Coronavirus Disease 2019

Update on Coronavirus Disease 2019 Outcomes and Vaccine Efficacy in Patients With Immune-Mediated Inflammatory Disease

Jeffrey A. Sparks; Zachary S. Wallace; Philip C. Robinson


Curr Opin Rheumatol. 2021;33(5):412-418. 

In This Article


As in rheumatology and gastroenterology, there has been great interest and concern in the dermatology community concerning the risk of COVID-19 in patients with psoriasis, atopic dermatitis, and other immune-mediated conditions. As in rheumatology, early concern was informed by findings from the OpenSAFELY population-based study in England, which reported a 20% higher risk of COVID-19 death among patients with RA, lupus, or psoriasis (hazard ratio 1.19), a large, heterogeneous group.[11] Two large cohort studies sought to evaluate the risk of COVID-19 infection in patients with psoriasis compared with the general population. In one study, investigators estimated the incidence of COVID-19 in patients with psoriasis on systemic therapies in a previously established large, multicenter prospective cohort study.[44] Compared with the general population estimate, the investigators reported a nonstatistical significant trend toward a higher standard incidence rate for COVID-19 infection [SIR 1.58, 95% confidence interval (CI) 0.98–2.41]. Among other limitations, the number of confirmed infections (n = 21) and severe outcomes (n = 13 hospitalized, n = 1 death) was relatively small, which limited the study's power to estimate SIRs for infection and outcomes, such as hospitalization and death. Reassuringly, in a similar study conducted in a prospective psoriasis cohort in Italy, investigators found that psoriasis patients did not have a higher SIR for COVID-19 hospitalization or death.[45] In that study, the investigators also found no association between biologic DMARD use and a higher SIR compared with the general population. However, the number of infections was similarly small in this Italian cohort study as in the Spanish cohort study. Both studies were limited by their reliance on standardized incidence rates, which may not account for other potential confounders of the association of psoriasis with COVID-19 risk and outcomes.

In addition to prospective cohort studies, two physician-reported registries were established early on by the dermatology community. The design of SECURE-AD (atopic dermatitis) and PsoProtect (psoriasis) are similar to the SECURE-IBD and GRA registries previously discussed. The findings from the SECURE-AD registry will be particularly interesting because of the unique treatments used in atopic dermatitis compared with those used in psoriasis, IBD and rheumatic diseases. At the time of this publication, results from SECURE-AD have not yet been published. In contrast, results from the first 374 patients in the physician-reported PsoProtect registry confirmed several observations reported by the GRA and SECURE-IBD registries.[46] First, similar risk factors for worse disease were observed in the psoriasis population as in the general population, including older age, male sex, nonwhite ethnicity and comorbid lung disease. Second, patients who used biologic therapies had a 65% lower risk of hospitalization compared with those using nonbiologic therapies.

Observed differences in outcomes according to DMARD use in SECURE-IBD prompted the investigators to explore factors that may contribute to differences in outcomes according to treatment. In an analysis of 1626 patients who reported their experiences during the pandemic to a patient-facing psoriasis registry, patients on biologic treatments were 39% more likely than those on nonbiologic DMARDs to practice shielding (OR 1.39, 95% CI 1.23–1.56).[47] These findings highlight the caution with which one should interpret estimates of the risk of COVID-19 in patients on various DMARDs as shielding practices may have differed between users of different treatments.