key: cord-0879173-ft9f61pp
authors: Uchida, Hideaki; Kamata, Masahiro; Egawa, Shota; Nagata, Mayumi; Fukaya, Saki; Hayashi, Kotaro; Fukuyasu, Atsuko; Tanaka, Takamitsu; Ishikawa, Takeko; Ohnishi, Takamitsu; Tada, Yayoi
title: Impact of the COVID‐19 pandemic on biologic treatment in psoriasis patients: A single‐center retrospective study in Japan
date: 2022-03-23
journal: J Dermatol
DOI: 10.1111/1346-8138.16362
sha: aa82a071dbfec8b7d062cb6f14daf7ed4509d170
doc_id: 879173
cord_uid: ft9f61pp

The impact of the COVID‐19 pandemic on biologic treatment for psoriasis in Japan remains to be elucidated. This study aimed to investigate changes in biologic treatment and patients' behavior of visiting our department, especially in psoriasis patients treated with biologics before and during the pandemic. Data were collected from medical records retrospectively. The numbers of new psoriasis patients before (2019) and during (2020) the pandemic were compared. Patients' behavior of visiting our department was evaluated. The number of new psoriasis patients who visited our department in 2020 decreased by 35.7% compared with that in 2019. The reduction rate of new patients with psoriasis vulgaris was 49.3%, whereas the numbers of new patients with psoriatic arthritis (PsA) and generalized pustular psoriasis (GPP) were almost the same in 2019 and 2020. The number of patients who newly initiated biologics did not decrease in 2020 compared with that in 2019. As of January 1, 2020, 215 psoriasis patients were treated with biologics. Six patients (2.8%) discontinued biologics treatment possibly due to COVID‐19 in 2020. Among 212 patients with good adherence to visiting our department in the previous year, 24 patients (11.3%) refrained from their visits for at least 1 month. In most cases, refrainment was observed in April and May when the first state of emergency was in effect in Japan. In conclusion, the COVID‐19 pandemic hindered patients from visiting our department. However, its impact on patients who needed intensive care, such as patients with PsA and GPP, and psoriasis patients treated with biologics, was limited.

The outbreak of coronavirus SARS-CoV-2 disease (COVID-19) which was firstly identified in Wuhan, China, began in December 2019. The virus then spread all over the world, resulting in the declaration of a global pandemic by the World Health Organization on March 11, 2020. 1, 2 In Japan, the first patient infected with the coronavirus was identified on January 15, 2020. A state of emergency was declared in seven prefectures in Japan 3 months later on April 7, and then the state of emergency was expanded across the nation on April 16.

Although lockdown laws were not in force in Japan, people were asked to stay at home unless it was necessary to go out. Almost all commercial facilities and schools were closed until the state of emergency was completely lifted nationwide on May 21.

The fear of the risk of infection with the coronavirus and the recommendation that people reduce coming into contact with other people issued by the government could have hindered some patients from visiting a hospital or clinic. Tanacan et al. conducted a retrospective cohort study in Turkey and reported a significant decrease in hospital admissions during the pandemic period compared with the pre-pandemic period. 3 A cross-sectional observational study performed in Iraq revealed that the pandemic's psychologic impact, the fear of attending hospitals, and the shortage of medications have led to an increase in the relapse rate of common chronic skin diseases, including psoriasis. 4 Although there were no strict restrictions on going to a hospital or clinic in Japan, certain patients refrained from visiting a hospital or clinic. Focusing on psoriasis patients, since data on whether taking biologics for psoriasis had an effect on COVID-19 transmission were limited at the beginning of the pandemic, some patients were worried about continuing the biologic treatment. However, the impact of the pandemic on biologic treatment in psoriasis patients remains to be elucidated.

The pandemic popularized telemedicine, namely, remote consultation over the phone or on the internet 5 in many countries, including Japan. Our hospital began to offer telemedicine to patients with chronic diseases who were in a stable condition in April 2020.

In this study, we investigated changes in the behavior of patients visiting our department before and during the pandemic, especially psoriasis patients. In addition, the impact of the pandemic on biologic treatment in psoriasis patients was examined by comparing the use of biologics before and during the pandemic. We also investigated patients' refrainment from visiting our department and utilization of telemedicine in psoriasis patients treated with biologics.

Data on patients visiting our department from January 2016 to December 2020 were collected retrospectively from their charts.

To examine the impact of the pandemic on the visiting behavior of patients, the numbers of new patients who visited our department and patients referred to our department each year were investigated from 2016 to 2020. To assess the impact of the first declaration of a state of emergency, the ratio of the mean number of patients who visited our department per day in each month of 2020 to that in the same month of 2019 was calculated.

