Biologic agents in psoriasis: our experience during coronavirus infection.

Dear Editor,

Since December 2019, a novel coronavirus (SARS‐CoV‐2) was reported in Wuhan, Hubei Province, China, causing severe acute respiratory syndrome, particularly in the elderly population, with quick spread worldwide. Clinical presentation can range from no symptoms to fever, dry cough, fatigue, sore throat, until severe pneumonia and death. It remains unknown to what extent SARS‐CoV‐2 infection impacts chronic inflammatory skin diseases, such as psoriasis, and their treatment. In particular, there is no clear evidence if systemic treatment such as biologic agents can increase the risk of infection or worsen the course of COVID‐19. We report here our experience with COVID‐19 infection in psoriatic patients treated with biologic agents. One‐hundred thirty‐nine patients in biologic therapy for chronic plaques psoriasis, followed at our Hospital in Lecco, Northern Italy (the most coronavirus affected area in Italy), were reviewed for evidence of COVID‐19 infection. Clinical data, aimed at the detection of SARS‐CoV‐2 related symptoms, were obtained as follows: 40% of the patients were directly examined in a scheduled visit from March 9th to May 6th; the other patients were interviewed by phone in the period from May 4th to 6th. Clinical history and comorbidities were retrieved from medical records. Five patients, all of whom were in treatment for more than a year, developed symptoms consistent with SARS‐CoV‐2 infection (Table 1). Three patients developed fever and flu‐like symptoms, and two developed pneumonia. A nasopharyngeal swab gave a positive result for SARS‐CoV‐19 in three patients, whilst two patients had no specific diagnostic tests but had symptoms highly suggestive of SARS‐CoV‐2 infection and reported contact with positive COVID‐19 relatives. The mean age was 51.8 years (range 36–72). Hospitalization was necessary for one patient, diagnosed with interstitial pneumonia, receiving therapy with infliximab. In the specific case, the patient was treated with mask oxygen therapy, azithromycin, hydroxychloroquine, lopinavir, and enoxaparin. The patient was discharged after 2 weeks. Biologic therapies are engineered to target specific mediators of inflammation, such as tumor necrosis factor‐alpha, interleukin 17, and interleukin 23, therefore they have the potential to impact both on the risk of viral infection and on the risk of more severe disease. The incidence of SARS‐CoV‐2 infection in our psoriatic patients (3.6%) is higher than that of the general population in the Lecco district (0.7%, data as of May 4th from the Italian Ministry of Health), but the small sample investigated does not allow to draw reliable conclusions about any increased risk of infection. In our series, biologic therapy does not seem to worsen the severity of COVID‐19, since all our patients had a mild course of the disease with complete resolution in 2–3 weeks. This finding is consistent with previous observations in rheumatologic patients. A hypothesis could be that biologic therapies would lessen the overall inflammatory response to SARS‐CoV‐2. In conclusion, the lack of scientific data, at the moment, does not enable us to set reliable guidelines to help with patients in immunomodulating therapy in the COVID‐19 era. All in all, our limited experience suggests that biologic therapies, probably because of their mechanism of action, do not seem to increase the severity of COVID‐19 nor the risk of complications. Additional data are needed to confirm this preliminary observation.

Table 1

Characteristics of patients

Patient	Gender	Age	Covid‐19 swab	Manifestations	Biologic therapy	Start of therapy	Comorbidity	Hospitalization
1	F	63	+	Interstitial pneumonia	Etanercept	2008	—	‐
2	F	43	+	Fever, fatigue, ageusia, anosmia	Adalimumab	2015	Psoriatic arthritis	‐
3	M	45	Not performed	Fever, fatigue, dry cough	Ustekinumab	2018	—	‐
4	F	36	Not performed	Fever, fatigue, dry cough	Ixekizumab	2018	Psoriatic arthritis	‐
5	M	72	+	Interstitial pneumonia	Infliximab	2013	Nonalcoholic fatty liver disease, hypertension, obesity (BMI 35)	+

Abbreviations: F, female; M, male; +, positive; BMI, body mass index.