Biologic therapy for psoriasis during the COVID‐19 outbreak: The choice is to weigh risks and benefits

Dear Editor,

1.

We read with interest the letter recently published in Journal of Dermatological Treatment by Bardazzi et al ¹ with regard to the treatment of psoriasis during the coronavirus disease 2019 (COVID‐19) pandemic and we would like to respond to the authors with a view to a constructive dialogue.

In the first days of March, when international guidelines on the management of therapies for psoriasis patients were not yet available, we felt the immediate need to ask ourselves and question the worldwide dermatologists about the management of biologics during the COVID‐19 pandemic. In our work published in Dermatologic Therapy, ² we concluded that, while awaiting official and reliable data about the risk of SARS‐CoV‐2 infection in patients treated with immunosuppressants, it was necessary to discontinue immunosuppressive treatments in COVID‐19 patients and to carefully evaluate the initiation of immunosuppressive treatments for patients living in high risk areas. ²

Bardazzi et al write that “This personal statement contrasts not only with the indications of the major scientific societies […] but also with the Guidance on the use of biologics during COVID‐19 outbreak by the American Academy of Dermatology association.” Obviously, there are currently no data available but our statement was based on a thoughtful weight of benefits and risks. Moreover, our “personal” statement is not in contrast but in perfect line with those of other major scientific societies. In fact, the American Academy of Dermatology suggests (a) to discontinue biological treatment in COVID‐19‐positive patients, (b) to carefully consider whether to start biological therapy in patients with various comorbidities by stating that they consider deferring initiation of biological therapy, and (c) to consider alternative treatments to treat high‐risk patients. ³

The International League of Dermatological Societies has issued guidelines stating that (a) in patients with COVID‐19 negative and no symptoms, therapeutic discontinuation has no scientific evidence and that (b) in case of suspicion of COVID‐19 infection treatment should be deferred and a new treatment should not be initiated. ⁴

The International Psoriasis Council (IPC) recommends, in COVID‐19 patients, to discontinue or postpone use of immunosuppressant medications. Indeed, IPC takes an even stronger position by stating that “Individuals over the age of 60 years and/or patients with comorbid conditions including cardiovascular diseases, diabetes, hepatitis B, chronic obstructive pulmonary disease, chronic kidney diseases, and cancer have a higher risk for developing a more serious course of the illness.” ⁵

In our letter, we perfectly recommended at the very early phase of the pandemic what most societies recommended later on a national and international level; moreover, reading carefully our letter the authors should have noticed that it has never been claimed to suspend biological treatments. ²

We concluded with the suggestion to discontinue biological or immunosuppressive therapies in COVID‐19 patients and to weigh carefully the risks and benefits of immunosuppressive therapy in this historical moment. Similarly, Di Lernia et al ⁶ proposed to decide whether or not to discontinue biological treatment case‐by‐case considering the severity of psoriasis or other comorbidities.

To date, about a month after our first work, despite different opinions, we would like to emphasize the importance of cohesion and scientific union on questions that deserve scientifically proven and tested answers. ¹ , ⁷ In our clinical practice, in a real‐life setting, we evaluate patients on a case‐by‐case basis, following the recommendations of both international and Italian guidelines by SIDeMaST (vademecuum SIDeMaST ⁸ ), while waiting for certain data that can reassure us about the safety and absolute non‐impact of biological therapies in the risk of infection. In fact, we are all united against COVID‐19 and we have all sworn, in Hippocratic oath, primum non nocere (first do not harm).

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.