COVID-19 in Context

The COVID-19 pandemic is now regarded as a global health crisis, but despite an ongoing international research effort, our understanding of the disease remains limited. This includes a lack of data regarding how the virus affects patients treated for immune-mediated inflammatory diseases like psoriasis (Schett et al., 2020).

COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the seventh member of the coronavirus family known to infect humans (He et al., 2020).

Advice for patients receiving immunosuppressive therapies

Previous research investigating the safety of biologic drugs suggests that use of these agents does not generally increase patient susceptibility to upper respiratory tract infections (Lebwohl et al., 2020). However, people on immunosuppressive therapies sufficient to significantly increase risk of infection are listed among those most vulnerable to developing severe cases of COVID-19 (Public Health England, 2020). Concerns have therefore been raised regarding the possibility of an elevated risk of infection and/or developing serious complications among patients with psoriasis whose condition is treated using biologic or systemic therapies (Bell & Van Voorhees, 2020).

Nevertheless, discontinuation of treatment with these agents is not currently recommended in all of these patients (IPC, 2020). Decisions concerning whether or not to continue treatment with biologic agents require careful consideration of a number of factors including (Bell & Van Voorhees, 2020; Brownstone et al. 2020):

• Severity of baseline psoriatic disease
• Concomitant immunosuppressive medications/conditions
• Risk of exposure based on occupation or living situation
• Risk factors for COVID-19 (older age, cardiovascular disease, hypertension, lung disease, diabetes, cancer, obesity)
• Patient preference
• Inter-drug differences

Importantly, several of the diseases identified as risk factors for COVID-19 are common comorbidities in patients with psoriasis. However, it is also worth noting that the beneficial effects of biologic therapies are sometimes lost following temporary discontinuation of treatment and in some cases antibodies to the discontinued biologic may form (Lebwohl et al., 2020).  

This being said, established psoriasis treatment guidelines recommend discontinuation of immunosuppressive psoriasis treatments in patients with active infections. Therefore, physicians are currently advised to discontinue or postpone treatment with immunosuppressive therapies in patients diagnosed with COVID-19 (IPC, 2020).

In patients diagnosed with COVID-19, discontinuation of immunosuppressive therapy is recommended (IPC, 2020).

How soon after recovery from COVID-19 can patients resume treatment with immunosuppressive therapies?

Treatment with immunosuppressive therapies can be resumed once the infection and its related symptoms have subsided. This can be confirmed by two negative COVID-19 tests carried out 24-hours apart, but where availability of tests is limited, allowing one month before treatment reintroduction is generally deemed adequate (Bell & Van Voorhees, 2020; Brownstone et al. 2020).

What other measures can you take to ensure the wellbeing of patients with psoriasis during this pandemic?

A recent statement issued by the International Psoriasis Council (IPC), promotes vigilance with respect to the potential dangers of infection with COVID-19 in patients with psoriasis (IPC, 2020).

In this statement, the IPC urges physicians to ensure that their patients keep well-informed about the steps that can be taken to prevent disease transmission (IPC, 2020). These include infection prevention measures, such as frequent hand washing, social distancing in all and shielding among those identified as being at particularly high risk as well as use of telehealth services(Brownstone et al. 2020). If possible, use of nose and mouth coverings in public spaces is also advisable as an additional precaution in this patient group (Murrell et al., 2020). The decision as to whether or not patients should continue to attend appointments with their dermatologist should be made on a case-by-case basis, with consideration of the patient’s baseline and treatment history (Bell & Van Voorhees, 2020).

Around the world, medical professionals have been forced to adopt new approaches to patient care in response to the COVID-19 pandemic. Amid the crisis, telemedicine has emerged as an effective means of providing certain patients with continued access to healthcare services while minimising risk of viral transmission (Smith et al., 2020).

Telemedicine leverages telecommunication technologies to provide remote access to healthcare services.

In some regions, it has been possible to upscale existing telemedical programmes to meet a growing demand for these services, however, in areas without established telemedicine programmes, this has proved more challenging (Hollander & Carr, 2020).

Teledermatology in psoriasis

Dermatology is a particularly good example of a field in which telemedical practices can be successfully implemented to provide an alternative to traditional in-person consultations. This telemedical speciality is known as teledermatology (Campagna et al. 2017). The success of teledermatology lies in the fact that skin disorders, including psoriasis, lend themselves to virtual assessment in that they are visible to the human eye (Lee & English, 2018). By reviewing diagnostic images in conjunction with patient medical histories, teledermatologists are able to formulate treatment plans in much the same way that they would do in person. Teledermatology may be either synchronous, asynchronous, or a hybrid of the two (Campagna et al. 2017; Lee & English, 2018).

Synchronous teledermatology - live interaction modality involving real-time video interaction between two parties (Campagna et al. 2017).

Asynchronous teledermatology - store-and-forward teledermatology involving transmission of recorded data or medical images to a medical professional to assess at their convenience (Campagna et al. 2017). 

Despite concerns that diagnostic reliability may be compromised when conducting consultations remotely, this does not appear to be the case (Campagna et al. 2017). Current evidence suggests that teledermatologists are generally able to produce sound clinical decisions based on photographic images of their patients. This is perhaps unsurprising given that dermatologists are often trained using photographic material (National Psoriasis Foundation, 2017). A previous study also reported a comparable quality of care among patients with psoriasis whose follow-up was carried out exclusively online and those who had in-person follow-ups (Chambers et al., 2012). Improvements in both skin and quality of life were similar between the two groups, providing support for the use of teledermatology as a tool for the treatment of patients with psoriasis.

