Flexible, Personalized Care Needed for Psoriatic Disease During COVID-19 Pandemic

As COVID-19 expanded throughout the country, health care and treatment regulations evolved to prevent further spread. More recently, as states have started to reopen, providers have had to adapt to ever-changing recommendations.

In June, the National Psoriasis Foundation’s COVID-19 Task Force updated its list of recommendations for patients with psoriasis and practitioners regarding treatment options, office visits and risk factors.

“In general, most patients with psoriatic disease should probably remain on their systemic therapy if they’re on it. And if they need to start systemic therapy for their disease, that should be considered as well,” Joel M. Gelfand, MD, MSCE, co-chair of the task force and professor of dermatology and epidemiology at the Perelman School of Medicine at the University of Pennsylvania, said. “The burden of psoriasis is quite substantial. It’s hard enough to deal with the emotional and difficult effects of the pandemic, and then having to deal with psoriasis on top of it.”

Data on how biologic treatment for psoriatic disease affects COVID-19 infection rates have been limited to date, but what has been discovered so far is reassuring.

Jerry Bagel, MD, of the Psoriasis Treatment Center of Central New Jersey, has treated 500 patients on biologic therapy since his clinic reopened in June. Of those, five had contracted COVID-19, with one being hospitalized for pneumonia.

“What kills people in COVID is the cytokine storm, which is an elevation in many of the pro-inflammatory molecules, which you see elevated in immunologic diseases such as psoriasis, Crohn’s disease and rheumatoid arthritis,” Bagel said. “The biologic agents we use diminish or decrease the amount of pro-inflammatory molecules, potentially decreasing the cytokine storm that results in fatality.”

Many patients are concerned about the immunomodulatory effects of biologic medications and if the medications will increase their risk for contracting COVID-19 or other transmittable diseases, he said.

“I don’t think these agents are as immunosuppressant as people think,” Bagel said. “Especially in the newer IL-17 and IL-23 agents, there hasn’t been an increase in serious infections. In many cases, they are taking people who have very high inflammatory markers and bringing many of those markers down.”

High-risk patients

Patients who are at a higher risk for contracting COVID-19 and experiencing the more dangerous effects of the virus, however, have to be handled with a different approach.

“My biggest concern is patients who have one or more of the ‘big four’ comorbidities for COVID: diabetes, hypertension, obesity and advanced age,” Jeffrey Crowley, MD, MS, FAAD, of Bakersfield Dermatology in California, said. “A patient who has a combination of those and psoriasis is just a higher-risk patient, and I would be more careful about what I recommend for them.”

Prescribing methotrexate, cyclosporine, steroids or JAK inhibitors could potentially put patients at risk for infection due to their immunosuppressant nature. In addition, patients with psoriatic disease are often prone to these comorbidities, creating a challenge for treatment.

In these cases, practitioners must stress the importance of social distancing, regular hand washing and sanitizing, and wearing a mask in public in order to mitigate risk, according to Gelfand.

The rise of telehealth

In the early days of the pandemic, many specialists’ offices closed completely or began seeing patients in person only if necessary. Telehealth use rose, with insurance companies reevaluating their remote medicine policies and doctors switching to remote contact appointments.

“On March 12, we pivoted to telehealth in our clinic, with 95% of our care done by telehealth throughout March and April. The other 5% were patients who had to come in for intravenous infusions,” Philip J. Mease, MD, clinical professor at the University of Washington and director of rheumatology research at Swedish Medical Center in Seattle, said.

The effectiveness of telehealth varies with the patient population and the diseases being treated. Throughout June and early July, offices began to accept more in-patient clients; however, telehealth remains an option for many.

For Mease, who treats patients in the tech-savvy Seattle area, the switch to telehealth was an easy one.

“We’re figuring out how to provide care effectively and securely via telehealth,” he said. “The genie is out of the bottle. Going forward it will be hard for insurance companies and Medicare to go back to the restrictions we had on telehealth before. As long as we don’t have a vaccine, we’re going to be doing a lot of telehealth.”