Next, we focused on psoriasis patients. The number of patients who were newly diagnosed with psoriasis vulgaris (PsV), psoriatic arthritis (PsA), or generalized pustular psoriasis (GPP) and the number of patients who newly initiated biologic treatment each year were examined from 2018 to 2020. Patients who switched biologics were excluded. In addition, we assessed the impact of the pandemic on patients who had already been treated with biologics for psoriasis in 2020. First, we counted the total number of patients who were being treated with biologics as of January 1, 2020, and then assessed the number of patients who discontinued biologics possibly due to the COVID-19 pandemic and the number of patients who refrained from visiting our department during 2020. Discontinuation of biologics was defined as ceasing biologic treatment and never receiving any biologic treatment at least until July 2021, when the data were collected. Patients who discontinued biologics due to having a good response or adverse events were excluded. A patient with refrainment from visiting our department was defined as a patient who had good adherence to visiting our department in the previous year (2019) and who canceled their appointment in 2020, refrained from their visit for at least 1 month, and made another appointment thereafter in 2020. The utilization of telemedicine was also evaluated.

An unpaired t-test was used to compare the means of two independent groups. Fisher's exact probability test was conducted to determine whether there were associations between two categorical variables. Statistical significance was set at P <0.05. GraphPad This study was approved by the ethics committee of Teikyo University (21-062) and was carried out under the principles of the Declaration of Helsinki. We obtained consent for this study by an opt-out method on the university website.

The number of new patients who visited our department each year is shown in Figure 1a Figure 1c , which revealed that some patients refrained from visiting our department from March 2020, when COVID-19 began to spread in Japan. The reduction rate was high especially in April and May, during the first state of emergency.

The number of patients who were newly diagnosed with PsV, PsA, or GPP at our department each year is shown in Figure 2a . 

Next, we assessed the impact of the pandemic on patients who had already started treatment with biologics for psoriasis. Two hundred and sixteen patients with psoriasis (PsV 132, PsA 65, GPP 18) were being treated with biologics as of January 1, 2020 (Table 1) Table 1 . Among the 145 patients treated with biologics that can be self-injected at home (adalimumab, secukinumab, ixekizumab, or brodalumab), 125 patients (86.2%) were treated under self-injection at home and 20 (13.8%) received the injection by nurses or doctors at our department instead of self-injection. The mean age of patients treated under selfinjection at home was siginificantly younger than that of patients without self-injection (52.4 ± 14.9 years old and 62.6 ± 11.8 years old, respectively; P = 0.0041).

Among the 215 patients treated with biologics as of January 1, 2020, six patients (2.8%) discontinued biologic treatment in 2020 for reasons other than having a good response or adverse events, namely, possibly due to the COVID-19 pandemic ( Table 2 ). One patient (case 1 in Table 2 

As 

Six (4.8%) of the 125 patients who were treated with biologics under self-injection at home utilized telemedicine in 2020 ( Table 3) . Most of the patients first utilized telemedicine in April or May, namely, during the first state of emergency. Patients who needed to be injected at the hospital did not utilize telemedicine.

The demic on psoriasis patients whose eruption and/or arthritis was so severe or their quality of life due to psoriasis was so impaired as to need biologics.

The first state of emergency was in effect from April to May 2020, during which many patients refrained from visiting our department (Figures 1c and 2c) . Furthermore, six patients who were being treated with biologics began to utilize telemedicine. Thus, the pandemic affected patients' behavior of visiting our department TA B L E 2 Psoriasis patients who discontinued biologic treatment in 2020 for reasons other than having a good response or adverse events enormously, especially during the first state of emergency. Among psoriasis patients who were being treated with biologics and refrained from visiting, most (75%) of the patients were undergoing self-injection at home, which indicates that self-injection of biologics at home resulted in flexibility in visiting behavior.

As for the study limitations, the data were collected at a single center in Japan. The trends could be different in individual hospitals and clinics. In addition, our hospital is located in the urban area in Tokyo.

Accessibility to a hospital or clinic and the extent of the pandemic In conclusion, the COVID-19 pandemic hindered patients from visiting our department, especially during the first state of emergency in Japan. However, its impact on patients who needed intensive care, such as those with PsA and GPP, and those treated with biologics, was limited. 

Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia

Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study

Changing trends in dermatology practice during COVID-19 pandemic: a single tertiary center experience

Impact of COVID-19 on medical practice: a nationwide survey of dermatologists and health care providers in Iraq

Virtually perfect? Telemedicine for Covid-19

Impact of the COVID-19 pandemic on biologic treatment in psoriasis patients: A single-center retrospective study in Japan

with biologics who utilized telemedicine in 2020