Pemphigus Treatment Considerations During COVID-19

Several treatment considerations for patients with pemphigus during the current the coronavirus disease 2019 (COVID-19)  pandemic were outlined in a report published in the Journal of the American Academy of Dermatology.

COVID-19-related mortality risk factors include immunosuppression, which, in certain diseases potentiates tissue damage. Pemphigus heightens infection risk via several mechanisms, including epithelial barrier breakdown and therapy-related immunosuppression.

To balance pemphigus treatment with lessening of COVID-19-associated mortality risk, the authors outlined several treatment considerations. These recommendations include, but are not limited to:

· Postponing rituximab infusions temporarily, geared towards delaying peak patient immunosuppression during COVID-19 incidence to minimize risk for adverse outcomes.

· Tapering of glucocorticoids and steroid-sparing immunosuppressives to lowest possible dose.

· Discontinuing immunosuppressive steroid-sparing medications in patients with active COVID-19 infection, although glucocorticoid cessation may not be an option due to risk for adrenal insufficiency

· IV immunoglobulin use.

· Hydroxychloroquine use in the elderly and in pregnant patients.

· Compassionate use of a new oral Bruton Tyrosine Kinase inhibitor (currently in phase 3 trials).

The authors concluded that “until sufficient experience with pemphigus and COVID-19 is available to guide therapeutic decision making, we advocate for thoughtful pharmacologic selection, as well as adherence to basic infection prevention principles, such as social distancing, hand washing, and reduction of iatrogenic immunosuppression as feasible.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

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Reference

Shakshouk H, Daneshpazhooh M, Murrell DF, Lehman JS.  Treatment considerations for patients with pemphigus during the COVID-19 pandemic (published online April 10, 2020). J Am Acad Dermatol. doi: 10.1016/j.jaad.2020.04.005