Dear Editor
Some systemic and biologic psoriasis treatments [SBT] have been associated with an increased risk of infection. 1 To date, more and more data regarding the risk of COVID‐19 infection in patients receiving SBT become available. 2 , 3 , 4 , 5
To enrich these data, we evaluated the frequency of severe COVID‐19 infections, defined as hospitalization or death, in psoriasis patients receiving SBT, especially during the 4 months following SBT initiation.
From 27 April to 7 May 2020, we conducted a national, multicentre, cross‐sectional study during consultations or teleconsultations, including adult psoriasis patients receiving SBT.
The following elements were collected: gender, age, current psoriasis treatment, treatment period (initiation [up to 4 months] or maintenance [from 5th month]), treatment continued or stopped during the pandemic. Moreover, we collected data about comorbidities such as obesity, hypertension and diabetes putting patients at risk of a severe form of COVID‐19 infection, and information about a clinically confirmed diagnosis of COVID‐19 defined as acute febrile respiratory infection, or sudden onset of headache, myalgia, ageusia, anosmia or asthenia, 6 as well as COVID‐19 confirmation by PCR testing and hospitalization.
Overall, data from 1418 patients were included. Patient characteristics are detailed in Table 1. Of the included patients, 300 were receiving methotrexate, 26 cyclosporine, 4 acitretin, 48 apremilast, 25 etanercept, 165 adalimumab, 40 infliximab, 8 certolizumab pegol, 240 ustekinumab, 206 secukinumab, 112 ixekizumab, 38 brodalumab, 146 guselkumab, 25 risankizumab and 35 combination of methotrexate and biologic. In total, 22.4% of patients on systemic therapy and 13.8% on biologics discontinued treatment during the pandemic.
Table 1.
Patient characteristics
| Overall population | Treatment initiation period | Maintenance treatment period | ||||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| 1418 | 100 | 230 | 16.22 | 1188 | 83.78 | |
| Sex | ||||||
| Men | 797 | 56.29 | 131 | 56.96 | 666 | 56.16 |
| Women | 619 | 43.71 | 99 | 43.04 | 520 | 43.84 |
| Missing data | 2 | 0 | 2 | |||
| Treatment | ||||||
| Systemic | 330 | 23.27 | 62 | 26.84 | 268 | 40.18 |
| Biologic | 1005 | 70.87 | 156 | 67.53 | 849 | 127.29 |
| Anti‐TNF | 238 | 16.78 | 14 | 6.06 | 224 | 18.86 |
| Anti‐interleukin | 767 | 54.09 | 142 | 61.47 | 625 | 52.61 |
| Apremilast | 48 | 3.39 | 10 | 4.33 | 38 | 3.20 |
| Combination of methotrexate and biologic | 35 | 2.47 | 2 | 0.87 | 33 | 2.78 |
| Risk factor for severe COVID‐19 infection | ||||||
| Diabetes | 111 | 7.83 | 12 | 5.15 | 99 | 8.32 |
| Obesity (BMI> 30) | 245 | 17.28 | 27 | 5.15 | 218 | 18.32 |
| HTA | 232 | 16.36 | 31 | 13.30 | 201 | 16.89 |
| None | 920 | 64.88 | 163 | 69.96 | 757 | 63.61 |
Treatment initiation period defined as the 4 months following treatment initiation. Maintenance treatment period defined as starting the 5th month of treatment. Systemic treatment: acitretin, methotrexate, cyclosporine. Anti‐TNF: etanercept, adalimumab, infliximab, certolizumab pegol. Anti‐interleukin: ustekinumab, secukinumab, ixekizumab, brodalumab, guselkumab, risankizumab.
We reported five patients with COVID‐19 infection requiring hospitalization: a 27‐year‐old obese woman with Crohn’s disease treated with adalimumab, a 36‐year‐old man treated with guselkumab, a 53‐year‐old man treated with methotrexate, and two patients required intensive care: a 71‐year‐old obese woman treated with methotrexate and etanercept, a 34‐year‐old obese man treated with ustekinumab. No deaths were reported. In all, 54 patients presented with a possible COVID‐19 infection; confirmation by PCR testing was performed for 12 patients. The frequency of cases according to treatment and treatment period is specified in Table 2.
Table 2.
