COVID-19, vaccination, and psoriasis: the latest in what you need to know

Despite our best hopes, COVID is still with us, and now vaccination news and debates confront us wherever we turn, from the internet to the local convenience store.

For people with psoriasis and/or psoriatic arthritis, it raises many questions, as we try to balance potential risks from the coronavirus with our psoriatic disease and often, other health issues. Here are the answers as best we can discern them, though we must warn you, there are still questions and uncertainties as well! [This page was last updated on 10-28-2021.]

Please know that scientists and medical practitioners are hard at work, worldwide, to tackle this virus and resolve these uncertainties, led by the US National Institutes of Health (NIH), the world’s largest producer of biomedical research.

Should people with psoriasis and/or psoriatic arthritis get one of the COVID vaccines?

Short answer: Yes.

COVID has killed some 760,000 Americans and more than 5 million people worldwide. Serious hospitalizations and severe symptoms for others have compounded the danger of this virus.

There is some evidence that patients with moderate to severe psoriasis and/or psoriatic arthritis whose disease warrants treatment with biologics or high-dose steroids, are at increased risk of having a COVID infection, as well as a higher risk of having a poor outcome from COVID, compared to the general public. Those increased risks may be due not to the psoriasis itself, but rather to the other ailments and diseases that are more common in psoriasis patients than the general public. (Other researchers have asserted that the studies demonstrating this increased risk are flawed, given the race to get data concerning this new pandemic.)

The COVID vaccines available in the US do a great job of reducing the likelihood of coming down with the virus, and if you do get the virus, vaccination greatly reduces your risk of death or serious injury from the virus.

Significant side effects from the vaccines have been rare, and for the vast majority of adults, the dangers of COVID outweigh the very small risk of a bad outcome from the vaccine.

Still, some people are hesitant to get the COVID vaccine, which is certainly an understandable reaction to the COVID pandemic and record-fast creation of COVID vaccines, especially for those with other health issues like psoriasis and psoriatic arthritis. Fortunately, the research done to date, and the results from billions of people who have already received these vaccines worldwide, has given a broad range of experts the confidence to conclude that adult psoriatic disease patients eligible for the COVID vaccine should get vaccinated.

There are three COVID vaccines available in the United States. There are two mRNA vaccines, one from Pfizer-BioNTech, and the other from Moderna. There is also a viral vector vaccine from Johnson & Johnson’s Janssen.

If our psoriatic disease is being treated with prescription medications, is it still safe to get a COVID vaccine?

Evidence to date strongly suggests that vaccination is as safe for those with psoriatic disease as those without it, regardless of your psoriasis treatment(s).

There are a few, but only a few, reports of patients having had psoriasis flares an average of about 10 days after receiving the vaccine; of course, illness also can trigger a flare, making a case of COVID a potential trigger as well.

Psoriasis experts have urged most patients, after discussions with their health care practitioner, to continue taking their psoriasis treatments during the COVID pandemic and throughout the vaccine process, unless they develop COVID or are in close proximity to someone with COVID, in which case they should contact their physician for additional guidance.

For prednisone or similar steroids, however, the recommendation is to work with your physician to try to avoid or minimize these treatments, if possible, as they may increase the risk of bad incomes if they are being used at the time of COVID infection. (This is true even though steroids are sometimes prescribed for COVID patients requiring oxygen therapy.)

We would stress that you should consult your physician before altering your treatment regimen, particularly with steroids, as reducing steroids too quickly can trigger a psoriasis flare that can be extensive.

How do psoriasis treatments interact with COVID vaccines?

The US Centers for Disease Control and Prevention (CDC) has reported that certain psoriasis and psoriatic arthritis treatments – including biologic agents, methotrexate, and active treatment with high-dose corticosteroids (i.e., ≥20 mg prednisone or equivalent per day when administered for ≥2 weeks) – can interfere with the ability of COVID vaccines to trigger a sufficient immune response. It is not yet clear if that lesser response translates to a higher risk of getting COVID or having a more serious case of COVID if infected. Research is ongoing.

Nevertheless, because a weakened response could leave those using those treatments less than fully protected against COVID, the CDC is urging these patients to follow a different flow of vaccine shots. (These patients are part of a group known as “moderately to severely immunocompromised.”)

It is confusing, and keeps changing, so we will try to lay out the different scenarios here, and will update this page as needed.

* A moderately to severely immunocompromised adult who has received a two-dose series of the Pfizer or Moderna vaccines, should receive an additional dose of Pfizer or of the full-dose (100 μg) of Moderna, “immediately” after more than 28 days have elapsed since the second shot.

* At least six months after that third shot, those patients should receive a booster dose with any of the three vaccines. (A booster dose of Moderna is 50 μg, which is 1/2 the normal 100 μg dose.) That means a total of four shots over about eight months.

* A moderately to severely immunocompromised adult who has first received the one shot dose of the J&J/Janssen vaccine, should, after at least two months have passed, receive one booster dose of any of the three vaccines. (Note that the booster-sized dose of the Moderna vaccine is 50 μg, which is 1/2 the normal 100 μg dose.) That means if your first shot was the J&J/Jannsen vaccine, you should only get one more shot, a booster at least two months later, which means a total of two shots.

Note also that the CDC has now given the official green light to switching to a different vaccine for your additional shot. That is despite the limited research to date on the appropriateness of mixing the different vaccines. At least part of the basis for allowing switching vaccines for additional doses is reportedly to avoid doses of a particular brand of vaccine being wasted, for example by passing its expiration date. That would mean that public health considerations, rather than solely what is best for an individual patient’s health, have crept into the CDC’s recommendations.

We would like solid evidence of the safety and personal health benefit to someone switching vaccines, before we would recommend that route. The FDA approvals were all based on boosters of the same vaccine. (Similarly, we are concerned that a substantial reason for promoting vaccination of children is to help adults, which is a tricky moral issue that should be left to parents to decide. We are psoriasis patients, not philosophers or ethics professors!)

Finally, to mitigate the potential of these psoriasis treatments to weaken the desired response of COVID vaccines, many experts suggest that patients using these treatments should try to hold off on taking them for one or two weeks after each vaccine shot, particularly for those taking methotrexate. But because that gap in treatment could disrupt the course of psoriatic disease in these patients, they are urged to discuss this with their dermatologist or rheumatologist in advance, to weigh the costs and benefits of such a pause in treatment.

What about those of us battling psoriasis, who also have other significant health issues?

Population studies show that people with psoriatic disease have a higher rate of serious comorbidities (including obesity, diabetes, a history of smoking; or significant kidney, liver, heart, or lung disease) than the general public. While older age (particularly 65+) is the biggest factor that increases one’s risk for a case of COVID to become severe or dangerous, these other ailments also increase the risk of a severe case of COVID. This makes vaccination even more important for these people.

What else can we do to stay safe?

The CDC recommends that even after vaccination, people who are immune compromised should continue to wear a mask and stay six feet apart when indoors around others they don’t live with; avoid crowds and poorly ventilated indoor spaces; and urge close contacts to be vaccinated against COVID.

Where can I get additional information on these issues?

CDC’s COVID portal

American College of Rheumatology COVID-19 Vaccine Clinical Guidance

NPF COVID-19 Task Force Guidance Statements

Further background on the COVID pandemic, and psoriatic disease

Short summary

• 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 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.
• Roughly 40 percent of U.S. COVID-19 deaths in the first year of the pandemic occurred in nursing homes and assisted living facilities, a shocking statistic.

Additional information

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.

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.

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.]

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.

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.
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.

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-free, and surviving the upheaval to the economy and to children’s education.

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 10-28-2021]