key: cord-0839401-xnz3hxno
authors: Mahil, S.K.; Yates, M.; Yiu, Z.Z.N.; Langan, S.M.; Tsakok, T.; Dand, N.; Mason, K.J.; McAteer, H.; Meynell, F.; Coker, B.; Vincent, A.; Urmston, D.; Vesty, A.; Kelly, J.; Lancelot, C.; Moorhead, L.; Bachelez, H.; Capon, F.; Contreras, C.R.; De La Cruz, C.; Di Meglio, P.; Gisondi, P.; Jullien, D.; Lambert, J.; Naldi, L.; Norton, S.; Puig, L.; Spuls, P.; Torres, T.; Warren, R.B.; Waweru, H.; Weinman, J.; Brown, M.A.; Galloway, J.B.; Griffiths, C.M.; Barker, J.N.; Smith, C.H.
title: Describing the burden of the COVID‐19 pandemic in people with psoriasis: findings from a global cross‐sectional study
date: 2021-08-19
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.17450
sha: 4e728b8791fa0a411b552ee41ea080b1104eb197
doc_id: 839401
cord_uid: xnz3hxno

Indirect excess morbidity in the COVID-19 pandemic may arise from public health risk-mitigation efforts such as stay-at-home orders and re-purposing of healthcare services1 . Increased mental health disorders and shortfalls in the care of long-term conditions are described.

Editor, Indirect excess morbidity in the COVID-19 pandemic may arise from public health risk-mitigation efforts such as stay-at-home orders and re-purposing of healthcare services. 1 Increased mental health disorders and shortfalls in the care of long-term conditions are described. 2, 3 We used global self-reported crosssectional data to characterise the factors associated with worsening psoriasis in the pandemic, focussing on the impact of anxiety and depression.

Data from a cross-sectional survey (PsoProtectMe 4 ) were extracted on 15th January 2021. After excluding participants self-reporting COVID-19, the association between mental health and worsening psoriasis was assessed using a fully adjusted logistic regression model including covariates selected a priori as potentially influential on psoriasis severity and anxiety/depression. Participants scoring ≥3 in GAD-2 or PHQ-2 defined a positive mental health screen. 5 4043 people with psoriasis from 86 countries were included (Table 1) A fully adjusted regression model for worsening psoriasis estimated an odds ratio (OR) 2.01 (95% CI, 1.72-2.34) for those with a positive screen for anxiety or depression compared to those without a positive screen (Fig. 1 Table 1 ). The commonest reason was concern regarding complications related to COVID-19 (n = 217). Non-adherence was associated with worsening psoriasis (OR, 2.90, 95% CI, 2.31-3.63). A positive mental health screen was more common in those reporting non-adherence compared to those who were adherent (42.8% vs. 32.4%).

These data indicate a burden due to the COVID-19 pandemic in people with psoriasis; worsening psoriasis is common and is associated with poor mental health. We find that in the subset on systemic therapy, non-adherence is associated with worsening disease and is driven by concerns about immunosuppressant-related risks of COVID-19. This is an important observation since current guidelines (informed by reassuring data on drug-related risks of severe COVID-19 6 ) recommend continuing immunosuppression in people without COVID-19 to maintain disease control. 7 Our findings parallel data from the general population indicating an increased mental health burden during the pandemic, particularly in women. 8 People with psoriasisespecially those with severe psoriasis, and womenhave a high prevalence of anxiety and depression and may thus be particularly vulnerable to the adverse impact of the pandemic on mental health. 9 Whilst men are known to be at greater risk of severe outcomes from COVID-19, our data suggest that women may be more susceptible to indirect excess morbiditypoor mental health and worsening skin diseasethan men.

The generalisability of results is limited given the self-selecting bias of our study population towards UK white women. Individuals non-adherent to treatment, with low computer literacy or less anxiety, may be disinclined to participate, which may introduce ascertainment bias.

Our data underscore the importance of holistic models of care and indicate a need to provide access to psychological support. In those with worsening psoriasis, possible non-adherence should be explored. Evidence-based communication around medication-related COVID-19 risks and behavioural approaches for supporting adherence may help address fears, anxieties and confusion. 10 Attention given now to address this may mitigate a long-lasting detrimental impact of the pandemic on health outcomes in people with psoriasis. Ingelheim, Roche and Merck. Dr. Mason reports personal fees from LEO Pharma and Novartis, outside the submitted work. Ms. Moorhead reports personal fees from Abbvie, personal fees from Celgene, personal fees from Janssen, personal fees from LEO Pharma, personal fees from Novartis, personal fees from UCB, outside the submitted work. Dr. Puig reports grants and personal fees from AbbVie, grants and personal fees from Almirall, grants and personal fees from Amgen, grants and personal fees from Boehringer Ingelheim, personal fees from Bristol Myers Squibb, personal fees from Fresenius-Kabi, grants and personal fees from Janssen, grants and personal fees from Lilly, personal fees from Mylan, grants and personal fees from Novartis, personal fees from Pfizer, personal fees from Sandoz, personal fees from Sanofi, personal fees from Samsung-Bioepis, grants and personal fees from UCB, outside the submitted work. Dr. Mahil reports departmental income from Abbvie, Celgene, Eli Lilly, Janssen-Cilag, Novartis, Sanofi, UCB, outside the submitted work. Dr. Di Meglio reports grants and personal fees from UCB, personal fees from Novartis, personal fees from Janssen, outside the submitted work. Prof. Warren reports grants and personal fees from Abbvie, grants and personal fees from Celgene, grants and personal fees from Eli Lilly, grants and personal fees from Novartis, personal fees from Sanofi, grants and personal fees from UCB|, grants and personal fees from Almirall, grants and personal fees from Amgen, grants and personal fees from Janssen, grants and personal fees from Leo, grants and personal fees from Pfizer, personal fees from Arena, personal fees from Avillion, personal fees from Bristol Myers Squibb, personal fees from Boehringer Ingelheim, outside the submitted work. Prof. Smith reports grants from Abbvie, Sanofi, Novartis, and Pfizer and through consortia with multiple academic partners (psort.org.uk, BIOMAP-IMI.eu), outside the submitted work. Dr. Torres reports grants and personal fees from AbbVie, Almirall, Amgen, Arena Pharmaceuticals, Biogen, Biocad, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, LEO Pharma, MSD, Novartis, Pfizer, Samsung-Bioepis, Sandoz, during the conduct of the study. Dr. Waweru is on the Board of the International Federation of Psoriasis Associations who have received grants from Abbvie, Almi-

