COVID-19, syphilis, and biologic therapies for psoriasis and psoriatic arthritis: A word of caution
Authors: Naveen Kumar Kansal
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: I read the timely and thought-provoking article about the coronavirus disease 2019 (COVID-19) pandemic and biologic therapy for psoriasis by Lebwohl et al.1Lebwohl M. Rivera-Oyola R. Murrell D.F. Should biologics for psoriasis be interrupted in the era of COVID-19?.J Am Acad Dermatol. 2020; 82: 1217-1218Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar The authors compiled research data about almost all the most commonly used biologics in dermatology and their rates of infection, upper respiratory infections, and nasopharyngitis based on current published studies. However, I would like to offer a word of caution: the article is based on trials of biologic therapies, which are the criterion standard. It should be noted that certain groundbreaking (initial) adverse effects were published in the past as case reports or letters and may not have gotten much attention if published today. One of the foremost examples is the thalidomide tragedy. The initial adverse effects of thalidomide were described by Florence2Florence A.L. Is thalidomide to blame?.Br Med J. 1960; 2: 1954Crossref Scopus (64) Google Scholar and later, other workers reported the embryopathy adverse effects.3Ward S.P. Thalidomide and congenital abnormalities.Br Med J. 1962; 2: 646-647Crossref PubMed Scopus (26) Google Scholar More recently, Uslu et al4Uslu U. Heppt F. Sticherling M. Secondary syphilis infection under treatment with ustekinumab.Clin Exp Dermatol. 2017; 42: 836-838Crossref PubMed Scopus (5) Google Scholar described a unique case of possible reactivation of latent syphilis infection in a patient with psoriasis and psoriatic arthritis who was receiving therapy with interleukin-12/23 monoclonal antibody (ustekinumab). The authors suggested the possibility of reactivation of latent syphilis infection in their case, although they considered it unlikely. Similar reports had earlier appeared with antitumor necrosis factor-alpha therapy. The possibility that the natural progression of syphilis may have been accelerated by biologics in these cases cannot be completely excluded.5Kansal N.K. Syphilis screening before initiation of immunosuppressive and biologic therapy for psoriasis and psoriatic arthritis.Clin Exp Dermatol. 2018; 43: 831Crossref PubMed Scopus (1) Google Scholar Unlike syphilis, which is well known, the prognosis of COVID-19 cannot be predicted in individual cases (particularly in middle aged and older patients, with co-morbidities like diabetes mellitus or cardiovascular disease etc, if they are being treated with biologics). Therefore, in my opinion, the clinician must weigh the risk of loss of efficacy of a particular biologic in a responsive patient. It may be useful to consider that the patient is likely to be responsive to another biological agent when needed. Although the risk-to-benefit ratio must always be considered before discontinuing any effective medication, the unpredictable behavior of COVID-19 may be a priority at present. Patients who continue to receive therapy with biologics will need to be closely monitored as more knowledge about this infection becomes available. Should biologics for psoriasis be interrupted in the era of COVID-19?Journal of the American Academy of DermatologyVol. 82Issue 5PreviewTo the Editor: With daily media warnings of a looming pandemic, physicians are understandably concerned about immunosuppressive or immunomodulating effects that might render patients receiving biologic therapies more susceptible to COVID-19 infection. At this early stage, we do not have specific data about susceptibility to the virus, but we have data on infectious complications for biologic therapies from their pivotal trials for psoriasis. Full-Text PDF Reply to: "COVID-19, syphilis, and biologic therapies for psoriasis and psoriatic arthritis: A word of caution"Journal of the American Academy of DermatologyVol. 82Issue 6PreviewTo the Editor: We thank Dr Kansal1 from the All India Institute of Medical Sciences for her pertinent comments in response to our publication on the use of biologic agents for psoriasis patients in the current COVID-19 pandemic.2 Certainly, there are other diseases for which screening could be considered in particular populations before starting a biologic, such as syphilis, as Dr Kansal makes a point about in her study. Strongyloides and leprosy are others. These screening tests apply to all immunosuppressants, not just biologic immunomodulators. Full-Text PDF