Does Having Psoriasis Put You at Higher Risk for Contracting COVID-19?
Experts don’t have enough information to say whether people with psoriasis are more likely to contract COVID-19 compared with the rest of the population. According to the National Psoriasis Foundation, “it is not known whether having psoriasis and/or psoriatic arthritis meaningfully alters the risks of contracting SARS-CoV-2 (the virus which causes COVID-19 illness) or having a worse course of COVID-19 illness.” What is known is that people with psoriasis, particularly those who have severe cases, are more prone to other serious medical conditions such as cardiovascular disease, diabetes, hypertension, and even chronic obstructive pulmonary disease (COPD). “We know that all those comorbidities increase the risk for people of having bad outcomes from COVID-19,” says Joel Gelfand, MD, professor of dermatology and a practicing dermatologist and epidemiologist at Penn Medicine in Philadelphia If you have psoriasis and high blood pressure, for example, or psoriasis and diabetes, you would be well-advised to take every precaution against coronavirus infection, Dr. Gelfand adds — especially if you are also in the higher-risk group of people who are 65 or older.
Are There Extra Safety Precautions People With Psoriasis Should Take to Avoid Exposure?
“For my patients with psoriasis, I explain the importance of social distancing, regular hand-washing, wearing a mask when outside of their house, and things of that nature,” says Gelfand. “I think working from home as much as possible is a good way to limit exposure as well.” The standard recommendations from the Centers for Disease Control and Prevention (CDC) make the most sense to follow, Gelfand adds. Some of these reports describe what has happened to people with psoriasis who’ve gone on Plaquenil (hydroxychloroquine), a drug that has been used in COVID-19 treatment that is known to aggravate psoriasis, notes Gelfand. “There’s also some data from when people who become infected and stopped their immune-suppressing drugs, such as cyclosporine, and then had their psoriasis get worse.” “In general, viral infections often make psoriasis flare in people because it revs up the body’s immune response, and psoriasis is an immunologic disease,” says Gelfand. “It wouldn’t be surprising to me if some people experienced flares of psoriasis related to having the COVID-19 infection.” Doing a little research and making plans accordingly can help reduce some of the confusion and anxiety around COVID-19. Understanding if and how your medication should change during the pandemic and making sure you can follow your doctor’s treatment plan in any scenario are important items to check off your list. “There’s still a lot of uncertainty out there; we’re still trying to gather and interpret the scientific evidence because right now we don’t really know the safety of some of our therapies in the setting of having COVID-19 infection,” he says. Until there’s more data, it’s really an individual decision between the patient and the physician about whether or not the uncertainty is outweighed by the benefits of being on therapy, he adds. There is currently a clinical trial underway in Italy to assess the prevalence and incidence of COVID-19 in people with chronic plaque psoriasis who are on immunosuppressant therapies, including biologics, methotrexate, cyclosporine, and corticosteroids. “There is a hypothesis that immunosuppression is bad early on for COVID-19 because it could make a person more likely to get it and have a more severe case,” says Gelfand. The National Psoriasis Foundation does not recommend that all patients stop their biologic or oral systemic therapies, but the group does recommend that patients on these medications who develop COVID-19 talk with their doctor. The decision on whether to stop or continue therapy should be considered on a case-by-case basis by the individual and their doctor and will depend on a variety of other factors, including the severity of the psoriasis as well as any additional risk factors the person may have, according to the National Psoriasis Foundation guidelines. Gelfand offers a few examples from his patient population. “In the case of an older patient with mild psoriasis with an underlying condition like heart disease, I might suggest to them that we stop the biologic for now. We could always restart if the psoriasis becomes significant again; some people have a long remission off of their drug,” he says. “In contrast, I may have a patient who has horrible underlying psoriasis and has failed multiple therapies. In that case, I would be less inclined to stop their medication because the concern is that they would lose response and not be able to regain it when they are restarted on the drug,” he says. RELATED: What You Need to Know About Living With a Compromised Immune System During the COVID-19 Outbreak “In that study the drug arm of the trial had a slightly higher infection rate than the placebo arm for nonserious infections. So we know that methotrexate can increase the risk of infections from that data, but it wasn’t a significant medical problem in an at-risk patient population,” says Gelfand. Given that it was a large trial that included thousands of people and went on for three or four years, that data should be somewhat reassuring, he adds. Gelfand and his colleagues recently completed a meta-estimate that will be published in The Journal of the American Academy of Dermatology, which examined the risk of respiratory tract infections with interleukin-17 (IL-17) inhibitors, such as Cosentyx (secukinumab) and Taltz (ixekizumab). “In analyzing the clinical trials that were used to grant [U.S. Food and Drug Administration] FDA approval of the medications, there was a higher rate of respiratory infections with these drugs compared with placebo — about 40 percent higher,” says Gelfand. “Pre-COVID-19, no one was really concerned about this because respiratory infections are usually mild and don’t need any treatment because they just go away. But in COVID-19, a respiratory tract infection could kill you or kill someone you give it to. That small risk difference could now be important and should be considered in making decisions about drug therapy,” he says. The bottom line is when it comes to different therapies for psoriasis, no one knows for certain what the risks are with COVID-19, says Gelfand. “That’s why we have to do the trials. Sometimes we have theories based on our best scientific knowledge and when those theories are tested in humans we find the opposite,” he says.