Frequency of COVID‐19 infection cases according to treatment and treatment period
| Overall population | Treatment initiation period | Maintenance treatment period | ||||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Overall population | ||||||
| Probable case | 54 | 3.81 | 6 | 2.58 | 48 | 4.04 |
| Case confirmed by PCR | 12 | 0.85 | 1 | 0.43 | 11 | 0.93 |
| Case confirmed by PCR and hospitalized | 5 | 0.35 | 1 | 0.43 | 4 | 0.34 |
| Systemic treatments | ||||||
| Probable case | 17 | 5.15 | 2 | 3.17 | 15 | 5.60 |
| Case confirmed by PCR | 3 | 0.91 | 0 | 0.00 | 3 | 1.12 |
| Case confirmed by PCR and hospitalized | 1 | 0.30 | 0 | 0.00 | 1 | 0.37 |
| Biologics | ||||||
| Probable case | 33 | 3.28 | 3 | 1.92 | 30 | 3.53 |
| Case confirmed by PCR | 8 | 0.80 | 1 | 0.64 | 7 | 0.82 |
| Case confirmed by PCR and hospitalized | 3 | 0.30 | 1 | 0.64 | 2 | 0.24 |
| Apremilast | ||||||
| Probable case | 3 | 6.25 | 1 | 10.00 | 2 | 5.26 |
| Case confirmed by PCR | 0 | 0.00 | 0 | 0.00 | 0 | 0.00 |
| Case confirmed by PCR and hospitalized | 0 | 0.00 | 0 | 0.00 | 0 | 0.00 |
| Combination of methotrexate and biologics | ||||||
| Probable case | 1 | 2.86 | 0 | 0.00 | 1 | 3.03 |
| Case confirmed by PCR | 1 | 2.86 | 0 | 0.00 | 1 | 3.03 |
| Case confirmed by PCR and hospitalized | 1 | 2.86 | 0 | 0.00 | 1 | 3.03 |
Probable case defined as acute febrile respiratory infection, or sudden onset of headache, myalgia, ageusia, anosmia or asthenia. Treatment initiation period defined as 4 months following treatment initiation. Maintenance treatment period defined as starting the 5th month of treatment. PCR: polymerase chain reaction.
In our study, 0.35% of patients had a severe form of COVID‐19 requiring hospitalization, 60% of whom (all in intensive care units) presented with other risk factors for severe infection. Two patients were hospitalized, due to their SBT, considered at the beginning of the pandemic as a risk factor for a severe form of COVID‐19 infection.
Our data are consistent with those collected and analysed in Italy: Damiani et al. reported 5 hospitalizations out of 1193 patients treated by biologic or small molecules for their psoriasis, and no death was reported. 6 Gisondi et al. reported in Northern Italy 4 hospitalizations out of 5206 patients receiving biologic treatment for psoriasis, again no death was reported. There was no over‐risk of hospitalization in intensive care and death reported for patients receiving biological psoriasis treatment when compared to the general population. 2 Moreover, biologic treatment using immunosuppressive drugs such as guselkumab, ustekinumab, adalimumab, secukinumab, brodalumab or ixekizumab may even protect against the onset and evolution of COVID‐19 infection. 3 , 4 , 7
[Correction added on 28 August 2020, after first online publication: On paragraph 8, the word ‘brodalumab’ has been added in this version.]
We did not observe a significant difference in the number severe cases of COVID‐19, according to whether the patient was in the treatment initiation period (1 out of 230 patients) or in the maintenance period (4 out of 1188 patients), Fisher test P = 0.58, OR = 1.29 [95%CI 0.03–13.4].
The absence of a control group and no PCR or serologic confirmations of all probable cases were limitations of this study.
In conclusion, our study provides first data showing that there is no increased incidence of severe COVID‐19 in psoriasis patients receiving SBT in the treatment initiation period compared to those in the maintenance period. Results may allow physicians to initiate, on a case‐by‐case basis, SBT in patients with severe psoriasis in the context of COVID‐19 pandemic.
Conflict of interest
None.
Funding sources
None.
References
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Acknowledgements
The authors acknowledge Dr Charlotte Fite, Dr Domitille Thomas‐Beaulieu and Karl Patrick Göritz, SMWS France, for editing services.