Vaccines remain main aspect to COVID-19’s evolving landscape
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The COVID-19 landscape has continued to evolve during the 2 years since it was first detected in the United States, and research continues to explore how both the virus and its multiple vaccines affect people in different populations.
Individuals with psoriasis or psoriatic arthritis often also have comorbidities that increase negative outcomes of COVID-19, reinforcing the importance of vaccination for this population. However, vaccine hesitancy continues to be an issue that clinicians should be aware of and focus on when counseling psoriatic disease patients.
COVID-19 risks
While the risk of contracting COVID-19 is similar in the psoriatic disease population and the general population, those with psoriasis must be aware of comorbidities and how their systemic psoriasis medications might affect transmission and outcomes.
“Having psoriatic disease does not increase risk of getting COVID-19. However, psoriatic disease is associated with multiple comorbidities that are connected to poor COVID-19 outcomes, including hypertension, diabetes, obesity and cardiovascular disease,” Cassandra Calabrese, DO, assistant professor of medicine at Cleveland Clinic Lerner College of Medicine and director of the Rheumatology–Infectious Disease Clinic and training program at the Cleveland Clinic, said.
In the early stages of the pandemic, a study of 374 patients in 25 countries published in The Journal of Allergy and Clinical Immunology found increased hospitalization risk in older, non-white psoriasis patients.
Further research confirmed that demographic factors such as gender, age and ethnicity were the highest risk factors for COVID-19 hospitalization among all populations.
“The data is very consistent in that having psoriasis itself does not predispose you to having a worse course with COVID-19,” Christopher T. Ritchlin, MD, MPH, professor and chief of the division of allergy, immunology and rheumatology at the University of Rochester Medical Center, said.
How immunosuppressive biologic medications, would affect COVID-19 risk or mortality was another early-pandemic fear. However, research has since found that individuals taking these medications do not have increased risks and some long-term treatments might have increased benefits.
“We have learned that most medications used to treat psoriatic disease do not increase risk for COVID-19. While rarely used in psoriatic disease, an exception would be systemic glucocorticoids (prednisone equivalent of 10 mg per day or more), which has been shown to increase risk of poor COVID-19 outcomes,” Calabrese said.
A matched cohort study out of Massachusetts, which included more than 7,000 psoriasis patients on biologics and almost 75,000 matched controls, found no correlation between biologic medications and COVID-19 mortality, and in fact found those on TNF inhibitors to have slightly lower odds of COVID-19 diagnosis.
“TNF antagonists may actually lessen the severity of COVID-19, probably because by inhibiting tumor necrosis factor, this is a major cytokine that’s induced by the virus,” Ritchlin said.
Vaccines and systemic treatments
Since the development of COVID-19 vaccines, of which three are currently approved for use in the U.S. (Pfizer-BioNTech, Moderna and Johnson & Johnson), the impact of psoriasis medications on the efficacy of these vaccines has become the focus.
“As time has gone on, the questions have changed, and the spotlight has shifted to understanding COVID-19 vaccine responses in our patients who are taking immunosuppressants,” Satveer K. Mahil, PhD, MRCP, of St. John’s Institute of Dermatology, Guy’s and St. Thomas’ NHS Foundation Trust and King’s College London, said.
Mahil participated in a cohort study evaluating the humoral and cellular responses to each of the two Pfizer-BioNTech COVID-19 vaccine doses in patients taking methotrexate or biologic therapies for psoriasis.
“After the first dose of the vaccine, there looked to be an impairment in functional humoral immunity to the vaccine in individuals who were on methotrexate compared with those who are on biologics or healthy controls,” Mahil said.
After the second dose, a proportion of patients on immunosuppression (methotrexate or biologics) did not have detectable T cell responses, unlike controls. This raises questions regarding the durability of the antibody response in individuals on these drugs.
These results suggest that a booster dose will be necessary for individuals with psoriasis who are taking these treatments. Additionally, those on methotrexate may want to hold off on their treatment after vaccination, according to Ritchlin.
“Oral methotrexate can lessen the antibody response to a certain degree, although that magnitude is generally not high,” he said. “But there have been recommendations that one should consider holding the methotrexate for 1 to 2 weeks after receiving the vaccine in order to ensure a more robust vaccine response.”
Additionally, oral steroids, which are often given during a psoriasis or psoriatic arthritis flare, could inhibit vaccine response as well.
Vaccine importance
Receiving one of the vaccines remains the most important thing to stress to individuals with psoriasis, as it is vital to help control the spread of the virus.