What Resources Are Available if You Can No Longer Afford Your Medications?
If your insurance or job status has changed and you’re concerned about paying for psoriasis medication, you need to let your doctor know what’s going on, says Gelfand. “I really need to know if a person is having issues related to access or if the expense is prohibiting them from following the treatment plan that I want to give them,” he says. “Unfortunately, doctors are unable to predict what the cost to the patient will be because it’s so variable from insurance company to insurance company,” he says. The good news is that often there are small tweaks to your therapy that could save you thousands of dollars on your psoriasis medication, says Gelfand. “In most cases we might be able to find something similar that would probably work just as well,” he says. A website called GoodRx, which lets you compare drug prices and find psoriasis coupons, can be very helpful for some patients, says Gelfand. “People can learn how and where to find their prescription medication for the lowest price,” he says. You can also visit an individual drug company’s website; many have psoriasis assistance programs that can help defray costs or even get you psoriasis medication for free, he adds.
What Can Someone With Psoriasis Take to Safely Boost Their Immune System?
There really isn’t any sort of vitamin or supplement that a person with psoriasis can take to protect themselves from COVID-19, says Gelfand. “Maintaining good overall health is the most important thing. The best people can do, including people with psoriasis, is to eat healthy, exercise regularly, try to maintain a healthy body weight, and not drink to excess,” he says. Experts continue to debate whether vitamin D offers any protection against COVID-19, following the release of a study in the Irish Medical Journal on May 12 suggesting that vitamin D deficiency may lead to increased risk of contracting COVID-19 or having a more severe case.
Can Anxiety Around the Coronavirus Make Psoriasis Worse?
For most of us, the novelty of the lifestyle changes required by the pandemic is beginning to wear off, says Gelfand. “We’re probably entering the more difficult phase of all this and for a lot of people stress levels may start to rise and mood problems may begin to present.” “Many people notice that stress makes psoriasis worse; there’s been a lot of data on this over the years,” says Gelfand. “When people go through a divorce or have another traumatic event in their life, that can often trigger their first bout of psoriasis.” Attention to diet, regular exercise, and plenty of sleep, along with stress-relieving approaches like mindfulness meditation can help improve stress and psoriasis for some people. “Sometimes adding a few simple things to your day, such as walking regularly or mindfulness meditation, can improve mood,” Gelfand says. RELATED: Facing My Anxieties During the Coronavirus Crisis He adds, “There are situations in which professional help or medications are necessary; talk with your doctor about your mental and emotional health, and make sure to ask for help when you need it.” There’s also evidence that treating psoriasis can reduce the incidence of depression. A review published in June 2015 in the Journal of European Academy of Dermatology and Venereology found that treating psoriasis with biologics was associated with statistically significant reductions in depressive symptoms.
Should You Continue to Go to Regularly Scheduled Doctor’s Appointments?
Whether you should venture outside to an in-person appointment is largely dependent on the prevalence of the coronavirus your community, according to Gelfand. “Check in with resources like your local health department and your doctor. Ask your doctor if you can do a virtual appointment or if a physical appointment is necessary,” he says.
Wear a face covering.Keep hand sanitizer with you and use it when needed.Try to avoid public transportation.Ask your doctor if you can wait in your car and have them call or text you when it’s time to come in so that you can avoid the waiting room.Try to maintain social distancing whenever possible.
