Psoriasis and risk of the COVID-19: is there a role for angiotensin converting enzyme (ACE)?

Risk Factors for Psoriasis Flares: A Narrative Review

Psoriasis is a chronic inflammatory cutaneous disease with multifactorial pathogenesis involving both genetic and environmental factors as well as the innate and acquired immune response. Several triggering factors may exacerbate or worsen the disease. In this context, we performed a review manuscript with the aim of investigating current literature on psoriasis risk factors, also showing possible mechanisms by which they act on psoriasis. Globally, risk factors can be divided in classic risk factors (eg, mechanical stress, infections and dysbiosis of the skin, common drugs, environment and pollution, lifestyle, psychological stress, hormonal and metabolic alterations) which have long been known to be responsible for worsening and/or reoccurrence of psoriatic manifestations, and emerging risk factors (eg, biological drugs, immunotherapy for oncologic disease, Covid-19, and vaccines) defined as those newly identified risk factors. Accurate patient information and monitoring of risk factors as well as planned follow-ups may help to prevent and treat the worsening of psoriasis and consequently improve the quality of life of psoriatic patients.

The Renin-Angiotensin System: The Challenge behind Autoimmune Dermatological Diseases

Autoimmune dermatological diseases (AIDD) encompass a diverse group of disorders characterized by aberrant immune responses targeting the skin and its associated structures. In recent years, emerging evidence suggests a potential involvement of the renin-angiotensin system (RAS) in the pathogenesis and progression of these conditions. RAS is a multicomponent cascade, primarily known for its role in regulating blood pressure and fluid balance. All of the RAS components play an important role in controlling inflammation and other immune responses. Angiotensin II, the main effector, acts on two essential receptors: Angiotensin Receptor 1 and 2 (AT1R and AT2R). A disturbance in the axis can lead to many pathological processes, including autoimmune (AI) diseases. AT1R activation triggers diverse signaling cascades involved in inflammation, fibrosis and tissue remodeling. Experimental studies have demonstrated the presence of AT1R in various cutaneous cells and immune cells, further emphasizing its potential contribution to the AI processes in the skin. Furthermore, recent investigations have highlighted the role of other RAS components, beyond angiotensin-converting enzyme (ACE) and Ang II, that may contribute to the pathophysiology of AIDD. Alternative pathways involving ACE2, Ang receptors and Ang-(1-7) have been implicated in regulating immune responses and tissue homeostasis within the skin microenvironment. Understanding the intricate involvement of the RAS in AIDD may provide novel therapeutic opportunities. Targeting specific components of the RAS, such as angiotensin receptor blockers (ARBs), ACE inhibitors (ACEIs) or alternative RAS pathway modulators, could potentially ameliorate inflammatory responses, reduce tissue damage and lessen disease manifestations. Further research is warranted to outline the exact mechanisms underlying RAS-mediated immune dysregulation in AIDD. This abstract aims to provide a concise overview of the intricate interplay between the RAS and AIDD. Therefore, we elaborate a systematic review of the potential challenge of RAS in the AIDD, including psoriasis, systemic sclerosis, vitiligo, lupus erythematosus and many more.

COVID-19 Among Patients with Psoriasis: A Single-Center Retrospective Cross-Sectional Study

Objective

Psoriasis patients may have been affected by COVID-19 differently than the normal population due to using different types of treatments, including immunosuppressive agents and biological therapies, the probability of lower effectiveness, and different side effects of the vaccines. This study aimed to evaluate the epidemiologic and clinical features of COVID-19 and the effect of the psoriasis treatment on it.

Materials and Methods

Psoriasis patients followed up in our clinic between March 2020 and July 2022 were evaluated in terms of clinicodemographic characteristics, treatment methods, and COVID-19 vaccination status and compared regarding COVID-19 history.

Results

A total of 110 patients (female:male ratio=1:1.2) with a mean age of 45.6±14.3 years were evaluated. Thirty patients (27.2%) developed COVID-19 during psoriasis treatment. Unvaccinated patients had COVID-19 (6/11, 55%) more frequently than vaccinated ones (24/99, 24%), but it was not statistically significant (p=0.067). Although patients who received biological therapy were also more frequently infected with SARS-CoV-2 than patients who received other types of therapies (18/53 [34%] versus 12/57 [21%], respectively), the difference was again not statistically significant.A patient with hypertension using acitretin was hospitalized for pulmonary involvement because of COVID-19. No exacerbation of psoriasis was observed in patients who developed COVID-19, while psoriasis flares occurred following COVID-19 mRNA vaccination in two patients.

