Does having psoriasis increase the risk of severe COVID-19 outcomes?

Psoriasis and COVID-19 Risk

Patients with psoriasis do not appear to have an inherently higher risk of contracting SARS-CoV-2 or developing severe COVID-19, but those with severe psoriasis may be at increased risk due to associated comorbidities rather than the psoriasis itself. 1

Risk Assessment for Patients with Psoriasis

Direct Impact of Psoriasis on COVID-19 Risk

• Psoriasis alone does not meaningfully alter the risk of contracting SARS-CoV-2 or developing severe COVID-19 1
• Most evidence suggests patients with psoriasis have similar rates of SARS-CoV-2 infection and COVID-19 outcomes as the general population 1
• However, some limited data suggests a potential small increased risk:
  • A UK study with over 17 million patients found a slightly increased risk of death from COVID-19 (adjusted hazard ratio 1.19) in individuals with psoriasis, rheumatoid arthritis, or lupus 1
  • A meta-analysis of 7 case-control studies found higher risk of COVID-19 in autoimmune diseases compared to controls (OR 2.19) 1

Comorbidity-Related Risk Factors

• The primary drivers of COVID-19 severity in psoriasis patients are:
  • Older age
  • Male sex
  • Comorbidities (chronic heart, lung, kidney disease, diabetes, obesity) 1
• Patients with severe psoriasis are more prone to these comorbidities, which is the likely explanation for any observed increased risk 1
• Chronic lung disease particularly increases hospitalization risk (OR 3.87) 2

Impact of Psoriasis Treatments on COVID-19 Risk

Biologic Therapies

• Biologic treatments for psoriasis do not appear to increase COVID-19 risk and may even be protective:
  • A meta-analysis of 19 studies with 4,073 psoriasis patients found lower hospitalization rates (14.1%) and fatality rates (0.5%) in patients on biologic therapy 3
  • Patients on biologics had 38% lower risk of hospitalization compared to those on other treatments (RR 0.62) 3, 2
  • A study of 6,501 psoriasis patients on biologics showed no increased risk of hospitalization (standardized incidence ratio 0.94) or death (standardized incidence ratio 0.42) compared to the general population 1

Non-Biologic Systemic Therapies

• Non-biologic systemic therapies may be associated with slightly higher risk compared to biologics:
  • Hospitalization was more frequent in patients using non-biologic systemic therapy than biologics (OR 2.84) 2
  • Overall hospitalization rate after systemic treatment was 18.0%, with a fatality rate of 0.7% 3

Corticosteroids

• Chronic systemic corticosteroids should be avoided if possible for psoriatic arthritis management 1
• If required, taper to the lowest effective dose 1

Clinical Recommendations

1. Continue psoriasis treatments during the pandemic:

   • Patients should continue their biologic or oral therapies in most cases 1
   • Stopping treatment may lead to disease flares and worsening quality of life 4
   • Disease worsening rate was 24.2% during the pandemic, with drug withdrawal increasing this risk 8.71 times 4

2. Consider biologics as potentially safer options:

   • Biologics appear to have equal or better safety profiles regarding COVID-19 outcomes compared to conventional systemic therapies 3, 2
   • Some evidence suggests biologics may even protect against COVID-19 exacerbation of psoriasis 5

3. Monitor for COVID-19 symptoms:

   • Be vigilant for COVID-19 symptoms in all psoriasis patients
   • Patients with multiple comorbidities require closer monitoring

4. Vaccination recommendations:

   • The National Psoriasis Foundation recommends COVID-19 vaccination for patients with psoriatic disease 6
   • Patients should continue psoriasis treatments during vaccination in most cases 6
   • Monitor for potential psoriasis flares following vaccination, which are generally treatable and temporary 6, 7

Common Pitfalls to Avoid

1. Unnecessarily stopping psoriasis treatments due to COVID-19 fears

   • This can lead to disease flares and reduced quality of life
   • Current evidence does not support discontinuation of treatments

2. Overlooking comorbidities that increase COVID-19 risk

   • Focus on managing comorbidities in psoriasis patients to reduce COVID-19 risk
   • Address modifiable risk factors like obesity, diabetes, and cardiovascular disease

3. Assuming all psoriasis treatments carry equal COVID-19 risk

   • Different treatments may have different risk profiles
   • Biologics may have a more favorable safety profile regarding COVID-19 outcomes

4. Failing to recommend COVID-19 vaccination

   • Benefits of vaccination outweigh the small risk of psoriasis flares
   • Vaccination is especially important for patients with comorbidities