Concerns related to the coronavirus disease 2019 pandemic in adult patients with atopic dermatitis and psoriasis treated with systemic immunomodulatory therapy: a Danish questionnaire survey.

Dear Editor

Patients with moderate‐to‐severe atopic dermatitis (AD) or psoriasis often require systemic immunomodulatory therapy. The uncertainty of the potential of these therapies to increase the risk of more serious illness due to coronavirus disease 2019 (COVID‐19) may have caused anxiety and led to treatment discontinuation. Therefore, we conducted an anonymous questionnaire on concerns of COVID‐19 in patients with AD or psoriasis treated with systemic immunomodulatory therapy.

Adult AD and psoriasis patients with an outpatient visit at the Department of Dermatology at Aarhus University Hospital or Gentofte Hospital, Denmark, between 2 April 2020 and 15 June 2020 were invited to participate. We assessed whether patients were concerned about becoming ill with COVID‐19 due to their disease and/or their systemic immunomodulatory therapy and whether patients discontinued their treatment during the COVID‐19 pandemic.

A total of 301 adult patients including 68 with AD and 233 with psoriasis completed the questionnaire. Of these, 35.7% were female and 24.5% were ≥60 years old (Table 1). The most common comorbidities were hay fever (69.1%) and asthma (60.3%) among AD patients, and psoriatic arthritis (32.6%) and cardiovascular diseases (18.0%) among psoriasis patients. Patients felt to a great extent well treated (67.0%) and safe about their treatment in general (76.4%).

Table 1

Baseline demographics

	Patients with atopic dermatitis n = 68	Patients with psoriasis n = 233	All patients n = 301
Female, n (%)	31 (46.3)	74 (32.6)	105 (35.7)
Age, n (%)
18–29 years	15 (22.1)	27 (11.7)	42 (14.1)
30–39 years	10 (14.7)	38 (16.5)	48 (16.1)
40–49 years	19 (27.9)	49 (21.2)	68 (22.7)
50–59 years	12 (17.7)	56 (24.2)	68 (22.7)
60–69 years	6 (8.8)	43 (18.6)	49 (16.4)
70–79 years	5 (7.4)	17 (7.4)	22 (7.4)
80–89 years	1 (1.5)	1 (0.4)	2 (0.7)
Smoking status, n (%)
Current smoker	19 (28.4)	60 (26.0)	79 (26.5)
Prior smoker	18 (26.9)	109 (47.2)	127 (42.6)
Never smoker	30 (44.8)	62 (26.8)	92 (30.9)
Comorbidities, n (%)
Hay fever	47 (69.1)	32 (13.7)	79 (26.3)
Asthma	41 (60.3)	25 (10.7)	66 (21.9)
COPD	5 (7.4)	7 (3.0)	12 (4.0)
Diabetes	2 (2.9)	29 (12.5)	31 (10.3)
Cardiovascular diseases	9 (13.2)	42 (18.0)	51 (16.9)
Cancer (ex. skin cancer)	1 (1.5)	8 (3.4)	9 (3.0)
Psoriatic arthritis	—	76 (32.6)	—
Type of treatment, n (%)†
Conventional systemics	38 (55.9)	114 (48.9)	152 (52.5)
Prednisolone	12 (17.7)	0	12 (4.0)
Biologics	30 (44.1)	155 (66.5)	185 (61.5)
Duration of treatment, n (%)
<12 months	30 (44.1)	59 (25.3)	89 (29.6)
≥12 months	38 (55.9)	174 (74.7)	212 (70.4)
Feeling disease being well treated, n (%)
To a great extent	36 (55.4)	163 (70.3)	199 (67.0)
To some extent	18 (27.7)	57 (24.6)	75 (25.3)
To a lesser extent	10 (15.4)	10 (4.3)	20 (6.7)
Not at all	1 (1.5)	2 (0.9)	3 (1.0)
Feeling safe about treatment, n (%)
To a great extent	37 (56.9)	190 (81.9)	227 (76.4)
To some extent	24 (36.9)	36 (15.5)	60 (20.2)
To a lesser extent	3 (4.6)	6 (2.6)	9 (3.0)
Not at all	1 (1.5)	0	1 (0.3)

COPD, chronic obstructive pulmonary disease; COVID‐19, coronavirus disease 2019; ex, excluding.

