Coronavirus, COVID-19, and psoriasis: what you need to know

Short summary, with June 17 update

• Take seriously the social distancing, hand-washing, face covering, and other recommendations from the CDC so we can stop the spread of COVID-19/coronavirus. It is NOT over yet.
• Those with psoriasis and/or psoriatic arthritis should check in with their doctor to ask if treatment alterations should be made in light of the COVID-19 virus, particularly if you are taking pills, shots, or infusions to treat your psoriatic disease.
• For most patients who do NOT have coronavirus or its symptoms, sticking with your current treatment plan is probably the better route. A rheumatologist confirmed to us on June 9 that the current sense of the medical community continues to be that systemic psoriasis treatments are NOT causing problems related to COVID-19, though prednisone could be an exception.
• Do not make any treatment changes without asking your physician first.
• If you DO test positive for coronavirus or have symptoms of it, or if you believe you have been exposed to the virus or are living with someone who has it, contact promptly your primary care doctor as well as the medical professional who treats your psoriatic disease and explain the situation, so that you can discuss if or how to alter or delay your psoriasis or psoriatic arthritis treatments.
• Dexamethasone, which is used by some psoriasis patients, has been shown to help COVID-19 patients on ventilators or requiring oxygen, but not others with less severe coronavirus. (Quick stoppage of dexamethasone can cause a severe psoriasis flare in psoriasis patients.) Antimalarials like hydroxycholoquine, also in the news regarding COVID-19, have NOT been shown to be helpful in recent studies. (Antimalarials can trigger psoriasis flares in some psoriasis patients.)
• Some of the serious health issues that increase coronavirus risks are common in patients with psoriasis and psoriatic arthritis, a timely reminder that our overall health is important even beyond our psoriatic disease.
• A registry for patients with psoriasis and COVID-19 will help identify patterns to improve treatment of both conditions. Those with both should inform their health care provider about the registry.
• 42 percent of U.S. COVID-19 deaths have occurred in nursing homes and assisted living facilities, a shocking statistic.

Main article

Coronavirus continues to upend lives across the world. For those of us with chronic health issues, concerns about the risk of contracting the virus can be magnified. The many unknowns surrounding coronavirus only exacerbate the situation.

Here we share what we have learned about the coronavirus (COVID-19, which started in Wuhan, China) and its potential impact on those with psoriasis and psoriatic arthritis.

First, for everyone, the standard preventative measures should be followed as best you, your loved ones, friends, and coworkers can. A good place to find the latest information on coronavirus prevention, symptoms, and breaking news, is the US Centers for Disease Control and Prevention (CDC) Coronavirus (COVID-19) website at coronavirus.gov.

Your state (and possibly county or city) has supplemental information directly relevant to specific regulations in effect for your jurisdiction.

Certain categories of people are at increased risk from coronavirus, particularly:

• People age 65 and older;
• People who live in a nursing home or assisted living facility; and
• People of all ages who have serious chronic medical conditions, including heart disease, diabetes, severe obesity, lung disease, liver disease, and those on kidney dialysis. Note that many psoriasis patients also have one or more of these conditions.

People in these groups should follow the enhanced safety measures suggested by CDC, which can be summarized as “stay home and avoid other people.”

Those in, or who have loved ones in, nursing homes and assisted living facilities, should insist that those locations follow the strictest protocols, as a stunning 42 percent of U.S. COVID-19 deaths have occurred in nursing homes and assisted living facilities, where just 0.6% of the U.S. population lives.

What about those with psoriasis or psoriatic arthritis?

People who are immunocompromised are also believed to be at increased risk from coronavirus. While this clearly includes cancer chemotherapy patients and those with poorly-controlled HIV; it could also theoretically include many people taking pills, injections, or infusions to treat their psoriasis and/or psoriatic arthritis.

There are several issues of potential concern.

First, people with psoriasis have a higher risk of infection, including respiratory infections and pneumonia, than the general population. The risk is higher for those with severe psoriasis than those with mild disease.

Second, many psoriasis medications partially inhibit the immune system, further increasing infection risk. This could theoretically make it easier to catch COVID-19. (However, just to add confusion to this fast-moving situation, some experts believe that some immune-modulating medications used in treating psoriasis and arthritis could actually be used to treat some cases of coronavirus, as part of the danger in some COVID-19 cases is caused by an excessive response of the immune system – a “cytokine storm” – that these treatments might control.)

We spoke to two dermatologists and a rheumatologist to get their views on whether people with psoriatic disease should adjust their treatment regimen while COVID-19 is spreading across America. We also reviewed statements from psoriasis experts, both physicians and scientists, who have published their thoughts on the issue.

Here are the takeaway messages we are hearing.

You have heard this before but it bears repeating: each patient should speak to the medical professional who manages their psoriasis and/or psoriatic arthritis treatment, to discuss if or how the pandemic might alter their particular medical profile and current treatments. And no one should make treatment changes without first speaking to their physician.

