key: cord-0710058-hr13taxx
authors: Diotallevi, F.; Campanati, A.; Radi, G.; Martina, E.; Rizzetto, G.; Barbadoro, P.; D'Errico, M.M.; Offidani, A.
title: Vaccination against SARS‐CoV‐2 and psoriasis: the three things every dermatologist should know
date: 2021-04-17
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.17256
sha: 0143fc6cb09b455972fd8840784204b73449f158
doc_id: 710058
cord_uid: hr13taxx

Currently there are two vaccines already authorized from FDA and EMA for Emergency Use (1). They are the BNT162b2 and the mRNA-1273, respectively produced by Pfizer/BioNTech® and Moderna® (Tab.1). Both vaccines consist of nucleic acid, mRNA able to induce our human cells to use protein factories to make the antigen (viral spike protein) that will trigger an immune response.

1 What are the characteristics of the vaccines approved by FDA (Food and Drug Administration) and EMA (European Medicines Agency) against SARS-CoV-2? Currently, there are two vaccines already authorized from FDA and EMA for Emergency Use. 1 They are the BNT162b2 and the mRNA-1273, respectively, produced by Pfizer (New York, NY, USA) /BioNTech â (Mainz, Germany) and Modernaâ (Cambridge, MA, USA) ( Table 1) . Both vaccines consist of nucleic acid, mRNA able to induce our human cells to use protein factories to make the antigen (viral spike protein) that will trigger an immune response.

According to data published by the two companies, the BNT162 and the mRNA-1273 vaccines showed 95% and 94.5% efficacy in preventing COVID-19, respectively. 2, 3 Regarding safety profile, phase III studies demonstrate an excellent safety profile for both vaccines. 2, 3 In mRNA-1273, Modernaâ vaccine solicited adverse events at the injection site occurred in 84.2% of patients after first dose and in 88.6% of patients at second dose. The most common injection-site event was as follows: pain after injection (86.0%), delayed injection-site reactions in 0.8% of patients after the first dose and in 0.2% after the second dose.

Solicited systemic adverse events occurred in 54.9%, after first dose and in 79.4% of patients after second dose.

The most common treatment-related adverse events were fatigue (1.5%) and headache (1.4%).

In BNT162b2, Pfizer/BioNTechâ mild-to-moderate pain at the injection site within 7 days after an injection was the most commonly reported local reaction, with <1% of participants across all age groups reporting severe pain.

The most commonly reported systemic events were fatigue and headache (59% and 52%, respectively). 2 Which is the specific risk for psoriatic patients in case of SARS-CoV-2 infection? According to Dadras et al., 4 there would be a close connection between psoriatic disease and COVID-19 disease due to the angiotensin-converting enzyme (ACE) role. SARS-CoV-2 spike protein shows strong binding affinity to human angiotensinconverting enzyme 2 (ACE2) receptor. This has been recognized as the major reason for skin involvement during SARS-CoV-2 infection. 5, 6 Serum level of ACE tends to be higher among psoriatic patients and correlates with higher cardiovascular comorbidities, including subclinical atherosclerosis. 7 Moreover, tissue ACE activity seems to be higher among psoriasis subjects and correlates with disease activity. 8 The overactivity of ACE in COVID-19 patients may aggravate psoriatic condition, favouring higher incidence of cardiovascular events in the subset of COVID-19 psoriatic patients. Thus, Dadras et al. 4 proposed that psoriasis patients may be at an increased risk of both deterioration of the disease and higher incidence of cardiovascular events in case of COVID-19 infection. They concluded that prevention of SARS-CoV-2 infection by vaccine is crucial for patients with psoriasis. 3 Which specific recommendations may be drawn for psoriatic patients receiving vaccine? In this phase, specific data on the efficacy or safety of vaccines against COVID-19 in patients with psoriasis on immunosuppressive therapy are not available yet, as these patients are naturally excluded from clinical trials.

However, given the nature of the vaccine and the results of studies on the efficacy of other types of inactivated vaccines in patients undergoing biological therapy, there are no obvious contraindications to the use of the vaccine. The major international scientific societies, such as the National Psoriasis Foundation, in fact, recommend the use of the SARS-CoV-2 vaccine even in patients undergoing biological therapy without the necessity to discontinue the therapy. 9 Although further study will be required to define mainly efficacy of SARS-CoV-2 vaccines in psoriatic patient undergoing biological treatments, nowadays their vaccine immunization against SARS-CoV-2 infection is strictly recommendable in our opinion.

Assessing a case-by-case approach, evaluating the risk-benefit ratio of maintaining the ongoing immunosuppressive therapy before performing the vaccine is mandatory at the moment. 10 

No funding sources have supported this work.

The authors declare no conflicts of interests.

All authors have contributed to the writing of the manuscript. 

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Offidani A Global coronavirus pandemic (2019-nCOV): implication for an Italian medium size dermatological clinic of a II level hospital

A new virtual inpatient dermatology electronic referral service: a timely solution in the COVID-19 pandemic and beyond?Dear Editor, The use of teledermatology in an inpatient setting is not well-established, with limited data published compared to the outpatient setting. It has, however, been demonstrated that teledermatology may be effective for managing inpatient dermatologic disease, leading to highly concordant diagnostic and management decisions. 1,2 Involvement of dermatologists in the care of hospitalized patients has been found to improve patient outcomes 3 with inpatient teledermatology reducing response times. 4 We set up a store-and-forward, fully digitized, virtual inpatient referral service to replace our traditional paper-based, faceto-face (FTF) inpatient referral pathway, amidst the COVID-19 pandemic. Our health board in Wales, UK, covers a relatively wide geographical area across 1553 km 2 , accounting for 30% of the Welsh landmass, but covering only 18% of the population of 3.1 million. We cover inpatients across six different hospital sites, two of which have traditionally had inequitable access to a dermatology opinion as they lack regular onsite clinics. The old system was onerous for both clinicians and administrative staff, as historically inpatient referrals comprised handwritten forms manually delivered or faxed between hospitals. Referrals often lacked vital clinical information, comprised illegible handwriting and frequently went missing. We therefore implemented an entirely paperless, electronic referral pathway that integrated with the electronic patient record (EPR) and enabled virtual rather than FTF review.An e-referral form was designed for referrers to include essential clinical information, with medical photographs requested alongside. High-quality images were taken by the medical illustration service and uploaded securely onto the EPR. Dermatology residents reviewed referrals virtually, relaying advice back to the referring clinician. Referrals, including patient metadata, from all inpatient specialties across the six hospitals over a 10-week period from 14 July to 30 September 2020 were assessed. A five-point Likert scale was used to assess the degree of confidence residents felt in managing inpatients virtually.Of 95 consecutive referrals, 55% were male and 45% female (age range 0-103 years; average 63.8). Almost all (96%) were judged to be appropriately directed to dermatology. Most referrals (84%) were successfully dealt with virtually. The majority of the remaining 16% comprised patients that required a biopsy, paediatric cases needing parental reassurance and complex medical cases. A wide variety of dermatological conditions were diagnosed and managed, both inflammatory and lesions, and 87% were discharged with appropriate advice.The average response time was 1.9 days, 66% were dealt with within 24 h and 77% within 48 h (Fig. 1a) . The rate-limiting step was waiting for accompanying images, accounting for 74% of variance in the time awaiting review (Fig. 1b) . Residents felt highly confident in 62% cases (Fig. 1c) . A senior review was needed in 65%, of which 99% were easy to obtain.Our virtual platform has widened the reach of timely specialist input across sites where dermatology services have not traditionally been based, ensuring equitable access for patients, independent of location. It establishes a secure and permanent