Risk of COVID-19 in dermatologic patients receiving long-term immunomodulatory therapy.

To the Editor: As the coronavirus disease 2019 (COVID-19) pandemic has rapidly spread around the globe, concern has been raised regarding susceptibility of patients receiving immunomodulatory therapies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Although general guidance has been put forth, data regarding infection rate and outcomes in immunosuppressed patients are still rare. Recent articles, including the work by Gisondi et al, suggest that outcomes of patients receiving systemic immunomodulatory therapies who are infected with SARS-CoV-2 are similar to those of the general population. These findings may relate to the aberrant cytokine and inflammatory responses in severe COVID-19, which may be treated or partially blunted by cytokine-targeted therapy. Given the substantial outbreak of COVID-19 in our community, we tested whether, in addition to similar outcomes, patients receiving systemic immunomodulatory therapy had infection rates similar to those of the general population.

We performed a retrospective cross-sectional analysis of patients treated across all providers at Beth Israel Deaconess Department of Dermatology. Our clinical practice has 412 patients receiving systemic immunomodulatory medications, including biologics and traditional immunosuppressives, prescribed within the past year. Patients were surveyed by a clinic telephone call, by a telemedicine visit, or through an outreach wellness check-in call from March 15 to May 8, 2020, corresponding to the peak incidence of new cases of COVID-19 in Massachusetts.

Of our 412 patients, 327 were successfully contacted, with approximately 80% contacted after April 19, 2020. We were not able to identify any hospitalizations in Boston-area hospitals for the other 85 patients. Results are shown in Table I , with age distributions and conditions requiring immunomodulatory therapy displayed in Fig 1 . There were no statistical differences in age, sex, or medications between the patients who were reached and those who were not.

Table I

Baseline characteristics of patients receiving immunosuppressive therapy

Characteristic	All patients (n = 412)	Patients with positive and presumed-positive results (n = 5)
Demographics
Mean age (SD), y	48.2 (15.9)	48.4
Men, No. (%)	196 (48)	2 (40)
Women, No. (%)	216 (52)	3 (60)
Live in Massachusetts, No. (%)	382 (93)	5 (100)
Medications, No. (%)
Biologics
TNFα inhibitor	117 (28.4)	2 (40)
IL-17 inhibitor	29 (7)	0
IL-23 inhibitor	30 (7.3)	0
IL-12/23 inhibitor	54 (13.2)	1 (20)
JAK inhibitor	12 (2.9)	0
Traditional immunosuppressives No. (%)
Methotrexate	48 (11.7)	1 (20)
Cyclosporine	5 (1.2)	0
Mycophenolate mofetil	8 (1.9)	0
Other immunomodulatory therapies, No. (%)
IL-4Rα inhibitor	65 (15.8)	0
Apremilast	26 (6.3)	1 (20)
Multiple medications (combination of multiple biologics, traditional immunosuppressives, and other immunomodulatory therapies)	18 (4.4)	0
COVID-19 outcomes, No. (%)
COVID-related hospitalization	1 (0.2)	1 (20)
Any cause of death	0	0
Degree of contact with others, No. (%)
	n = 260	n = 5
None (patient generally not leaving home)	158 (60.8)	1 (33)
Patient with minimal degree of contact at work	31 (11.9)	0
Patient with minimal degree of contact at home	31 (11.9)	1 (33)
Patient with minimal degree of contact both at work and home	9 (3.5)	0
Patient with high degree of contact at work and home	22 (8.5)	1 (33)
Household member with high degree of contact at work	9 (3.5)	0
COVID-19 symptoms/testing, No. (%)
	Patients self-reporting symptoms (n = 25)∗	Patients with positive and presumed-positive results (n = 5)
Patients with symptoms and positive COVID-19 PCR test result	2 (8)	2 (40)
Patients with symptoms and negative COVID-19 PCR test result	9 (36)	1 (20)†
Patients with symptoms who were not tested for COVID-19	14 (56)	2 (40)†

IL, Interleukin; JAK, Janus kinase; PCR, polymerase chain reaction; TNF, tumor necrosis factor.

Symptoms include any patient-reported symptom of cough, fever, diarrhea, body aches, loss of smell, or dyspnea. These patients would meet COVID-19 testing criteria at our institution while receiving immunosuppression.

Patient was evaluated by a primary care physician who believed that the patient had COVID-19.

Fig 1

A, Age distributions of all patients receiving immunomodulatory therapy. B, Underlying diagnoses being treated. ∗Other diagnoses included bullous pemphigoid (6), pyoderma gangrenosum (4), alopecia areata (2), lichen planopilaris (2), unspecified pruritus (2), vasculitis (2), acne keloidalis nuchae (1), discoid lupus erythematosus (1), granuloma annulare (1), lichen planus (1), lichen simplex chronicus (1), morphea (1), pemphigus vulgaris (1), pityriasis lichenoides (1), pityriasis rubra pilaris (1), and systemic lupus erythematosus (1).

As one of the hot spots of viral spread in the United States, Boston and the surrounding areas are ideal locations for studying effects of viral transmission. At data collection, slightly greater than 1% of Massachusetts residents had received a diagnosis of COVID-19, and slightly fewer than 10% of these patients required hospitalization. These numbers were similar in our patient population, with only 5 infections and 1 hospitalization, suggesting that the risk of both COVID-19 and poor outcomes is minimally affected by dermatologic immunomodulatory medications. However, many patients were successfully isolating to a large degree, and the low infectious rates appear to be due, at least in part, to enhanced social distancing efforts. As has been proposed previously, our findings suggest that when combined with patient education and encouragement to minimize exposure risks, systemic immunomodulatory therapies for dermatologic indications can be safely continued during the COVID-19 pandemic.

Limitations include the unknown number of asymptomatic infections, lack of available confirmatory COVID-19 testing in some cases, and the effect of social distancing as a confounding factor on infection rates. Also, our practice consists of only adult patients. Despite these limitations, we did not observe evidence of increased infectious risk, and we hope that these data will inform treatment decisions for patients who need these medications despite the ongoing COVID-19 pandemic.