COVID, Biologics, and Psoriasis Therapy.

In this issue of the Journal of the American Academy of Dermatology, the National Psoriasis Foundation provides guidelines regarding the use of immunomodulating agents for psoriasis during the coronavirus 2019 (COVID-19) pandemic. Although there are still many unanswered questions, these guidelines, together with guidance issued by the American Academy of Dermatology, provide a practical framework for dermatologists and their patients to aid with therapeutic decisions during the pandemic. The guidelines emphasize shared decision making, as well as attention to Centers for Disease Control and Prevention recommendations for risk assessment, social distancing, and personal protection, including wearing of masks and hand hygiene.

Although there have been reports of poor COVID-19–related outcomes among patients with psoriasis, this is strongly correlated with comorbidities, and the guidelines note that most existing data suggest that treatments for psoriasis and psoriatic arthritis do not meaningfully alter either risk of acquiring severe acute respiratory syndrome coronavirus 2 infection or COVID-19 outcomes. Consistent with guidance issued by the American Academy of Dermatology, the guidelines recommend that patients who are not infected continue their biologic or oral treatments in most cases. Other published data indicate that nonadherence to psoriasis treatment during the pandemic is associated not only with the aggravation of psoriasis but also perceived stress and symptoms of anxiety and depression, emphasizing the important role of patient education and communication.

Cytokines upregulated in psoriasis are also upregulated in COVID-19 infection. Although the guidelines caution against chronic systemic corticosteroid use for the treatment of psoriasis and published data suggest that glucocorticoid exposure of more than 10 mg/day is associated with a higher odds of hospitalization, anti–tumor necrosis factor therapy has been associated with decreased odds of hospitalization among patients with rheumatologic disease. Some data suggest that anti-interleukin 1 and anti-interleukin 6 therapy may have benefits in regard to the cytokine storm in severe COVID infection, and baricitinib has both antiviral and anti-inflammatory properties.

Although chronic prednisone therapy for psoriatic arthritis is discouraged, recent data suggest that intravenous dexamethasone plus standard care improves outcomes for hospitalized COVID-19 patients with moderate or severe adult respiratory distress syndrome compared with standard care alone. A meta-analysis of clinical trials of critically ill patients with COVID-19 suggests that systemic corticosteroids are associated with lower 28-day all-cause mortality. The guidelines acknowledge recent data and note that systemic corticosteroids for the management of COVID-19 inpatients should not be withheld because of concern about psoriatic flares.

All guidelines are intended as living documents that evolve as additional information emerges. Recommendations are based on the best currently available data. We hope that readers will find it helpful in counseling their patients.