PracticalDermatology

When COVID-19 first arrived in the US in early 2020, there were concerns that psoriasis patients could be at increased risk for severe COVID-19 infection because of the autoimmune nature of the disease and their higher rates of comorbidities.

However, over the last year, most of the data generally suggest that psoriatic patients have similar rates of COVID-19 infection compared to the general population. Multiple new studies from Italy provide no evidence that patients with moderate-to-severe psoriasis on systemic treatment, including biologics, have higher risk of COVID-19 infection and/or increased hospitalization and death related to COVID-19, compared to the general population.

Current Recommendations

The National Psoriasis Foundation (NPF) COVID-19 task force recently published updated guidance for the management of psoriatic disease during the pandemic.¹ They reaffirmed that treatments for psoriasis and/or psoriatic arthritis (PsA) do not appear to meaningfully alter the risk of acquiring SARS-CoV-2 infection or restult in worse COVID-19 outcomes if infected. Based on existing data, it is recommended that patients who are not infected with COVID-19 continue their biologic or oral therapies for psoriasis and/or psoriatic arthritis in most cases.

Furthermore, the CDC doesn’t list people with psoriasis among those deemed highest risk for severe COVID-19, however patients with psoriasis may have additional conditions that increase their risk of COVID-19 severity, including heart disease, diabetes, lung conditions, or kidney and liver disease. In mid-August, the CDC recommended that people who have a compromised immune system get a booster dose of mRNA COVID-19 vaccines. This means that anyone with psoriatic disease who is being treated with immuno-modulating drugs is eligible for a third dose, but the patients who are most likely to benefit include:

• People aged 50 or older
• People taking abatacept, cyclosporine, leflunomide, glucocorticoids (e.g., prednisone), methotrexate, or tofacitinib
• People who received their second dose of an mRNA vaccine more than six months ago
• People with comorbidities known to increase the risk of severe COVID-19, such as being overweight, being a current or former smoker, or having diabetes, cardiovascular disease, chronic lung, liver, or kidney disease.

Patients taking methotrexate with well-controlled psoriatic disease may, in consultation with their prescriber, consider holding the medication for two weeks after receiving a third “booster” mRNA vaccine to potentially improve vaccine response, NPF states.

Many people living with psoriasis have also experienced stress during the COVID-19 pandemic. Some patients have found that their psoriasis symptoms worsened during the pandemic. Data from an international registry, PsoProtectMe, describes the burden of psoriasis and worsening of psoriasis during the pandemic.² Pandemic-related stressors, such as fear of COVID-19 infection, job insecurity, financial struggles, changes to work schedules, and lack of access to health care, contributed to stress, anxiety, and depression.

Proceed with Caution

While we have learned a lot about coronavirus since early 2020, caution should be maintained, and more data are needed to draw definitive conclusions. In my practice, shared decision-making is emphasized by reviewing the known benefits of psoriasis treatment, recognizing the uncertainty related to the COVID-19 pandemic along with discussing the patient’s individual circumstances and preferences.

1. Gelfand JM, 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. 2021 May;84(5):1254-1268.

2. Mahil, SK, et al. (2021). Describing the burden of the COVID-19 pandemic in people with psoriasis: Findings from a global cross-sectional study. J Eur Acad Dermatol Venereol. 2021 Oct;35(10):e636-e640.