








key: cord-318866-3arxrm8m
authors: Magnano, M.; Balestri, R.; Bardazzi, F.; Mazzatenta, C.; Girardelli, C.R.; Rech, G.
title: Psoriasis, COVID‐19 and acute respiratory distress syndrome: focusing on the risk of concomitant biological treatment
date: 2020-05-30
journal: Dermatol Ther
DOI: 10.1111/dth.13706
sha: 
doc_id: 318866
cord_uid: 3arxrm8m

nan

The management of psoriatic patients under biologics during SARS-CoV-2 outbreak is of great concern, as well as the outcome of the COronaVirus DIsease (COVID-19) in this population.

We report here 9 cases of 3 Italian districts largely hit by COVID-19 (Bologna, Lucca and Trento).

On a pool of 720 psoriatic patients followed by our 3 referral centers for severe psoriasis, we registered 9 swab-confirmed cases of SARS-CoV-2 infection (Table 1) . Mean age was 53.9±9.7 years. The most common comorbidity was obesity (mean BMI=30.9±5.5), followed by hypertension. This article is protected by copyright. All rights reserved.

Our case series roughly reflects the study of Gisondi et al. 1 , who concluded that, despite the cardiovascular and metabolic comorbidities affecting psoriatic patients and also representing risk factors for severe COVID-19, patients seldom required hospitalization.

Among our cases, one middle-aged man developed critical COVID-19. This is the first report of ARDS in a psoriatic patient undergoing biological treatment, however this may be related to his other serious comorbidities. This percentage (1/9-11.4%) is consistent with the rate of ARDS in the general population, estimated at around 14.8% of affected individuals. 2 The appropriateness of withdrawing biologic therapies preventively in psoriatic patients is still debated and it is also unclear whether their use influences the course of COVID-19 or not. 3 Although it seems that most psoriatic patients experience mild COVID-19, our case series raises some considerations. We know that the main risk factor for severe COVID-19 is old age. 4 The psoriatic population treated with biologic therapies is on average young 5 , since elderly patients with multiple comorbidities are usually excluded from systemic treatments. Our sample is in line with this data, therefore we can expect a lower fatality rate than in the general population.

Nevertheless, the course of COVID-19 could be complicated by the concomitant administration of immunomodulators, which in pivotal trials have demonstrated to increase the susceptibility of respiratory infections. Particularly, anti-TNF drugs seem to increase such condition by up to 7% compared with placebo. 6 However, high levels of TNF-α have been observed in severe COVID-19 patients, while interleukin-17 may also be involved in the cytokine cascade, having been linked to severe cases. 7 Therefore, the abrupt interruption of biologics may increase the systemic inflammation, which may worsen the associated comorbidities and the prognosis of COVID-19.

However, we decided to withdraw biologic therapies in 8 of the 9 patients after the diagnosis, This article is protected by copyright. All rights reserved. mainly to avoid other microbial infections, although the asymptomatic patient did not develop any complications throughout the course of the disease.

It is also noteworthy that obesity was the most represented comorbidity. Despite the fact that obese patients tend to have more severe forms of COVID-19 also at younger ages 8 , 88.9% of our patients were mild or asymptomatic. Biologics may play a role in these cases, modulating the inflammatory response, usually overexpressed in obese patients.

Although this case series is limited, we evidenced that ARDS can represent a complication also in patients under biologics. However, these subjects do not seem to develop critical COVID-19 more often than the general population of same age range. 

The impact of COVID-19 pandemic on patients with chronic plaque psoriasis being treated with biologic therapy: the Northern Italy experience

Online ahead of print

The viral, epidemiologic, clinical characteristics and potential therapy options for COVID-19: a review

Biologic therapy for psoriasis during the covid-19 outbreak is not a choice

Epidemiologic study in a real-world analysis of patients with treatment for psoriasis in the French national health insurance database

Should biologics for psoriasis be interrupted in the era of COVID-19?

COVID-19 and immunomodulator/ immunosuppressant use in dermatology

Obesity could shift severe COVID-19 disease to younger ages

Acknowledgment: "The patients in this manuscript have given written informed consent to publication of their case details."

