COVID-19 and biologics for psoriasis: A high-epidemic area experience-Bergamo, Lombardy, Italy.

To the Editor: A severe outbreak of coronavirus disease 2019 (COVID-19) emerged in China in December 2019 and has rapidly spread worldwide. A large number of people in Italy have been infected with COVID-19, and it has become a serious public health emergency. The first case in our hospital was identified on February 21, 2020.

Information is still limited regarding the new coronavirus and its impact on patients receiving long-term immunosuppressive therapy. In a precoronavirus era, respiratory infection rates for biologic therapy patients were comparable to placebo.

As suggested by the Italian Society of Dermatologists (SIDeMaST), we advise patients treated with biologic drugs to carefully comply with hygiene rules, use protective devices, maintain social distancing, and to not spontaneously suspend ongoing therapy but to inform the dermatologist in case of symptoms. We report our experience with patients treated with biologic therapy for psoriasis in Bergamo, an area of high epidemic rates for COVID-19.

Patients being treated at the psoriasis outpatient service of the Bergamo Hospital live in Bergamo (86.2% [n = 137]), Milan (6.3% [n = 10]), Brescia (4.4% [n = 7]), Lecco (1.9% [n = 3]), and Lodi (1.3% [n = 2]), all Lombardy region areas with a high incidence rate of COVID-19 infections.

All patients were contacted by telephone or underwent a dermatologic visit 40 to 45 days after the beginning of the COVID-19 epidemic (population characteristics are reported in Table I ). Twenty-five patients (15.7%) reported contacting individuals with established (positive nasal swab test) or suspected COVID-19. Symptoms suggestive of COVID-19 developed in 18 of these 25 patients (72.0%; 15 mild, 3 moderate) (Table I).

Table I

Characteristics of patients with psoriasis on biologic therapy

Variable	All patients
Age, mean ± SD (range), y	51.5 ± 14.0 (17-84)
Sex
Male, % (n/N)	71.7 (114/159)
Female, % (n/N)	28.3 (45/159)
Biologic therapies
Anti–TNF-α (adalimumab, etanercept, golimumab), % (n/N)	33.3 (53/159)
Anti–IL-17 (secukinumab, ixekizumab, brodalumab), % (n/N)	47.8 (76/159)
Anti–IL-12/-23 (ustekinumab, guselkumab), % (n/N)	18.9 (30/159)
Contact with suspected/confirmed COVID-19 patient, % (n/N)	15.7 (25/159)
Patients with positive COVID-19 nasal swab, % (n/N)∗	0.0 (0/159)
Suspected COVID-19 symptoms, % (n/N)†	18.2 (29/159)
Mild	15.7 (25/159)
Moderate	1.9 (3/159)
Severe	0.6 (1/159)
Patients who had drug suspended, % (n/N)	5.6 (9/159)

IL, Interleukin; TNF, tumor necrosis factor.

In March 2020 almost only hospitalized patients were tested with COVID-19 nasal swab (n = 0/1 positive nasal swab/hospitalized patients)

Suspected COVID-19 symptoms defined as: Mild: flu-like symptoms, cough, low-grade fever, anosmia/ageusia, resolved in ≤7 days without hospitalization. Moderate: flu-like symptoms, cough, low-grade fever, anosmia/ageusia, resolved in 8-16 days without hospitalization. Severe: serious symptoms that required hospitalization; 1 patient reported serious symptoms that required hospitalization (pneumococcal pneumonia with negative COVID-19 nasal swab).

Six patients contacted us to report respiratory symptoms; as a precaution, given the limited information available on the risk due to COVID-19, we temporarily discontinued therapy for up to 30 days after the symptoms resolved. One patient reported serious symptoms that required hospitalization (pneumococcal pneumonia with negative COVID-19 nasal swab). Three patients without symptoms stopped therapy on their own and reported worsening of psoriasis; all resumed treatment after receiving reassurances. Twenty-three patients reported having had symptoms consistent with COVID-19 (22 mild, 1 moderate) but did not stop therapy. There were no significant demographic or comorbidity differences between patients who had COVID-19–like symptoms and those who did not (Table II ).

Table II

Characteristics of patients with suspected COVID-19 symptoms

Variable	With suspected COVID-19 symptoms		Without suspected COVID-19 symptoms	P∗
Age, mean ± SD (range), y	46.6 ± 12.7 (23-77)		52.8 ± 14.1 (17-84)	.04
Sex
Male, % (n/N)	62.1 (18/29)		73.6 (96/130)	.20
Female, % (n/N)	37.9 (11/29)		26.2 (34/130)	.20
Cardiometabolic comorbidities, % (n/N)†	13.8 (4/29)		20.0 (26/130)	.44
Contact with suspected/confirmed COVID-19 patient, % (n/N)	62.1 (18/29)		5.4 (7/130)	<.0001
Patients who had drug suspended, % (n/N)	20.7 (6/29)		2.3 (3/130)	<.0001
	Therapy suspended	Therapy continued
Age, mean ± SD (range), y	50.7 ± 14.6 (38-77)	45.6 ± 12.3 (23-68)		.39
Sex
Male, % (n/N)	50.0 (3/6)	65.2 (15/23)		.49
Female, % (n/N)	50.0 (3/6)	34.8 (8/23)		.49
Suspected COVID-19 symptoms‡
Mild, % (n/N)	50.0 (3/6)	95.7 (22/23)
Moderate, % (n/N)	33.3 (2/6)	4.3 (1/23)		.01
Severe, % (n/N)	16.7 (1/6)	0.0 (0/23)

Statistical analysis was performed by t test and χ2 test. Significance value was set at P < .05.

Myocardial infarction, stroke, diabetes, obesity, dyslipidemia, or nonalcoholic fatty liver disease.

Suspected COVID-19 symptoms defined as: Mild: flu-like symptoms, cough, low-grade fever, anosmia/ageusia, resolved in ≤7 days without hospitalization. Moderate: flu-like symptoms, cough, low-grade fever, anosmia/ageusia, resolved in 8-16 days without hospitalization. Severe: serious symptoms that required hospitalization; 1 patient reported serious symptoms that required hospitalization (pneumococcal pneumonia with negative COVID-19 nasal swab).

We observed a significant risk of infection in our area, especially for those who had close contacts with individuals potentially infected with COVID-19. Therefore, we think it is essential to advise and empower patients on activities that can help to limit the risk of infection. Fortunately, serious cases of COVID-19 infection have not been reported, and even patients who continued therapy showed almost exclusively mild symptoms. As a precaution, we decided on a case-by-case basis whether to discontinue therapy; however, we did not observe a more aggressive course of suspected COVID-19 symptoms in patients who continued treatment. Moreover, we observed the importance of creating an easy communication channel to provide clinical and human support for patients. Further observation on a larger number of patients is needed to investigate the risk of COVID-19 infection.