Reply: “Biologics for psoriasis during COVID-19 outbreak”
Authors: Vito Di Lernia
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: We read with interest the letter 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 "Should biologics for psoriasis be interrupted in the era of COVID-19?" We share the concern that has been expressed about the possible impact of biologic therapies on the patient's susceptibility to COVID-19 infection. In addition to the infectious complications for biologic therapies reported during pivotal trials for psoriasis, we would like to draw attention to other aspects that might guide the decision whether to continue biologic therapy during the COVID-19 pandemic. From a pathophysiologic point of view, a release of large amounts of proinflammatory cytokines, including some of those overexpressed in psoriasis, such as tumor necrosis factor-α and interleukin (IL)-33, occurs in patients with severe COVID-19, in particular during the acute respiratory distress syndrome, which is the main cause of death from the infection.2Huang C. Wang Y. Li X. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (33292) Google Scholar Pathogenesis of the widespread lung damage associated with severe acute respiratory syndrome (SARS) coronavirus, which shares many etiologic, clinical, and pathologic features with COVID-19, has been hypothesized to be caused more by an exaggerated immune response than the virus itself.3Sarzi-Puttini P. Giorgi V. Sirotti S. et al.COVID-19, cytokines and immunosuppression: what can we learn from severe acute respiratory syndrome?.Clin Exp Rheumatol. 2020; 38: 337-342Crossref PubMed Google Scholar This implies that immune dysregulation is regarded as a highly important therapeutic target, and a clinical trial is currently evaluating adalimumab in severe COVID-19 pneumonia.4Bashyam A.M. Feldman S.R. Should patients stop their biologic treatment during the COVID-19 pandemic.J Dermatolog Treat. 2020; : 1-2Crossref Scopus (57) Google Scholar Notably, a significant elevation in tumor necrosis factor-α and also IL-17 was found in plasma samples of patients with Middle East respiratory syndrome (MERS) coronavirus,5Mahallawi W.H. Khabour O.F. Zhang Q. et al.MERS-CoV infection in humans is associated with a pro-inflammatory Th1 and Th17 cytokine profile.Cytokine. 2018; 104: 8-13Crossref PubMed Scopus (459) Google Scholar another respiratory disease caused by a similar coronavirus and associated with high morbidity and mortality. In contradistinction, IL-12 blockade might impair the antiviral cytokine interferon-γ production. However, it must also be noted that patients with inherited defects in IL-12 signaling do not seem to be as severely affected by infection with respiratory viruses. Italy is strongly involved with COVID-19. Presently, an operating instruction on biologic therapies has been implemented in our hospital immunology network and shared by dermatologists, rheumatologists, and gastroenterologists. Patients treated with biologics are classified in 4 categories and treated according to their own characteristics as follows:1.Patients not showing symptoms, or with mild respiratory symptoms (such as mild cough without fever) and without close contact with confirmed COVID-19 patients: biologic therapy is continued.2.Patients experiencing moderate or severe respiratory symptoms (fever, cough, or difficulty breathing, or all 3) without close contact with confirmed COVID-19 patients: preventive transient interruption of biologic therapy until complete remission of respiratory symptoms and at least 72 hours without fever.3.Patients with mild respiratory symptoms and contact history with COVID-19 patients: preventative treatment discontinuation of biologic therapy until laboratory-confirmed negativity for the COVID-19 virus.4.Patients with moderate to severe respiratory symptoms and close contact or contact history with COVID-19 patients or with clinical/radiologic criteria consistent with COVID-19: interruption of biologic therapy and prompt admission to COVID hospital. A case-by-case evaluation in a high-risk population, such as older patients with cardiovascular and pulmonary comorbidities, should be cautiously performed. 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: "Biologics for psoriasis during COVID-19 outbreak"Journal of the American Academy of DermatologyVol. 82Issue 6PreviewTo the Editor: We thank Dr Di Lernia1 for his commentary on the stratification planning of dermatology patients on biologics that has been adopted in Italy. Because there are many patients on biologics and on immunosuppressants for psoriasis, hidradenitis, atopic dermatitis, pemphigoid, pemphigus, and other conditions in Italy and other countries hit by the COVID-19 pandemic, hopefully, we will soon have more information about whether the rate of respiratory decompensation in this population is greater or less than expected. Full-Text PDF