key: cord-0862049-8zrwu2qh
authors: Ricardo, Jose W.; Lipner, Shari R.
title: Recommendations for Treatment of Nail Psoriasis During the COVID‐19 Pandemic
date: 2020-06-04
journal: Dermatol Ther
DOI: 10.1111/dth.13757
sha: dcd32e91cdec927cbbac1387d5fdb6600bfb8d3a
doc_id: 862049
cord_uid: 8zrwu2qh

nan

To the editor:

The rapid dissemination of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing coronavirus disease 2019 (COVID-19), caused a global pandemic. Since immunosuppression is a COVID-19-related mortality risk factor, 1 it is hypothesized that systemically-treated psoriasis patients may be more susceptible to COVID-19. Prior efforts focused on cutaneous psoriasis therapy during the pandemic, with no guidelines for nail psoriasis (NP) treatment. Therefore, in this communication we review the literature and recommend safe and effective NP therapies during the COVID-19 pandemic.

Randomized controlled trials (RCT) reporting on adverse events with NP treatment are scarce. Table 1 lists infection rates in clinical trials involving NP patients.

Tumor necrosis-alpha (TNF-α) inhibitors theoretically impair immunity against viral infections, 2 with a black box warning of increased infection susceptibility. Amplified TNF-α levels are implicated in cytokine release syndrome (CRS), the main cause of COVID-19 mortality. 3 Thus, TNF-α blockers may be beneficial for COVID-19-related CRS treatment.

There was no increased susceptibility to respiratory infections with TNF-α inhibitors in NP clinical trials.

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The interleukin (IL)-17 inhibitors interfere with mucosal immunity against candida infections. 4 Since SARS-CoV-2 infects through ocular, airway and oral mucosae, impaired mucosal integrity may increase SARS-CoV-2 susceptibility. 5 In RCTs, secukinumab-treated NP patients had increased nasopharyngitis and overall infections rates, 9.7% and 17%, respectively, compared to placebo. For ixekizumab, compared to placebo, overall infections increased by 7%, while URIs increased by 4.1%.

Ustekinumab, an IL-12/23 inhibitor, showed 36.1% and 39.5% increases in nasopharyngitis and overall infection rates compared to placebo. Although IL-12 protects against viral infections, 6 patients with inherited IL-12 signalling defects are not severely impacted by viral respiratory infections. 7 For the JAK1/3 inhibitor tofacitinib, viral infections increased by 13.1%, while URIs increased 2.3%. Nonetheless, nasopharyngitis and overall infections were comparable to placebo. JAK inhibitors have short half-lives and can be discontinued in the setting of acute infection. 8 There are no controlled studies on conventional systemic treatments for NP. Cyclosporine showed minimal incidence of URI and overall infections and there were no infections reported with acitretin use. Notably, cyclosporine has anti-coronavirus activity in vitro; 9 there is no data on COVID-19 patients. Retinoids inhibit viral replication (human herpesvirus eight, human immunodeficiency one, herpes-simplex one, measles, mumps, polyoma, hepatitis B, hepatitis C viruses) in vitro. Methotrexate is associated with a 25% and 58.3% incidence of nasopharyngitis and overall infections, respectively. Therefore, methotrexate This article is protected by copyright. All rights reserved.

should be tapered to the lowest effective dose in patients without COVID-19 during the pandemic; in infected patients, the medication should be discontinued. In cutaneous psoriasis and NP patients treated with apremilast, URIs, nasopharyngitis and overall infections were 8.5%, 6.9% and 15.6% compared to placebo. 

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Tumor necrosis factor (TNF)-alpha and TNF receptors in viral pathogenesis

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Candida infections in patients with psoriasis and psoriatic arthritis treated with interleukin-17 inhibitors and their practical management

The risk of respiratory tract infections and symptoms in psoriasis patients treated with IL-17-pathway inhibiting biologics: A metaestimate of pivotal trials relevant to decision-making during the COVID-19 pandemic

Should biologics for psoriasis be interrupted in the era of COVID-19?

Biologics for psoriasis during COVID-19 outbreak

The use of Janus kinase inhibitors in the time of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

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The SARS-coronavirus-host interactome: identification of cyclophilins as target for pancoronavirus inhibitors

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Psoriatic arthritis study involving cutaneous and nail psoriasis patients 11, 12, 13, 15, 16, 19, 23, 24 Nail psoriasis study 17, 18, 20, 21, 22, 25, 26, 27, 28 Cutaneous psoriasis study involving nail psoriasis patients This article is protected by copyright. All rights reserved.