key: cord-0965852-gcl99bo5 authors: Blicharz, Leszek; Czuwara, Joanna; Samochocki, Zbigniew; Goldust, Mohamad; Olszewska, Małgorzata; Rudnicka, Lidia title: Immunosuppressive treatment for systemic sclerosis – therapeutic challenges during the COVID‐19 pandemic. date: 2020-05-19 journal: Dermatol Ther DOI: 10.1111/dth.13619 sha: 16c4203f96d32d3ebf68b34caa55e2ee2ecb3926 doc_id: 965852 cord_uid: gcl99bo5 nan the time of writing this letter, the novel coronavirus has claimed more than 200.000 casualties worldwide and continues spreading at a quick pace. 1 Common symptoms of COVID-19 include fever, cough and dyspnea. The infection may also be associated with acute respiratory distress syndrome and acute cardiac and/or renal injury with a potentially fatal outcome, especially in the population aged ≥70 years and in subjects with chronic comorbidities. 1, 2 Apart from disease-specific challenges, the universality of COVID-19 prompts the healthcare professionals to revisit and individualize the therapeutic approach in patients with chronic illnesses. In dermatological and rheumatological practice, systemic sclerosis (SSc) deserves particular attention because of the possibility of severe internal organ involvement and treatment regimens commonly based on immunosuppressive drugs. Progressive interstitial lung disease (ILD) and pulmonary hypertension (PH) are common manifestations of SSc with serious implications with regards to the COVID-19 pandemic. 3 ILD and PH can deteriorate both the respiratory and cardiovascular function, which can negatively influence the overall outcome of COVID-19 in SSc individuals. Immunosuppression was initially thought to be a risk factor of a severe course of COVID-19. This article is protected by copyright. All rights reserved. arthritis showed no such association. 4, 5 Furthermore, during the previous coronavirus outbreaks caused by SARS-CoV and the Middle East respiratory syndrome (MERS)-CoV, immunosuppression was not a documented risk factor of unfavorable outcome. 5 Immunosuppressants with the largest evidence base in SSc include methotrexate (MTX), mycophenolate mofetil (MMF), and cyclophosphamide (CYC) (Table 1) . 6, 7 The choice of a particular drug depends on the profile of symptoms presented by the patient and disease activity. MTX at a dose of 10-15 mg/week is currently recommended as the first-line systemic therapy for cutaneous sclerosis in SSc. 6, 7 Nevertheless, the benefits of MTX for internal organ involvement, including ILD, have not been documented. Current guidelines suggest MMF at a dose of 1-2 g/day as the second-choice drug following MTX for progressive cutaneous sclerosis in SSc. 7 MMF additionally improves SSc-associated lung disease. Based on these observations and a favorable profile of adverse effects, MMF at a dose of 2-3 g/day may be used as first-line therapy in SSc-ILD and as maintenance therapy after CYC for severe cases. Cyclophosphamide should be considered in case of severe, progressive SSc-ILD. It was also shown to improve the cutaneous symptoms of SSc. However, because of its toxicity, CYC constitutes a less favorable choice in the treatment of isolated cutaneous sclerosis and mild ILD. 6, 7 Literature data regarding the course of COVID-19 in patients treated with MTX, MMF, and CYC are lacking. However, Mohai et al. have recently reported a mild course of COVID-19 in a patient with SSc and ILD who was treated with tocilizumab. 8 The authors concluded that current data suggest increased mortality of COVID-19 in individuals with higher expression of This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak Systemic sclerosis Clinical course of COVID-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies Coronaviruses and immunosuppressed patients. The facts during the third epidemic European Dermatology Forum S1-guideline on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: localized scleroderma, systemic sclerosis and overlap syndromes Update of EULAR recommendations for the treatment of systemic sclerosis in a patient with systemic sclerosis treated with tocilizumab for SSc-ILD Systemic sclerosis and the COVID-19 pandemic: World Scleroderma Foundation preliminary advice for patient management This article is protected by copyright. All rights reserved.