Atopic Dermatitis: Pathophysiology Driving Management Decisions - Episode 8
Experts in dermatology discuss administering systemic treatments for atopic dermatitis in the climate of the COVID-19 pandemic
Peter A. Lio, MD: We discussed some of the different systemic treatments that are important for a lot of our patients with more moderate and severe disease who are not doing well with topical agents alone. We are now are in the middle of a pandemic, and I don’t know when it’s going to subside. Emma, how do you think about using some of the systemic agents in the time of the COVID-19 [coronavirus disease 2019] pandemic when you’re thinking about risks and benefits?
Emma Guttman, MD, PhD: That’s a great question, and our department is now creating a huge registry. We already have more than 2000 patients with atopic dermatitis and psoriasis in which we are ascertaining how biologics and systemics are affecting their COVID-19 immune responses. Generally speaking, knowing what I know from the registry and even without it, we now know that systemic immunosuppressants, such as cyclosporine, azathioprine, mycophenolate mofetil, and oral prednisone, are associated with a risk of infections, both viral and bacterial. With dupilumab, there was a nice paper for which Larry Eichenfield, MD, was the first author, and it looked at all the risk for infection in dupilumab studies, and if anything, it found that dupilumab lowered the risk of infections, particularly cutaneous infections, but also other infections.
So dupilumab does not predispose patients to increased risk of infections. I can tell you from our registry that we do not have a single patient who is treated with dupilumab and had COVID-19, who had more than mild symptoms, whereas that’s not the case with some of the patients who were treated with an immune suppressant. This needs more research, but we now need to be reminded to treat patients with a treatment that we consider completely safe, particularly in this time.
Peter A. Lio, MD: Linda, have you felt similarly in terms of counseling patients and giving them a bit of shepherding through this time?
Linda Stein Gold, MD: Yes, I feel similarly. We’ve been waiting for the data to come through and at Henry Ford [Health System], we’ve also been collecting data on biologic agents and atopic dermatitis and psoriasis, and we have not seen an increase in the severity of COVID-19 infections, which is great.
The problem is that a lot of our patients with various diseases have stopped their biologic on their own. The problem is not that they’re getting infections, but they’re coming in with flare-ups of their disease. That’s a problem, so we need to reassure patients that it’s important to maintain therapy, especially when we’re talking about targeted treatments, and not using broad immunosuppressants, and we need to reassure them that we think it’s safe. We want to keep them under control and let them weather the COVID-19 crisis under the best control possible.
Peter A. Lio, MD: Agreed, and we’ve seen a couple papers out of Italy also supporting the same concept: it does not seem to increase their risk of both getting the disease, getting sick, but also in terms of their clinical outcome. That’s reassuring. I also know that there have been a few small papers, some speculative, saying that some of the immunosuppressants might be useful at certain stages of COVID-19 infection because the cytokine storm could be dampened. We don’t know, but of course, the best first medicine is prevention.
If we can avoid immunosuppressing people a priori, we’re probably better off. I’m with you: that’s the better approach. Unfortunately, we only have our 1 choice right now in atopic dermatitis, unlike psoriasis, where we have different biologics falling over each other competing for our attention. In the next couple of years , the hope is that we’re going to have a few more options, and then we’ll be able to think about this as more of a category instead of just 1 medicine right now.