Some patients used more than one of the three types of therapies.

We found that 52.7% were concerned about becoming ill with COVID‐19 due to their skin disease and 68.0% due to their treatment, respectively, and 7.3% discontinued their treatment. No differences were observed for age, type of treatment or treatment duration, but female patients were more concerned about becoming ill with COVID‐19 due to their treatment than male patients (Table 2). AD patients with asthma were more concerned about becoming ill with COVID‐19 due to their AD and treatment, whereas psoriasis patients with psoriatic arthritis were more concerned about becoming ill due to psoriasis (Table 2). Further, patients who in general felt unsafe about their treatment were more concerned about becoming ill with COVID‐19 (P < 0.01) and were more likely to discontinue their treatment during the COVID‐19 pandemic (P = 0.018).

Table 2

Proportion of patients concerned due to COVID‐19 and discontinuing treatment during the COVID‐19 pandemic

	Patients concerned of their skin disease due to COVID‐19			Patients concerned of treatment due to COVID‐19			Patients discontinued treatment during COVID‐19 pandemic
	Yes	No	P‐value	Yes	No	P‐value	Yes	No	P‐value
	n = 159	n = 142		n = 205	n = 96		n = 22	n = 279
Sex, n (%)
Female	62 (39.7)	43 (31.2)	0.13	80 (39.8)	25 (26.9)	0.032	10 (45.5)	95 (34.9)	0.32
Male	94 (60.3)	95 (68.8)		121 (60.2)	68 (73.1)		12 (54.5)	177 (65.1)
Age, n (%)
<60 years	123 (77.4)	105 (73.9)	0.49	154 (75.1)	74 (77.1)	0.71	19 (86.4)	209 (74.9)	0.23
≥60 years	36 (22.6)	37 (26.1)		51 (24.9)	22 (22.9)		3 (13.6)	70 (25.1)
Type of treatment, n (%)
Biologics	103 (64.8)	82 (57.8)	0.21	133 (64.9)	52 (54.2)	0.08	11 (50.0)	174 (62.4)	0.25
Systemics	85 (53.5)	67 (47.2)	0.28	106 (51.7)	46 (47.9)	0.54	13 (59.1)	139 (49.8)	0.4
Prednisolone	9 (5.7)	3 (2.1)	0.12	9 (4.4)	3 (3.1)	0.6	1 (4.6)	11 (3.9)	0.75
Duration of treatment, n (%)
<12 months	48 (30.2)	41 (28.9)	0.8	63 (30.7)	26 (27.1)	0.52	6 (27.3)	83 (29.8)	0.81
≥12 months	111 (69.8)	101 (71.1)		142 (69.3)	70 (72.9)		16 (72.7)	196 (70.3)
Precautions during COVID‐19, n (%)
All precautions	133 (83.7)	65 (45.8)	<0.0001	161 (78.5)	37 (38.5)	<0.0001	—	—	—
Sought advice	98 (61.6)	51 (35.9)	<0.0001	119 (58.1)	30 (31.3)	<0.0001	15 (68.2)	134 (48.0)	0.07
Discontinued treatment	6 (10.1)	16 (4.2)	0.052	20 (9.8)	2 (2.1)	0.017	—	—	—
Social isolation	70 (44.0)	27 (19.0)	<0.0001	88 (42.9)	9 (9.4)	<0.0001	11 (50.0)	86 (30.8)	0.06
Comorbidities, n (%)
Hay fever†	33 (75.0)	14 (58.3)	0.16	27 (39.7)	20 (29.4)	0.27	2 (66.7.1)	45 (69.2)	0.93
Asthma†	32 (72.7)	9 (37.5)	0.0046	26 (72.2)	15 (46.9)	0.033	3 (100)	38 (58.5)	0.15
COPD	8 (5.0)	4 (2.8)	0.33	10 (4.9)	2 (2.1)	0.25	4 (18.2)	8 (2.9)	0.0004
Diabetes	16 (10.1)	15 (10.6)	0.89	19 (9.3)	12 (12.5)	0.39	4 (18.2)	27 (9.7)	0.21
Cardiovascular diseases	25 (15.7)	26 (18.3)	0.55	31 (15.1)	20 (20.8)	0.22	4 (18.2)	47 (16.9)	0.87
Cancer (ex. skin cancer)	4 (2.5)	5 (3.5)	0.61	4 (2.0)	5 (5.2)	0.12	0 (0)	9 (3.2)	0.39
Psoriatic arthritis†	51 (41.5)	25 (22.7)	0.0023	58 (36.0)	18 (25.0)	0.09	8 (42.1)	68 (31.8)	0.36
Feeling disease being well treated, n (%)
Yes, to a great extent	102 (64.2)	97 (68.3)	0.45	133 (64.9)	66 (68.8)	0.51	8 (36.4)	191 (68.5)	0.0022
Feeling safe about treatment, n (%)
Yes, to a great extent	108 (67.9)	119 (83.8)	0.0014	141 (68.8)	86 (89.6)	<0.0001	12 (54.6)	215 (77.1)	0.018
COVID‐19 symptoms, n (%)
Yes, having symptoms	32 (21.7)	17 (14.3)	0.12	40 (21.6)	9 (11.1)	0.042	9 (40.9)	40 (16.4)	0.0045

