key: cord-0820983-17ww4p9y authors: Queiro Silva, Rubén; Armesto, Susana; González Vela, Carmen; Naharro Fernández, Cristina; González‐Gay, Miguel Angel title: COVID‐19 patients with psoriasis and psoriatic arthritis on biologic immunosuppressant therapy versus apremilast in North Spain date: 2020-07-03 journal: Dermatol Ther DOI: 10.1111/dth.13961 sha: 6768d4f8950eb253b1ede0ca9750fb7c0fbd7e02 doc_id: 820983 cord_uid: 17ww4p9y Immunosuppressive and immunomodulatory treatments are critical for the management of inflammatory and autoimmune conditions such as psoriasis or psoriatic arthritis. Like in those illnesses, the lung injury and acute respiratory distress shown in COVID‐19 patients are the result of a disruption in the balance of pro‐ and anti‐inflammatory cytokines. This hyperinflammatory response to SARS‐CoV‐2, associated with the severity of the coronavirus disease, is called the cytokine storm. There is a growing concern regarding how patients on immunosuppressant biologic therapies might be at higher risk of being infected and whether they need to discontinue their treatment preemptively. Clinical data on COVID‐19 infected patients with psoriasis or psoriatic arthritis are still scarce. Here, we presented seven cases of this type of patients. The patient infected with COVID‐19 on apremilast and the one on apremilast with infected spouse showed the best safety profile and mildest symptoms. One of the secukinumab patients also presented a relatively good outcome. Infliximab patients and the one with serious comorbidities showed the worst outcome. Even though more clinical data are yet needed to draw strong conclusions, apremilast could be a safer alternative for dermatology and rheumatology patients in case of clinically important active infection. This article is protected by copyright. All rights reserved. COVID-19 pneumonia is characterized in some patients by an exaggerated immune hyperinflammatory response, with fast activation of innate immune cells and increased plasma concentration of interleukins (IL) and tumor necrosis factor alpha (TNFα). It is the so called "cytokine storm", associated with the severity of the disease. 1, 2 This response comprise a series of mediators that are pharmacologically targeted in immunemediated inflammatory diseases such as psoriasis and psoriatic arthritis. 2, 3 Therefore, it might be considered that immunosuppressant drugs can be harmful by making these patients more susceptible to infection and to develop a more severe coronavirus syndrome. 2, 4 With daily media warnings and dozens of articles published on the pandemic, patients and physicians are concerned on the possible higher risk of being infected, and whether they need to discontinue their biologic treatment preemptively. 1, 2, [4] [5] [6] [7] Moreover, these patients are often at greater risk of developing cardio-vascular disease, depression, and other health conditions which might increase the severity of the COVID-19 infection. 8, 9 Aggravation of previous skin diseases, such as rosacea, eczema, atopic dermatitis, and neurodermatitis has been observed in some COVID-19 patients. 8 It has been documented psoriasis exacerbation following established respiratory virus infection 10 and in a case of SARS-CoV-2 infection. 11 In our facilities, one COVID-19 patient developed psoriasis without previous personal or family history. Most current recommendations refer to guidelines and package inserts suggesting that biologics are contraindicated in case of clinically important active infection. It is not yet This article is protected by copyright. All rights reserved. known if biologic therapies render patients more susceptible to coronavirus infection. 1, 3, 6, 9 On the other hand, discontinuing biologics can result in loss of response when treatments are reintroduced, or even result in the formation of antibodies to the discontinued biologic. 6 Some physicians consider that immunosuppressant therapies should be suspended or reassessed until the infection is solved, 4,7,9 while others argue that this might be a premature decision considering the available evidence. 1,2,5 At present, clinical data on COVID-19 patients with psoriasis or psoriatic arthritis on biologic therapies are scarce. Nonetheless, slowly but surely, new cases are emerging that allow us to shed some light on this issue. In our facilities, we have had seven cases of patients with COVID-19 on different biologic therapies that we describe below. Main clinical features are summarized in Table 1 . Percentages of COVID-19 infected individuals among our psoriasis patients are shown in Table 2. 