key: cord-0982848-vb7cgwyh authors: Giamarellos‐Bourboulis, Evangelos J.; Bettoli, Vincenzo; Jemec, Gregor B. E.; del Marmol, Veronique; Marzano, Angelo V.; Prens, Errol P.; Tzellos, Thrasyvoulos; Zouboulis, Christos C. title: Anti‐COVID‐19 measurements for hidradenitis suppurativa patients date: 2021-06-04 journal: Exp Dermatol DOI: 10.1111/exd.14339 sha: 31ad33856a25a69302ffb4eb5690eeb578aee799 doc_id: 982848 cord_uid: vb7cgwyh The reported incidence of COVID‐19 among cohorts of patients with inflammatory bowel and skin diseases under treatment with biologicals is low. Treatment may further modify disease severity as some biological modifiers, such as anakinra, are also proposed for the management of COVID‐19 patients potentially providing HS patients with an advantage. The above preliminary evidence suggests that hidradenitis suppurativa (HS) does probably not provide an increased susceptibility for COVID‐19 and that any susceptibility is unlikely to be modified negatively by treatment with biologicals. On the occasion of its 10th International Conference, experts of the European Hidradenitis Suppurativa Foundation e.V. have prepared a consensus statement regarding anti‐COVID‐19 measurements for HS patients. Based on the available knowledge, patients with HS may be vaccinated against SARS‐CoV2 and patients affected by metabolic syndrome constitute a high‐risk group for COVID‐19 and should be vaccinated at the earliest convenient point in time. HS patients on treatment with adalimumab can be vaccinated with non‐living virus anti‐SARS‐CoV2 vaccines. A possible suboptimal effect of the vaccine may be suspected but might not be expected universally. The management of the biological treatment in HS patients is at the discretion of the dermatologist / responsible physician. The immunological basis of COVID-19 remains poorly defined. 1 SARS-CoV2 may cause a complex inflammatory disease through hyperstimulation of the immune system 2 and may influence the course of autoimmune and/or autoinflammatory diseases. 3, 4 Among them, hidradenitis suppurativa / acne inversa (HS; ICD-11: ED92.0, ORPHANET: 370) is a chronic, inflammatory, immune-mediated skin disease 5, 6 with the innate immune system reacting to different triggering factors ending up in the production of skin lesions, such as nodules, abscesses and tunnels. HS comorbidities, such as spondyloarthropathy, inflammatory bowel disease, obesity, metabolic syndrome and concomitant cardiovascular disorders, 7, 8 implicate both autoimmune and/or autoinflammatory mechanisms. 9, 10 Only few data on the course of COVID-19 in HS patients exist, 11 and the knowledge regarding the proper management of HS patients in the pandemic period is limited. 12 The answer to the crucial question whether patients with HS are more or less prone to infection by the novel coronavirus SARS-CoV-2 (COVID-19) relies on the evidence for the response of the human host to the virus. First data suggest that COVID-19 is mediated by an intense pro-inflammatory reaction of the host, which if unchecked, may lead to severe respiratory failure (SRF). In 25% of patients, progression to SRF is mediated by a hyper-inflammatory reaction of circulating monocytes and tissue macrophages with features of macrophage activation syndrome; serum ferritin is exceeding 4420 ng/ml, hyper-triglyceridemia is pronounced and liver dysfunction predominates. In the remaining 75% of cases progressing into SRF, monocytes lose their ability for antigen presentation leading to lymphopenia and hypoglobulinemia; in parallel, monocytes maintain their potential for hyper-production of proinflammatory cytokines. 13 Interestingly, circulating monocytes of HS patients have relative energy for the production of pro-inflammatory cytokines; this is explained as reciprocal feedback to the skin hyperinflammation. 14 This suggests that in the case of SARS-CoV-2, HS patients are not prone to excessive pro-inflammatory reaction. (Table 1) . Furthermore, it needs to be considered that biological modifiers used in HS therapy, such as anakinra, are proposed for the management of COVID-19 patients. 19 The above evidence suggests that HS does probably not provide susceptibility for COVID-19 and that any remaining, limited susceptibility seems unmodified after treatment with biologicals. Anti-SARS-CoV2 vaccines aim to produce specific antibodies against the active viral agents, the spike protein. 20 Such neutralizing universally. The management of the biological treatment in HS patients is at the discretion of the dermatologist / responsible physician. antibodies generate a T-cell response and lead to avoidance of immune-enhanced disease. 21 The B-cell / plasma cell side of the adaptive immunity plays the major role in producing antibodies, and the T-cell side is of great support as well. 22 There is no reliable databased awareness of possible interactions between the immunological events occurring in HS patients and the immunological effects induced by the anti-SARS-CoV2 vaccine. Taking into consideration the existing initial data, 23 it seems that HS patients can be vaccinated against SARS-Co2 without specific contraindications. The most frequent cause of death in COVID-19 patients is a severe acute pulmonary syndrome. 1, 24 Obesity, diabetes, cardiovascular disorders and pre-existing pulmonary conditions are comorbidities, which may induce an increased risk of severe COVID-19 and lead to increased rates of death. 24 Taking into consideration the available data, the participating authors reached unanimously a consensus on behalf of the European Hidradenitis Suppurativa Foundation e.V., which includes the following measures: • The prevalence of COVID-19 in patients with HS is apparently lower than that of the general population. This may be due to HS patients having been especially careful with social shielding. However, underestimation is also possible. • HS appears not to be associated with a more severe course of COVID-19. • Treatment of HS with antibiotics and the TNFα inhibitor adalimumab seems not to increase the risk for COVID-19 or induce a more severe course. 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