The National Psoriasis Foundation’s COVID-19 task force has continued to reinforce this with its updated guidance statements.
“The world has given more than 10 billion COVID vaccines and we really haven’t seen any big trends with regard to psoriasis,” Esther E. Freeman, MD, PhD, director of global dermatology at Massachusetts General Hospital, Harvard Medical School, and principal investigator of the COVID-19 dermatology registry, said. “Vaccines are safe. Vaccines are effective. They are very effective at preventing severe disease. We strongly recommend all our patients to get vaccinated and to get their booster shots as scheduled and as they become available based on eligibility criteria.”
The National Psoriasis Foundation’s task force recommends the Moderna or Pfizer-BioNtech mRNA-based COVID-19 vaccines over the Johnson & Johnson adenovirus vaccine for psoriasis and psoriatic arthritis patients.
Its most recent guidance, published in January 2022, also recommends booster doses for all patients.
“In some cases, patients on immunosuppressives might be eligible for a booster shot earlier and maybe be eligible for another shot. That is one thing they may want to discuss with their doctor,” Freeman said.
Dermatologists and rheumatologists who treat psoriasis and psoriatic arthritis patients should be prepared to have this discussion with their patients. Often these specialists are the only medical professionals some patients see, and vaccine hesitancy can be a problem.
“Many will be surprised at what a difference taking 5 minutes can make to ask why a patient is wary of vaccination, understand their fears and concerns and help to inform and give recommendations,” Calabrese said.
These open, honest conversations with patients are the best way to combat vaccine trepidation, which can stem from many reasons.
“Once patients hear rational explanations as to why it’s important to receive a vaccination and they understand the risk/benefit ratio, which is far in favor of the vaccination vs. not vaccination, many patients ultimately decide it is worthwhile to get the vaccine,” Ritchlin added.
Looking to the future
As the COVID-19 landscape continues to evolve and new variants emerge, collecting and analyzing data remains important to understanding the virus and how it impacts all populations.
Registries such as PsoProtect, which collects data on the outcomes, therapy and epidemiology for COVID-19 and psoriasis, and the American Academy of Dermatology’s COVID-19 registry, are aiming to assist in this data collection and use the information to research a variety of variables.
“Online registries have proven useful for rapid data collection, and engaging globally with clinicians and patients,” Mahil said. “The online platforms are not without their limitations, but can be useful as a hypothesis generating exercise that can then be tested in different prospective studies.”
One aspect that will be studied is how long-COVID will continue to affect patients. Research will also continue in the vaccine space as data and more experiences become available.
“As with all things COVID, the landscape is ever-changing, but I think what we can hope for is an endemic disease to which the vast majority of the population is protected against severe disease, and for us to be able to identify those who remain at higher risk of severe COVID and risk mitigate accordingly,” Calabrese said. – by Rebecca L. Forand
- References:
- Mahil SK, et al. J Allergy Clin Immunol. 2021;doi:10.1016/j.jaci.2020.10.007.
- Pahalyants V, et al. J Am Acad Dermatol. 2022;doi:10.1016/j.jaad.2021.08.065.
- Mahil SK, et al. Lancet Rheumatol. 2021;doi:10.1016/S2665-9913(21)00212-5.
- Mahil SK, et al. Lancet Rheumatol. 2022;doi:10.1016/S2665-9913(21)00333-7.
- COVID-19 Task Force Guidance Statement. https://www.psoriasis.org/covid-19-task-force-guidance-statements. Updated Jan. 21, 2022. Accessed March 14, 2022.
- For more information:
- Cassandra Calabrese, DO, can be reached at Cleveland Clinic Lerner College of Medicine, 9501 Euclid Ave., Cleveland, OH 44195; email: calabrc@ccf.org. Twitter: @CCalabreseDO.
- Esther E. Freeman, MD, PhD, can be reached at Massachusetts General Hospital, 50 Stanford St., Boston, MA 02114; email: esther.freeman@gmail.com. Twitter: @DrEstherFreeman.
- Satveer K. Mahil, PhD, MRCP, can be reached at St. John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London SE1 9RT, United Kingdom;; email: satveer.mahil@kcl.ac.uk. Twitter: @Satveer_Mahil.
- Christopher T. Ritchlin, MD, MPH, can be reached at University of Rochester Medical Center, Allergy, Immunology & Rheumatology Division, 601 Elmwood Ave., Box 695, Rochester, NY 14642 email: christopher_ritchlin@urmc.rochester.edu.
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