At the onset of the COVID-19 pandemic, people throughout the world with health issues that increased their risk for viral infection went on high alert, worried they would contract a severe form of the virus. Despite COVID not being a chronic disorder, people receiving certain systemic and biologic treatments (SBTs), which includes some treatments for psoriasis, have historically been a high-risk group for infectious diseases.
Researchers from the physician network Groupe d’Etude Multicentrique (GEM) Resposo in France investigated whether patients receiving SBTs for psoriasis are at an increased risk for contracting severe COVID-19, as defined by hospitalization or death. During the first wave of infections in spring 2020, these dermatologists had very little anecdotal evidence of elevated incidence rates in patients with psoriasis who were undergoing SBTs, which led them to conduct a formal study. The 1418-participant study confirmed their hypothesis, failing to find a significant difference in the number of patients who contracted severe cases of COVID-19, either during the initiation period (n = 1) or the maintenance period (n = 4, P =.58).
To learn more about the study, we interviewed lead investigator Anne-Claire Fougerousse, MD, researcher at GEM Resopso and physician in the dermatology department of the Bégin Military Teaching Hospital in Saint Mandé, France. GEM Resopso has been conducting research since 2011 to answer “real-life questions” regarding different types of chronic inflammatory dermatosis.
What were your reasons for conducting this study?
Dr Fougerousse: When we started the study, we only had the Italian perspective, which did not find any increased risk due to biologic treatment; however, they did not consider systemic ones. We also wanted to know whether COVID-19 risk at the beginning of treatment was different from during the maintenance period, because we all know that the risk for infection is more important at the beginning. So the underlying question was: Would we be able to re-initiate systemic or biologic treatment after the first peak of the pandemic?
What was the study’s hypothesis?
Dr Fougerousse: We all had the impression that there was not an augmented risk for severe COVID-19, because we had not experienced any of our patients being hospitalized, in intensive care, or dying from the virus.
Typically, are patients with psoriasis who receive SBTs considered immunosuppressed, especially during the times of COVID-19, because of this risk?
Dr Fougerousse: People under systemic or biologic treatment are not immunosuppressed. There is an immunomodulation that has been interpreted differently in terms of COVID-19 risk. For example, in France, patients under systemic or biologic treatment have priority access to the vaccine, but this is in contradiction with publications that do not prove any augmented risk for COVID-19 in these patients.
Which health disorders increase the risk for COVID-19 infection in patients with psoriasis receiving SBTs?
Dr Fougerousse: Other risk factors for severe COVID-19 are diabetes and obesity. These 2 conditions are quite frequent for psoriatic patients, so we now must be careful to ensure these patients who are more at risk for serious infection get immunized.
Which types of viruses or infections are most common among those who receive systemic biologic treatment for psoriasis?
Dr Fougerousse: The most frequent infections for patients and systemic or biologic treatment for psoriasis are upper respiratory tract infection and nasopharyngitis. They are very common infections and most of them are mild with no interruption of treatment.
Are the types of infection similar for all systemic biologic treatments?
Dr Fougerousse: There may be some differences due to the modes of action of different biologic treatments, but it’s always a mild to moderate infection, unless the individual has a history of tuberculosis.
What were the reasons that such a high percentage of patients (22.4% receiving systemic treatment; 13.8% receiving biologic treatment) discontinued their treatments?
Dr Fougerousse: Patients stopped by themselves most of the time because they feared complications or COVID-19 infection–that was the principal reason. And for psoriasis, it’s not life threatening pathology, so when you stop the treatments, the worst you can get is some plaques, so they chose to stop the treatment. On the other hand, when you have inflammatory chronic rheumatism or Crohn’s disease, when you stop the treatment, there is a risk of getting sicker in that time. For psoriasis, you get the plaques back, but there is nothing that can be life threatening or cause functional disabilities. A very small proportion stopped after consulting the dermatologist, which we don’t recommend.
Is there any data or suspicion as to why there is a lower risk of COVID-19 transmission for these patients, compared with other infections?
Dr Fougerousse: There are 2 important things to know: The first is that severe COVID-19 is due to a cytokine storm, so the hypothesis is that treatment targeting one of these cytokines can be a protective factor. That’s very hypothetical. The other is more pragmatic. At the beginning of the year, I read a similar study from the United Kingdom and the conclusion was that people under biologic treatment have taken much more precaution not to get infected. I think it’s the most important factor that can explain why our patients did not have as many incidences of severe COVID-19 as we would expect. Also, we had information for our patients at the beginning of the pandemic to let them know that they must take very careful measures and precautions, and what to do when they have symptoms or confirmed cases.
Fougerousse AC, Perrussel M, Bécherel PA,et al. Systemic or biologic treatment in psoriasis patients does not increase the risk of a severe form of COVID-19. J Eur Acad Dermatol Venereol. 2020 Nov;34(11):e676-e679. https://doi.org/10.1111/jdv.16761. Epub 2020 Jul 9. PMID: 32564417; PMCID: PMC7323155.