoriasis. Psoriasis patients, in particular, may have several high-risk comorbidities, and they are treated with immunomodulatory medications. How do we continue to manage psoriasis patients and ease their concerns in the era of COVID-19?

Assessing Safety

First and foremost, dermatologists must re-examine the safety of psoriasis treatments and determine what treatments should be considered “essential” during the COVID-19 pandemic. Multiple professional organizations, including the American Academy of Dermatology, the National Psoriasis Foundation, and the International Psoriasis Council, do not recommend that psoriasis patients stop biologic therapy in the absence of COVID-19 infection. At this early stage, there is no specific data on susceptibility to the virus among psoriasis patients.

There is data on infections—specifically upper respiratory tract infections (URTI) and nasopharyngitis—in patients using biologics from pivotal trials of biologics for psoriasis. In a recent Letter to the Editor in the Journal of the American Academy of Dermatology, Mark Lebwohl, MD and colleagues note that overall infections and upper respiratory tract infections (URTI) were increased by up to seven percent among psoriasis patients taking tumor necrosis factor (TNF) inhibitors (adalimumab, infliximab, certolizumab), but not etanercept, when compared with their counterparts taking placebo.¹ TNF blockers already come with a boxed warning for serious infections. Compared to placebo, the IL-12/23 blocker ustekinumab showed a small increase of two percent in overall infections but no increase in respiratory tract infections. The IL-17 blockers (secukinumab, ixekizumab, brodalumab) showed increases in overall infections, mostly due to cutaneous candidiasis, however no change in URTI (except for a slight increase with secukinumab). Finally, IL-23 blockers (guselkumab, tildrakizumab, risankizumab) showed an increase of nine percent in overall infections while upper respiratory infections were increased slightly in some trials but not in others.

Comparing the Efficacy of Approved Biologics

Safety is one important component of managing psoriasis, but choosing a biologic from the 11 FDA-approved biologics for psoriasis can be difficult. Recently, April Armstrong, MD and colleagues published in JAMA Dermatology a meta-analysis of 60 clinical trials comparing the efficacy of biologics and oral therapies.² They found risankizumab, brodalumab, ixekizumab, and guselkumab had the highest estimated Psoriasis Area and Severity Index (PASI)-90 improvement at weeks 10-16 (71.6 percent, 70.8 percent 70.6 percent, and 67.3 percent, respectively). These findings were consistent for short-term and long-term PASI responses. In the absence of head-to-head randomized studies, which are very expensive and time-consuming, this study allows comparison of efficacies among treatments for moderate to severe plaque psoriasis and helps us optimize treatment regimens.

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COVID-19 Impact

As part of the new series, Dermatology Dispatches, Practical Dermatology® magazine asked leading physicians about the impact of COVID-19 on management of common dermatoses. Jay Wu, MD, Founder of the San Diego Dermatology Symposium to be held in September, offers his take on how the pandemic affects care for patients with psoriasis.
Watch Now: PracDerm.com/COVIDWu

Do Not Delay

Wherever you are, COVID-19 has affected your ability to continue taking care of your existing psoriasis patients who are on systemic treatments. The government has significantly relaxed regulations around telemedicine so that physicians can continue to provide care during the pandemic. Telehealth visits ensure that psoriasis patients are monitored and continue safely on their medications, especially biologics and oral systemics. Insurers continue to require documentation of response to treatment to process prior authorizations for biologics. Importantly, care should not be delayed during the pandemic.

1. Lebwohl M, Rivera-Oyola R, Murrell DF. Should biologics for psoriasis be interrupted in the era of COVID-19? J Am Acad Dermatol. 2020 Mar 18. [Epub ahead of print] https://www.jaad.org/article/S0190-9622(20)30445-X/pdf

2. Armstrong AW, Puig L, Joshi A, et al. Comparison of Biologics and Oral Treatments for Plaque Psoriasis: A Meta-analysis . JAMA Dermatol. 2020;156(3):258–269. doi:10.1001/jamadermatol.2019.4029