COPD, chronic obstructive pulmonary disease; COVID‐19, coronavirus disease 2019; ex, excluding.

P‐values < 0.05 are marked in bold.

Only patients with atopic dermatitis. ‡Only patients with psoriasis.

Fear of serious consequences of COVID‐19 infection might lead patients to discontinue treatment without consulting a dermatologist. An Italian study found 5.2% of 515 psoriasis patients treated with biologics discontinued therapy by themselves. We found 7.3% patients discontinued their therapy. Interestingly, as Denmark has a low proportion of COVID‐19 cases, treatment discontinuation could be driven by media‐induced fear instead of COVID‐19 infections. Indeed, patients who discontinued treatment felt less safe with their treatment in general, highlighting the need of identifying these patients and informing them accordingly. More than half the patients found themselves concerned about becoming ill with COVID‐19 due to their disease and/or their treatment. This could be attributed to comorbidities related to increased risk for severe COVID‐19 infection, e.g. asthma in AD patients and conflicting information regarding COVID‐19. During the early phases of the COVID‐19 pandemic, experts disagreed on how to act regarding immunomodulatory therapy. , , Since then, studies have not found an increased risk of serious consequences of COVID‐19 infection in AD or psoriasis patients treated with immunomodulatory therapies. , , These therapies may even have a protective role against the cytokine storm seen in critical cases of COVID‐19. Currently, trials for targeted immunomodulatory therapies investigating the efficacy in COVID‐19 are undergoing, and dexamethasone has already shown promising results. Some limitations should be considered, e.g. the self‐reported nature of the study and that only patients with an outpatient visit at the department of dermatology were included resulting in risk of selection bias. In conclusion, identifying and informing patients feeling unsafe with treatment is important as this might avoid unnecessary treatment discontinuations.

Funding sources

There was no funding for the study.

Conflict of interest

Halling and Loft had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Skov and Thyssen. Acquisition, analysis, and interpretation of data: All authors. Drafting of the manuscript: Halling and Loft. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Loft. Administrative, technical, or material support: None.