Psoriasis and COVID-19: a multifactorial consideration

As dermatologists consider the best way to treat and counsel patients with psoriasis during the COVID-19 pandemic, we must consider all the ways in which psoriasis and its treatment may impact risk of infection or poor outcomes with COVID-19. Having psoriasis may – either directly or through associated comorbidities – predispose individuals to poor outcomes if they are infected with SARS-CoV-2. Psoriasis is associated with multiple comorbidities that are risk factors for poor outcomes with COVID-19 such as obesity, hypertension, and diabetes (1). Additionally, patients with psoriasis are at an increased risk of severe infection requiring hospitalization. Of all infections, this association was strongest with respiratory infections. Studies have also observed a dose-response relationship, suggesting that individuals with more severe psoriasis are at highest risk of infection (1). Early observational data from patients with psoriasis on biologics from the United States and Italy fail to identify one biologic agent or class of biologics that appears to increase risk of infection, hospitalization, or admission to the intensive care unit (ICU) for COVID-19 (2–5). While not a biologic, one series from New York identified methotrexate use as a risk factor for hospitalization with COVID-19 among patients with one of six immune-mediated inflammatory conditions, including psoriasis and psoriatic arthritis (2). Many of the patients requiring hospitalization or ICU care in these studies do share other risk factors for severe COVID-19 such as hypertension and obesity. This may suggest that the risk factors for COVID-19 in the general population are the most important determinants of severity of COVID19 disease among psoriasis patients as well. One case-control study did conclude that symptomatic COVID-19 was more common among individuals being treated with systemic therapies for psoriasis than the general population; however, this study did not include data on individuals with psoriasis on topical therapies or phototherapy or control for comorbidities (4). Therefore, it remains a possibility that immunosuppression from therapy, the increased risk of infection with psoriasis, or comorbidities, may have all contributed to the observed increased risk of symptomatic COVID-19. Patients with psoriasis may have a higher risk of serious infection and more commonly display risk factors for more severe COVID-19 such as hypertension, obesity, and diabetes. The COVID-19 pandemic may represent a teachable moment for encouraging weight loss and optimal management of comorbidities, which may improve psoriasis and decrease the risk of severe COVID-19. It is also important for dermatologists to consider, on an individual basis, how to best counsel patients about their risk of COVID-19. Most importantly, patients with psoriasis should be particularly careful in adhering to public health guidelines to minimize their risk of COVID-19. To better understand the root of any possible excess risk of infection or poor outcomes with COVID-19 among psoriasis patients, studies should compare psoriasis patients on topical therapies, phototherapy, and systemic therapy and compare psoriasis patients to controls based on comorbidity status.