Management of patients with pemphigus vulgaris during the COVID‐19 pandemic: Experience of a second level dermatology center

Dear editor,

With reference to the interesting article of Wang et al. ¹ , on the use of immunomodulatory agents for severe cutaneous disease during the COVID‐19 pandemic, we would like to share the real experience of a Medium‐size Regional Healthcare Dermatological Center treating 72 patients with autoimmune bullous diseases.

In Ancona Regional hospital, a specialist outpatient clinic dealing with the diagnosis and treatment of immunomediated skin disease has been operating since 1985, and 72 patients with pemphigus vulgaris are currently being treated. Since the end of February, when the SARS‐CoV‐2 pandemic had already spread in most of Italy, a task force composed of 4 dermatologists and 1 immunologist was set up with the aim of addressing problems relating to the specific risk for this class of patients. The main goal was to evaluate risk/benefit in modulating treatment, following a patient‐tailored strategy, taking into consideration patients' risk of exposure to SARS‐CoV‐2 virus, based on the geographical area of residence [coherently with different prevalence of infection between northern (higher prevalence) and southern (lower prevalence) part of the Marche region] and clinical situation. All patients were recommended to observe social isolation.

Treatment details of pemphigus vulgaris patients are summarised in Table 1.

Table 1.

Treatment details of 72 patients with pemphigus vulgaris. per os (po); quaque die (qd); intravenous (iv); bis in die (bid); quater in die (qid)

Treatment performed	N° of patients
Monotherapy
Betamethasone sodium phosphate 0.5 mg po qd	30
Methylprednisolone 16 mg po qd	9
Prednisone 12.5 mg po qd	6
Methylprednisolone 8 mg po qd	3
Betamethasone sodium phosphate 2 mg po qd	2
Rituximab 500 mg iv qd	2
Association therapy
Betamethasone sodium phosphate 0,5 mg po qd + mycophenolate mofetil 500 mg po bid	11
Methylprednisolone 8 mg po qd + azathioprine 100 mg po qd	5
Prednisone 10 mg po qd + mycophenolic acid 360 mg po qid	4

Out of the 72 affected patients, 50 were on monotherapy with systemic corticosteroids, 20 patients were on combined therapy with corticosteroid and steroid sparing agents, 2 patients were not taking any medication because they should have received the next dose of Rituximab 500 mg by the end of April 2020, according to the six‐month interval dosing practised in our centre and supported by literature. ²

Immunosuppression represents an independent risk factor for increasing mortality in COVID‐19, ³ however, it is generally accepted that only doses higher than 20 mg/day of prednisone or equivalent are considered immunosuppressive, with the risk of infection at doses of ≤10 mg considered low. ⁴ Therefore, all patients taking steroids at doses < 20 mg/day were recommended to continue therapy and for patients taking prednisone > 20 mg/day or equivalent (Supplementary Table 1), ⁵ , ⁶ , ⁷ , ⁸ a dose reduction was considered: prednisone 12.5 mg po qd (6 patients), methylprednisolone 16 mg po qd (9 patients) and betamethasone sodium phosphate 2 mg po qd (2 patients). For patients at higher risk for recurrence and/or coming from highly affected geographical areas, the full dosage of steroid was maintained in 11 patients, a reduction of methylprednisolone to 8 mg po qd was established in 4 patients and a reduction of betamethasone sodium phosphate to 1.5 mg po qd in 2 patients.

For patients under combination therapy, in order to discontinue the conventional immunosuppressant administered as steroid sparing agent, ¹ a possible increase of corticosteroid up to an equivalent dose of 20 mg of prednisone has been reported in literature. ⁹ By aligning with these recommendations, the immunosuppressant was discontinued and the steroid dose was increased. For patients who should have received rituximab therapy, a temporary delay of the drug administration was decided, they were instructed in the self‐assessment of their skin and mucosae, and strictly followed by phone, in order to rapidly detect recurrence of the disease.

Two months after, following this strategy, no patient reported a febrile syndrome or respiratory failure or death due to COVID‐19. Moreover, only one patient who should have been treated with rituximab, developed a relapse of disease, for which he was treated with betamethasone sodium phosphate 3 mg po qd.

Until official guidelines on pemphigus management in COVID‐19 era are available, good clinical practice recommendations, and adoption of behaviours aimed at reducing the risk of infection, such as social distancing and hand washing, ¹⁰ would seem to be the best care strategy.

Supporting information

Table S1. Corticosteroid Conversion Table (5–8).