Comment on "COVID-19 and psoriasis: Is it time to limit treatment with immunosuppressants? A call for action".

Dear Editor

Italian authors published recently in the journal of Dermatologic Therapy their recommendations for treatment of patients with psoriasis at time of new COVID‐19 pandemic. The authors pointed to the importance of therapeutic reassessment of all psoriatic patients, particularly those with moderate‐to‐severe disease, who are candidate to systemic, mostly immunosuppressive, therapies in the era of COVID‐19. The authors recommended topical and/or drugs with a lower impact on the immune system to avoid spread of the infection. Though of interest, we have few points to comment on these recommendations based on the current literature review.

Psoriasis is a worldwide systemic inflammatory disease that has been associated with a number of comorbidities and increased mortality. Older patients with moderate‐to‐severe disease are more prone to cardiovascular and neurological comorbidities, such as hypertension and dementia, respectively. Independent of treatment, there is a twofold increased risk of serious infections among older adults with psoriasis compared to those without psoriasis. COVID‐19‐infected patients with hypertension are associated with higher rate of morbidity and mortality. COVID‐19 virus has neurotropic potential that partially explains the higher rate of acute respiratory distress in elderly patients.2, 3

Psoriasis inflammatory mediators/cytokines may be amplified by viral infection, such as hepatitis C virus (HCV). Recently, researchers documented acute psoriasis flares following established respiratory virus infection, with rhinovirus and coronavirus as the most frequently detected pathogens, without evidence for group A Streptococcus. Psoriasis patients appear to have a slightly increased risk of cancer, particularly keratinocyte cancer, and lymphomas, regardless of their systemic therapies. Cancer patients are more susceptible to viral pneumonias, such as COVID‐19, due to weakened immune response to respiratory bacteria and virus. Neuroinvasive propensity of COVID‐19 is partially responsible for the acute respiratory failure of COVID‐19 patients.

Flare‐up of psoriasis usually controlled with systemic biologic or nonbiologic therapy and phototherapy. Schneeweiss et al found no evidence that biologics increase the 6‐month risk of serious infections when compared to systemic nonbiologics or phototherapy in elderly patients (≥65). Older adults should be offered the same level of disease control as all psoriasis patients. Others noted that new users of apremilast, etanercept, and ustekinumab are at lower risk rate of serious infection compared with those on methotrexate. interleukin 17 inhibitors have lower effects on personal immune functions compared to traditional immunosuppressives and could be also considered in the priority. The tumor necrosis factor‐α inhibitors, adalimumab is currently under evaluation for use in treating severe COVID‐19 pneumonia. Unwise patients stopping biologics temporarily with or without their physician recommendation may lead to development of antidrug antibodies, and possible loss of response when these drugs reintroduced.10, 11

According to a very recent study testing direct acting antiviral drugs against COVID‐19 model, the author noted that sofosbuvir, ribavirin, and remedisvir can tightly bind to COVID‐19 RNA‐dependent RNA polymerase and contradict its function leading to viral eradication. That would be plausible for patients living in HCV‐high prevalent countries, such as Italy. ultraviolet A1 (UVA1) phototherapy has a comparable efficacy in moderate‐to‐severe plaque‐type psoriasis and could improve the clinical manifestations and quality of life more quickly than narrow band ultraviolet B therapy with no significant side effects, including lack of increased risk of cutaneous malignancies.13, 14

With the recent COVID‐19 outbreak, dermatologists should prioritize and individualize treatment protocols to psoriatic patients based on diseases severity, patients medical conditions, and viral invasiveness. For biologics in the precoronavirus era, respiratory infection rates were comparable to placebo. Biologics may be tried in elderly patients with psoriasis. For the absolute highest risk patients, those with cardiovascular and pulmonary comorbidities, the risk‐benefit may favor discontinuation on a case‐by‐case basis. UVA1 may be also considered. HCV‐positive patients coinfected with COVID‐19 may benefit from direct acting antiviral. In other word, patients ranking for aggressive or conventional treatment modalities are to be considered.