For most patients who do NOT have coronavirus or its symptoms, sticking with your current treatment plan is likely the better route, based on the information currently available as well as the havoc that a psoriasis flare could have on you and your immune system. Some felt it is a closer call for those on prednisone or other systemic (ingested) corticosteroids that would typically require a taper period to avoid a rebound flare if stopped suddenly. [But see our note on dexamethasone, below.]

As of June 17, 2020, those with psoriatic disease being treated by biologics have NOT demonstrated increased risk of catching or being seriously harmed by COVID-19. (Of course, they still have the risk level suggested by their age and other factors and co-morbidities that appear to increase risk.)

If you test positive for coronavirus or have symptoms of it, or if you believe you have been exposed to the virus or are living with someone who has it, call your primary care doctor right away (and be sure to mention if you are taking immune-suppressing drugs); and also contact promptly the medical professional who treats your psoriatic disease and explain your potential coronavirus exposure, so that you can discuss how to proceed.

In these situations, you and your physician should seek to alter or delay your next dose or treatments that could suppress your immune system while you are actively at risk of the coronavirus. Of course, it should be done while taking steps to prevent a flare of psoriatic disease.

COVID-19 can come on rapidly, making it impractical to confer with a dermatologist prior to seeking treatment for the virus. But in all cases, when seeking treatment for potential or confirmed COVID-19, alert the doctor, clinic, or hospital of your psoriasis treatments and seek a dermatology consult as soon as possible.

Most importantly, all experts stress that you should not alter your treatment regimen without first discussing it with your physician. That is always sound advice.

A third issue of concern had been whether using non-steroidal anti-inflammatory drugs, specifically ibuprofen (brand name Advil, among others) could exacerbate the progression of the coronavirus. But the medical community has responded with one voice to affirm that there is NO actual risk, and that if you are taking ibuprofen for psoriatic arthritis, or other reasons, you can continue to do so without worrying about early media coverage of a supposed possible increased risk of COVID-19 from it. There is no evidence that ibuprofen poses risk with respect to COVID-19, and there are no case reports from doctors treating coronavirus patients identifying any issues related to ibuprofen.

What about dexamethasone and hydroxychloroquine?

Dexamethasone, a corticosteroid used by some psoriasis and psoriatic arthritis patients, has recently been shown to help hospitalized, seriously-endangered COVID-19 patients on ventilators or requiring oxygen, but NOT others with less severe coronavirus. This benefit may come from its anti-inflammatory effects and its ability to combat the “cytokine storm” referenced above. Note that quick withdrawal from systemic corticosteroids like prednisone and dexamethasone can sometimes trigger a severe psoriasis flare for psoriasis patients, one of the reasons using these steroid pills is somewhat controversial as a psoriasis treatment, given the other options now available.

Chloroquine (and its molecular cousin, hydroxychloroquine [HCQ, brand name Plaquenil, among others]) is already FDA-approved for treating malaria, lupus and rheumatoid arthritis. Investigators are trying to determine, according to the FDA, if it “can be used to treat patients with mild-to-moderate COVID-19 to potentially reduce the duration of symptoms, as well as viral shedding, which can help prevent the spread of disease.”

Most of the medical community is now of the view that further research has NOT found them to be useful in treating or preventing COVID-19. While some of that opposition appears to be driven by politics, not science, we have found no compelling evidence indicating that HCQ is useful with respect to COVID-19 (other than media reports early in the pandemic that some physicians had begun hoarding HCQ for their own families in case it proved effective).

This may remove a potential dilemma for psoriasis patients, as anti-malaria drugs can sometimes trigger a psoriasis flare in those who are susceptible to psoriasis. But the decision to use chloroquine in a patient with psoriasis has always been made on a case-by-case basis, balancing costs and benefits. Some psoriasis patients have used chloroquine successfully for its traditional uses without flaring.

Infusion Centers

For those who receive periodic infusions of their biologics at infusion centers, before you go to your next infusion, you can call to confirm that they have new procedures in place to reflect CDC best practices for social distancing, as well as disinfection strategies. Many centers have moved the stations further apart and all by now have likely taken other measures to ensure patient and staff safety while continuing to provide these important treatments.

In order to improve COVID-19 treatments for those who also have psoriasis, a registry has launched that is collecting data from health care practitioners about people they treat for coronavirus who also have psoriasis. The registry’s value comes from obtaining lots of data; so if you or anyone you know has or had both COVID-19 and psoriasis, let them know about the free and simple, web-based registry so their doctor can add them to it.

We hope you and your loved ones are remaining healthy and COVID-19-free, and we are also concerned for the tens of millions who are still being negatively affected economically or otherwise by this worldwide pandemic.

We urge you to take the CDC advice to heart, so that we can minimize the number of people who will be harmed by the virus and so we can all return to the freedom we love as soon as possible.

[Last updated 6-17-2020]