1) A 55 years old woman with palmoplantar psoriasis on apremilast therapy for the last 6 months was diagnosed of bilateral pneumonia and admitted to hospital during 3 days for COVID-19 treatment. Apremilast was maintained during hospitalization. A month later, COVID-19 tests were negative. 2) A 42 years old man with psoriasis and psoriatic arthritis treated with apremilast in outpatient confinement due to infected spouse with moderate COVID-19 symptoms. After quarantine period, both showed no respiratory affections. Apremilast was maintained during the confinement. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved. with infliximab for the last three years, after failure with adalimumab therapy. The disease was kept under control with moderate inflammatory symptoms. Even though self-confined at home, persistency of COVID-19 symptoms forces her to attend the emergency unit on several occasions, until disease recovery. Infliximab treatment was suspended during COVID-19 infection. Even though the number of patients presented here is still too low to draw strong conclusions, it is noteworthy that the patients on apremilast showed the best safety profile ( Table 1 ) and, along with secukinumab, the lowest infection rate (Table 2) . We have already indicated that apremilast could be a safer alternative in the COVID-19 era. 12 Several studies have reported a good efficacy and an excellent safety profile for apremilast in the treatment of psoriasis and psoriatic arthritis. 12, 13 Regarding virus infections, large studies have shown a significant decrease of serious infections rate in apremilast treated patients. 14 In a prospective safety study on the long-term safety of different medications for psoriasis, authors reported that apremilast patients had a lower risk of infections and infestations. 15 Apremilast does not affect B cells, T cells, or IgG and IgM secretion, but partially inhibit TNFα, INFγ, IL-17 and IL-23. 16 This article is protected by copyright. All rights reserved. specific mechanism of action, 12, 14, 16 apremilast does not favor neither the infections nor the cytokines storm, and it will not increase the risk of pulmonary fibrosis, one of COVID-19's mortality factors. 9 It has been reported that apremilast, as other systemic and biologic therapies, did not increase the risk of severe COVID-19 in psoriasis 17 and psoriatic arthritis 9 patients. Therefore, apremilast might offer a safe alternative, in the face of the ongoing pandemic, for those dermatology and rheumatology patients that This article is protected by copyright. All rights reserved. Should patients stop their biologic treatment during the COVID-19 pandemic COVID-19: risk for cytokine targeting in chronic inflammatory diseases? COVID-19 and immunomodulator/immunosuppressant use in dermatology COVID-19 and psoriasis: Is it time to limit treatment with immunosuppressants? A call for action Comment on "COVID-19 and psoriasis: Is it time to limit treatment with immunosuppressants? A call for action Should biologics for psoriasis be interrupted in the era of COVID-19? Considerations for safety in the use of systemic medications for psoriasis and atopic dermatitis during the COVID-19 pandemic Dermatology staff participate in fight against Covid-19 in China Psoriatic Arthritis and COVID-19 Pandemic: Consequences in Medical Treatment? Respiratory virus infection triggers acute psoriasis flares across different clinical subtypes and genetic backgrounds A case of exacerbation of psoriasis after oseltamivir and hydroxychloroquine in a patient with COVID-19: Will cases of psoriasis increase after COVID-19 pandemic? Opportunistic virus infections in psoriasis patients: the safer alternative of apremilast in the COVID-19 era Clinical efficacy, speed of improvement and safety of apremilast for the treatment of adult Psoriasis during COVID-19 pandemic Risk of serious infection in patients receiving systemic medications for the treatment of psoriasis Long term safety of nine systemic medications for psoriasis: a cohort study using the Biobadaderm Registry Apremilast is a selective PDE4 inhibitor with regulatory effects on innate immunity Systemic or biologic treatment in psoriasis patients does not increase the risk of a severe form of COVID-19 This article is protected by copyright. All rights reserved.