Are Virtual Doctor’s Visits as Effective as In-Person Visits?
“There’s very good data that telemedicine can be used as effectively as an in-person visit with a dermatologist to manage psoriasis,” says Gelfand. He was part of a team of physicians who contributed to a large clinical trial by April Armstrong, MD, MPH, published in October 2018 JAMA Network Open, which found that people with psoriasis who were seen remotely experienced improvement in disease severity equivalent to in-person management. “I’m almost exclusively managing my patients with psoriasis through telemedicine right now,” he adds.
What Types of Appointments Should You Do Virtually vs. In-Office?
Although patients already diagnosed with psoriasis can manage their condition remotely, a physical examination would usually be required for an initial diagnosis in determining the proper course of treatment, says Gelfand. “The people who need to come into the office with psoriasis are those for whom a diagnosis is not well-established and were not able to make one through pictures or a video assessment,” he says. Those patients may need a physical examination to help decide on the course of therapies. “If I’m trying to understand if a person’s joint pain is psoriatic arthritis, I often need to do that in person; I need to feel the small joints of the hand, for example,” says Gelfand.
What to Expect at a Telehealth Psoriasis Appointment and How to Get Prepared
“The value of a virtual psoriasis appointment is in large part dependent on the patient,” says Gelfand. “It’s really important to take this seriously — as seriously as if you were going to see me in the office.” Even though we live in an age where everyone is trying to continually multitask, when you have a telemedicine appointment you need to give it your full attention, he adds. “I’ve had patients out on walks with their dogs or listening to a webinar at work during our appointment,” he says. “This is serious business. We’re discussing the use of drugs that cost tens of thousands of dollars.” He adds, “There is important information conveyed during a doctor’s appointment, and the last thing you want to happen afterward is to wonder ‘What did he or she say again?’ Or, ‘Why did I forget to ask this?’” Gelfand offers a few tips for getting the most out of your telemedicine appointment.
Take a few minutes before your appointment time to make sure you are familiar with the conferencing platform if it’s a video appointment.Set yourself up in a private, well-lit room wearing clothes that are easy to take on and off in case there’s a need for the doctor to look at something on your skin during the video chat.Prepare your list of questions in advance and make sure it’s available.
“The Centers for Disease Control and Prevention (CDC) is a good source for up-to-date information; go there on a regular basis. Your local department of health website is another good resource because that is often going to determine what’s the right thing to do for an individual,” he says. If you’re in a community that has a lot of cases of COVID-19, you’re going to need to be very careful about social distancing; if you live in an area that has very few cases, then you may have more opportunities to socialize on a regular basis, according to Gelfand. “A lot of that depends on the local case count that you have in your community,” he says. If the information from the CDC and your local health authorities doesn’t make sense to you or seems contradictory, reach out to your doctor for direction, adds Gelfand. Gelfand also emphasizes the importance of having a plan should you become ill. “It’s important for people with psoriasis to be aware and knowledgeable about what they will do and who they will call if they begin to feel sick,” he says. Those things are important to know because how you feel can change rapidly with the coronavirus, he says. “For some people it’s pretty mild but for others it can be very severe. Even in a mild case, it can change rapidly; people may think they’re not feeling too bad, but then within a short period time be very sick,” says Gelfand. RELATED: A Coronavirus Checklist: Prepare for the Possibility You May Get Very Sick Additional recommendations from Gelfand for living with psoriasis in the age of COVID-19 include:
Practice CDC recommendations on hand-washing and social distancing.Stay in touch with your doctor and contact them immediately if your health status changes.Consult your doctor before you change or stop any of your medication.Keep your stress level to a minimum.Practice a healthy lifestyle around diet, exercise, and sleep.
The International Psoriasis Council is a group of dermatology-led nonprofits made up of psoriasis experts, professionals, and thought leaders. The website contains a COVID-19 psoriasis resource center. CreakyJoints.org is a digital community for people with arthritis and offers resources for people with psoriasis. The SECURE-Psoriasis Registry is an international pediatric and adult registry administered by the Wake Forest School of Medicine in North Carolina to monitor and report outcomes of COVID-19 cases in people with psoriasis. The registry will be periodically updated to report what cases have been submitted and the outcome of each.