Teledermatology and the COVID-19 pandemic

Given the reported efficacy of teledermatology, it is perhaps unsurprising that the COVID-19 pandemic has generated a surge of interest in harnessing its potential among dermatologists. As with all telemedical practices, teledermatology is an effective means of avoiding close physical contact between patients and physicians, eliminating the risk of infection with COVID-19, to the benefit of both parties (Price et al., 2020).

A major concern associated with the COVID-19 outbreak is the possibility that healthcare services may become overwhelmed by the large volume of virus-related admissions. Telemedicine can be used as a form of “forward triage”, prioritising patients based on virtual assessment to help mitigate this concern and limit the spread of disease (Hollander & Carr, 2020). In the context of teledermatology, this forward triage system can help ensure that patients in urgent need of direct medical attention, such as those with concerning lesions or life-threatening eruptions, are offered priority access to in-person visits (Price et al., 2020). In many cases, dermatologists have elected to delay or reduce the frequency of routine laboratory monitoring until the pandemic subsides (Bell & Van Voorhees, 2020).

An additional benefit of teledermatology during the pandemic is that it facilitates preservation of personal protective equipment (PPE), which is in high global demand and can be used instead for cases where an in-person consultation is unavoidable (Rismiller et al., 2020).  

However, as teledermatology relies upon the availability of high-resolution images and high-quality patient medical records, it is not a suitable option for all patients with psoriasis. For instance, it is difficult to generate photographs of scalp psoriasis which are of sufficient quality to allow successful dermatological assessment (National Psoriasis Foundation, 2017). Likewise, among patients who require regular treatment administration by their dermatologist, in-person visits may be necessary.

Special consideration must also be given to elderly patients, who are at high risk from COVID-19, and are often less familiar with the technologies required to utilise teledermatological services. In these cases, telephone calls may be used which, though limited in some respects, enable continuity of care in this group (Bell & Van Voorhees, 2020).

Recommendations regarding the implementation of teledermatology have been made available by various organisations including the European Academy of Dermatology and Vererology (EADV) and the American Academy of Dermatology (AAD) in response to the pandemic (American Academy of Dermatology, 2020; EADV Teledermatology Task Force, 2020).

The psychological impact of COVID-19 on patients with psoriasis

For many people around the world, enforced social isolation, increased health anxiety, media misinformation, and fears regarding the potential socio-economic impact of the COVID-19 pandemic have contributed to a considerable decline in psychological wellbeing (Rajkumar, 2020). The psychopathological conditions that have been associated with quarantine measures include (Garcovich et al., 2020):

• emotional exhaustion
• irritability
• anxiety
• increased anger
• symptoms related to depression
• symptoms related to post-traumatic stress disorder (PTSD)

The link between psychiatric disorders and chronic skin disease is well-established and, as such, the psychological impact of the present COVID-19 pandemic upon patients with psoriasis should not be overlooked (Lada et al., 2020).

As many as 1 in 5 patients with psoriasis have clinically significant depression (Lada et al., 2020)

It is thought that under the current circumstances, patient stress may be compounded by uncertainty as to whether their condition places them at greater risk of contracting COVID-19 and/or a worsened disease course (Rob et al., 2020). Some have also expressed concerns regarding the continued use of immunomodulatory drugs, though discontinuation of treatment is not currently recommended except in patients who develop symptoms of, or are diagnosed with COVID-19 (Chernyshov, 2020). Where medication changes are required, this may lead to a worsening of psoriatic disease and concomitant decline in mental well-being (Lada et al., 2020).

Moreover, high levels of stress are known to trigger flare-ups in patients with inflammatory skin conditions, perpetuating a cycle of reduced physical health and increasing patient distress (Chat et al., 2020; Tsamakis et al., 2020). Meanwhile, the introduction of stringent hygiene measures including use of personal protective equipment (PPE) and frequent handwashing has also been associated with exacerbations of existing skin conditions (Darlenski & Tsankov, 2020).

Given these circumstances, it is more important than ever that dermatologists remain alert to the potential adverse effects of the pandemic not only on physical, but also mental well-being of their patients. This requires timely recognition of at-risk individuals and the ability to provide them with whatever additional support they may require throughout this challenging period (Tsamakis et al., 2020). 

In particular, available advice emphasises the importance of providing patients with clear, up-to-date information regarding our evolving understanding of COVID-19 and how it might affect different patient groups (Tsamakis et al., 2020). It is hoped that equipping patients with this knowledge will have the effect of mitigating undue health-related stress and improving treatment compliance (Chawla, 2020). The importance of maintaining control of patients’ dermatological health throughout the crisis is highlighted in a position statement published by the EADV task force which lists prevention of skin diseases and their relapses, effective treatment and skin care as the main strategies for improving patient quality of life (Chernyshov et al., 2020).

It is also important that patients are well-educated regarding the measures that they can take to preserve their own wellbeing and basic self-care, with a focus on the importance of maintaining social relationships despite the need for physical distancing (Lada et al., 2020). This should be accompanied by resources providing readily available information on how to access medical help for their skin and mental health should these services be required (Lada et al., 2020). However, it is worth noting that patients with depression may not always seek help when required owing to a lack of self-worth and feelings of guilt (Lada et al., 2020).

Asking direct questions regarding the mental health of patients, particularly those with a history of suicidality may help to ease the burden of disease and give dermatologists the opportunity to refer patients to appropriate mental health services that they may now otherwise have accessed (Lada et al., 2020). Similarly, it has been suggested that where possible, attempts should be made to arrange follow-up appointments with patients who appear socially withdrawn or miss multiple appointments (Lada et al., 2020). This highlights the need for continued upscaling and utilisation of existing teledermatology services (Tsamakis et al., 2020).

It is hoped that the development of defined pathways to facilitate the prevention and management of mental health conditions, dermatology patients will benefit from more favourable health outcomes for the duration of pandemic and beyond (Lada et al., 2020).

Psoriasis and COVID-19

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