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We are grateful to all the patients who have contributed to PsoProtectMe, the professional and patient organisations who supported or promoted PsoProtectMe and for the input of Prof Lars Iversen, Prof Nick Reynolds, Prof Joel Gelfand, Ms Christine Janus and Ms Melissa Sweeney through their vital contributions. We would also like to acknowledge the following individuals for help with translating the PsoProtectMe survey; Dr Haleema Alfailakawi, Dr Wisam Alwan, Dr Rosa Andres Ejar-

DOI: 10.1111/jdv.17450 The significance of exanthems in COVID-19 patients hospitalized at a tertiary care centre Dear Editor, Cutaneous manifestations have been associated with COVID-19 infection, and their significance in hospitalized patients remains unclear. [1] [2] [3] This study catalogues the exanthems observed in hospitalized COVID-19 patients to determine prevalence and inform clinicians in devising diagnostic and management strategies.A retrospective review of 1216 adults hospitalized with laboratory-confirmed SARS-CoV-2 infection from 12 March 2020 to 31 May 2020 at a single institution was conducted. Keyword search of patient records combined with manual chart review by at least two dermatologists, with a third dermatologist for adjudication, identified patients with cutaneous manifestations based on chart documentation (Fig. 1 ).Exanthems occurred in 39 patients (3.2%) and were categorized clinically as morbilliform eruptions (n = 37/39; 94.9%) and urticarial eruptions (n = 2/39; 5.1%) based on chart documentation and visual morphology (Table 1 ). Reviewers were aided by photographs for 26 patients (66.7%) and inpatient dermatology consultations for 16 patients (41.0%). A minority of patients (n = 7/39; 17.9%) had exanthems occurring within 14 days of COVID-19 symptom onset and thereby could be considered a possible viral reaction. The remaining 32 patients developed a rash more than 14 days after initial COVID-19 symptom onset. 21 patients (n = 21/32; 65.6%) developed a rash within 14 days of a clear causative medication exposure, suggesting a drug reaction aetiology. Dermatology reviewers identified likely culprit drugs in these patients, most commonly beta-lactam antibiotics (n = 17/21; 81.0%). Within the remaining 11 patients (n = 11/32; 28.2%), five patients were favoured to have a drug reaction within 28 days of culprit drug exposure based on clear documentation from chart review. The remaining six patients had insufficient data to adequately confirm the aetiology of their late-onset rash, though drug exposure was suspected based on the timeline.Exanthems can present a diagnostic conundrum in distinguishing medication hypersensitivity versus viral infection as likely aetiologies. Exanthems due to viral infections typically present within 14 days of viral symptom onset. 4 Skin rashes in COVID-19 are believed to present around the same time as other symptoms, typically during the first few days of fever and respiratory symptoms. 1 In this cohort, only a minority of exanthems (n = 7/39; 17.9%) developed within 14 days of COVID-19 symptom onset to be considered for a viral rash. One of these seven patients was evaluated by dermatology and confirmed to have a drug hypersensitivity reaction by skin biopsy. The remaining six patients, 0.49% of all patients overall, could be potentially compatible with a viral aetiology for their exanthem based on timing of symptom onset.Drug eruptions can result within 14 days of initial administration of the culprit drug but may also be delayed further by up to several weeks. 5 The majority (n = 21/39; 53.8%) of exanthems in this cohort developed within 14 days of clear exposure to a common culprit drug and also after the 14-day window of COVID-19 symptom onset and resolved with cessation of drug use, supporting a medication-induced aetiology. In general, cutaneous drug reactions are estimated to develop in approximately 2% of patients, 6 increasing to 8% with exposure to certain antibiotic groups. 5 This is similar to the incidence of 3.2% (n = 39/1216) found within this study.In this study population of 1216 patients admitted with COVID-19, rashes from SARS-CoV-2 were exceedingly uncommon. These findings suggest that rashes previously ascribed to SARS-CoV-2 may have alternate explanations and highlight the importance of routinely considering medication exposures in the evaluation of generalized rashes occurring in hospitalized patients. Clinicians encountering exanthems in hospitalized patients with COVID-19 should maintain their usual standard of care for drug rashes 7 in providing symptomatic treatment if necessary and considering withdrawal of the offending agent if a prolonged course of exposure is anticipated.

The authors have no conflicts of interest to declare.

None.