However, those with an elderly or a less tech-savvy clientele need to weigh the benefits of telehealth with its detriments.

“For initial office visits, you don’t get enough information through telemedicine to help make the best diagnosis,” Bagel said. “It’s difficult to get precise body surface area, erythema, induration, scale, let alone nail pitting or joint swelling and tenderness. To make the diagnosis for psoriasis or psoriatic arthritis on telemedicine is possible but far from perfect.”

Crowley said telehealth is great for follow-up appointments or for those who need to refill a prescription, but it can be difficult for other visits.

“We didn’t use much telemedicine prior to COVID, but we have adopted it as an option,” he said. “Some patients are very comfortable with it, and for addressing concerns or questions a patient may have about a drug or about their psoriasis, it can be very helpful.”

For Gelfand, telehealth has been a positive way to treat his patients with psoriasis during the pandemic, but he is skeptical about its use for his full patient population.

“The data are pretty convincing that we can achieve pretty similar objective and subjective outcomes with telemedicine in comparison to in-person dermatology care for people with psoriasis, but we can’t really do a full skin check,” he said. “So, people who are at high risk of skin cancer or melanoma really need in-person care.”

Preparing to reopen

With more offices reopening for in-person care, practitioners are finding themselves answering a lot of questions about precautions being taken to stem the spread of COVID-19.

Regular sanitation, socially distant waiting rooms or having patients wait in their car, mask requirements and hand sanitizer stations have become the norm.

“People are still scared. Some people with psoriasis have always been a little reticent about getting treatment. I try to get them relaxed and to tell them the data that we have,” Bagel said.

“Reassuring patients that it’s OK to come into the office can be tricky,” Mease said. “When we were hearing deaths every day, we were actively encouraging them not to come into the office, but now we are a little more comfortable with it.”

There has also been an issue with access to care.

With many primary care offices closed for nonemergency cases, patients who need a referral to see a specialist have not been able to get an appointment. Meanwhile, the number of available appointments will be lower going forward as practitioners deal with limiting the number of people in their offices.

“I have had quite a few patients who have really neglected disease, as well as psoriatic arthritis, that just hasn’t been adequately addressed because of the pandemic,” Crowley said. “It’s a difficult problem. Nationwide, there are going to be fewer dermatology appointments available. Our offices can’t handle the volume and can’t function at more than about 75% of what we did pre-pandemic and won’t for the foreseeable future.”

Access to care continues to be a problem for those who are dealing with unemployment or lack of insurance due to record-high jobless numbers.

“The access issue is going to continue to be a problem for many months to come,” Crowley said.

Recommendations and regulations will continue to evolve. For those who treat patients with psoriatic disease, flexibility will be key in the coming months.

“Each patient is going to have their own unique concerns around the pandemic, and we need to tailor our treatment plans for the patient we are dealing with,” Gelfand said.

“Listen to the patient’s concerns about the disease and potential treatment and really tailor your care for the patient,” Crowley said. “Come up with a plan and be prepared to change the plan as conditions change. And certainly, give them an out. If a patient or a patient’s family member gets COVID, make sure they’re comfortable contacting you and potentially stopping therapy for a period of time to see how things play out.” – by Rebecca L. Forand

For more information:

Jerry Bagel, MD, can be reached at the Psoriasis Treatment Center of Central New Jersey, 59 One Mile Road, Extension, East Windsor, NJ 08520; email: dreamacres1@aol.com.

Joel M. Gelfand, MD, MSCE, can be reached at Penn Dermatology Perelman, South Pavilion, 1st floor, 3400 Civic Center Blvd., Philadelphia, PA 19104; email: joel.gelfand@pennmedicine.upenn.edu; twitter: @DrJoelGelfand.

Jeffrey Crowley, MD, MS, FAAD, can be reached at Bakersfield Dermatology, 5101 Commerce Drive, Suite 101, Bakersfield, CA 93309; email: crowley415@aol.com.

Philip J. Mease, MD, can be reached at Settle Rheumatology Associates, 601 Broadway, Seattle, WA 98122; email: pmease@philipmease.com.