Are Immune-Modulating Treatments for Skin Diseases Safe During the COVID-19 Pandemic?

🔍 Key Finding Several large-scale studies found no increased risk of COVID-19 infection or worse outcomes for patients on TNF-α inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, IL-23 inhibitors, dupilumab, and methotrexate, while data on JAK inhibitors, rituximab, prednisone, cyclosporine, mycophenolate mofetil, and azathioprine is mixed. Current guidelines generally support continuing immunomodulatory therapy for dermatologic conditions during the pandemic unless a patient has COVID-19, in which case individualized assessment is recommended.

🔬 Methodology Overview

• Design: Review of current data
• Data Sources: Not specified, but likely includes PubMed, medical journals, and organizational guidelines.
• Selection Criteria: Studies examining the impact of immune-modulating treatments used for dermatological conditions on the risk of contracting SARS-CoV-2 and the severity of COVID-19-related outcomes. Specific focus on biologics (TNF-α inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, IL-23 inhibitors, dupilumab), JAK inhibitors, rituximab, prednisone, methotrexate, cyclosporine, mycophenolate mofetil, and azathioprine.
• Analysis Approach: Qualitative synthesis of findings from various studies, including large-scale studies, retrospective studies, cohort studies, case series, and clinical trials.
• Scope: Evaluation of the safety of continuing immunomodulatory therapies for dermatological conditions during the COVID-19 pandemic.

📊 Results Here are the key findings of the review regarding the impact of immunomodulating therapies on COVID-19 risk and outcomes in dermatological patients:

• TNF-α inhibitors: May offer a protective effect against COVID-19. Meta-analysis showed lower probability of severe disease (OR 0.63, 95% CI 0.41–0.96) and hospitalization (OR 0.53, 95% CI 0.42–0.67) compared to patients not on TNF-α inhibitors.
• IL-17 inhibitors: Do not appear to increase the risk of COVID-19 infection or worsen outcomes. Large cohort study showed no increased risk of infection (adjusted HR 0.91-0.92) or hospitalization/death compared to methotrexate or non-systemic treatments.
• IL-12/23 and IL-23 inhibitors: Data is limited, but suggests no increased risk of COVID-19 or worse outcomes compared to the general population. Case series showed no increased hospitalization risk with either class.
• Dupilumab: Does not appear to increase the risk of SARS-CoV-2 infection or worsen COVID-19 outcomes. Cohort study showed no increased risk of infection, hospitalization, or death compared to other treatments for AD.
• JAK inhibitors: Evidence is mixed. Some studies suggest increased risk of severe COVID-19 outcomes, while others show no difference compared to the general population. No specific guidelines exist for dermatological use during the pandemic.
• Rituximab, Mycophenolate Mofetil, and Azathioprine: Associated with increased risk of infection and potentially worse COVID-19 outcomes. Studies show increased risk of hospitalization, ICU admission, and/or death. Close monitoring is recommended if continuing these medications during the pandemic.
• Prednisone/Prednisolone: Limited data on infection risk, but higher doses (≥ 10 mg/day) are associated with increased hospitalization risk. Paradoxically, some studies suggest prednisone may be an effective treatment for COVID-19.
• Methotrexate: Unlikely to increase infection risk and does not appear to worsen COVID-19 outcomes. One study even showed less severe COVID-19 in patients on methotrexate compared to controls.
• Cyclosporine: Data is mixed regarding COVID-19 severity. Some studies show increased hospitalization risk, while others show no difference compared to topical treatments. In vitro studies suggest a potential antiviral effect against coronaviruses.

💡 Clinical Impact Many immunomodulators used in dermatology appear safe regarding COVID-19 infection risk and do not worsen outcomes, allowing patients to continue treatment; however, some, such as rituximab, JAK inhibitors, mycophenolate mofetil, and azathioprine, may pose higher risks and necessitate individualized risk-benefit assessments. This reinforces the need for shared decision-making between dermatologists and patients to weigh treatment benefits against potential COVID-19-related risks, informed by the latest research.

🤔 Limitations

• Limited data exists regarding the association between SARS-CoV-2 infection risk and JAK inhibitor use.
• Limited case reports have been published regarding patients on ustekinumab who contract SARS-CoV-2.
• Few studies have assessed the impact of treatment with prednisone on the risk of COVID-19 infection.
• Data is limited and mixed regarding the impact of prednisone on COVID-19 incidence and outcomes.
• Findings are mixed regarding SARS-CoV-2 infection risk in patients on azathioprine.
• Given the mixed evidence, no formal guidelines have been published regarding azathioprine use during the COVID-19 pandemic.

✨ What It Means For You For dermatological patients on immunomodulating therapies, most can be safely continued during the COVID-19 pandemic except for rituximab, JAK inhibitors, mycophenolate mofetil, and azathioprine, which may require closer monitoring due to increased infection or severity risks. Shared decision-making, considering individual patient risk factors and the risks of untreated disease, should guide treatment decisions during active or suspected COVID-19 infection.

Reference Maynard N, Armstrong AW. The Impact of Immune-Modulating Treatments for Dermatological Diseases on the Risk of Infection with SARS-CoV-2 and Outcomes Associated with COVID-19 Illness. Current Dermatology Reports. 2023;12:45–55. https://doi.org/10.1007/s13671-023-00385-w