Conclusion

Patients with psoriasis should get vaccinated against COVID-19, as vaccination prevents the disease and does not result in serious side effects. Although using biological agents for the treatment of psoriasis could be related to a higher risk of getting COVID-19, these agents do not increase the risk of severe COVID-19. Therefore, they may be beneficial in reducing the risk of both psoriasis exacerbations and severe COVID-19 due to the cytokine storm among patients using biological for psoriasis.However, large-scale and controlled studies are needed to support our conclusions.

New Onset and Exacerbations of Psoriasis Following COVID-19 Vaccines: A Systematic Review

BACKGROUND

Vaccination has been promoted to control viral transmission in response to the coronavirus disease 2019 (COVID-19) pandemic. Cases of new-onset or exacerbation of psoriasis, an immune-mediated inflammatory disease, were reported following COVID-19 vaccination. However, a comprehensive review examining the association between COVID-19 vaccination and the occurrence or exacerbation of psoriasis has yet to be performed.

OBJECTIVE

The aim of this systematic review is to investigate the demographics, clinical variables, and outcomes associated with psoriasis following COVID-19 vaccination.

METHODS

A systematic literature search was conducted using the PubMed, Embase, Web of Science, and Cochrane databases from database inception to April 25, 2022. The review included studies with relevant terms, including 'psoriasis,' 'psoriasis vulgaris,' 'guttate psoriasis,' 'pustular psoriasis,' 'palmoplantar pustulosis,' 'psoriatic erythroderma,' 'psoriatic arthritis,' 'COVID-19,' and 'vaccine.' We included all studies reporting at least one patient who developed new-onset psoriasis or experienced a psoriasis flare following at least one dose of any COVID-19 vaccine. A flare was defined as the worsening of disease conditions after vaccination according to the study by Gregoire et al. The appraisal tool described by Murad et al. was used to assess the quality of case reports and series, whereas the National Institute of Health quality assessment tool was used to assess observational studies.

RESULTS

The initial search yielded 367 results, including 7 studies reporting new-onset psoriasis, 32 studies reporting psoriasis flares, and 4 studies reporting both. The most commonly observed psoriasis subtype was plaque-type psoriasis. mRNA vaccines, including those produced by Moderna and BioNTech/Pfizer, were frequently associated with subsequent psoriasis episodes. First, second, and third vaccine doses were associated with psoriasis incidents, with the second dose most frequently associated with psoriasis flares. Delayed onset was observed, ranging from 2 to 21 days in the new-onset group and from 1 to 90 days in the flare group. Most patients experienced favorable outcomes, with improvement or resolution occurring within 3 days to 4 months.

CONCLUSIONS

Both new-onset psoriasis and psoriasis flares were reported as cutaneous adverse events following COVID-19 vaccination. Psoriatic patients may require regular follow-up before and after COVID-19 vaccination.

TRIAL REGISTRATION

Review registration number PROSPERO database: CRD42022304157.

Psoriasis Flares in Patients With COVID-19 Infection or Vaccination: A Case Series

Much of the literature involving COVID-19 and chronic inflammatory dermatological conditions have focused on the safety of immunomodulatory therapy in the setting of this highly infectious virus. While general mortality associated with the infection and vaccine has been studied in depth, the effects of the virus and vaccine on inflammatory skin disease states have not been. It is well known that psoriasis can be triggered by stress, infection, certain medications, and, although not as common, vaccinations. Further, existing literature has briefly commented on psoriasis flares after COVID vaccination, but these have not touched on flares among their patients’ current therapy, nor flares after COVID infection. In this case report, we report five cases observed at our institution over the last year of either new-onset psoriasis or flares of previously well-controlled psoriasis shortly after infection with COVID-19 or COVID-19 vaccination, with no other identifiable triggers. These cases can serve to raise awareness of issues related to managing stubborn psoriatic flares and bring to the forefront conversations that are likely to arise with our patients regarding the risks and benefits of COVID vaccination and boosters. While the definitive etiology of the association between COVID and psoriasis remains unclear, it is important that the dermatologic community be aware when evaluating patients with new-onset or worsening psoriasis as we move forward in times of this COVID-19 era.

Treatment of Moderate to Severe Psoriasis during the COVID-19 Pandemic: Lessons Learned and Opportunities

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, clinicians have been overwhelmed by questions beyond the SARS-CoV-2 infection itself. In dermatology practice, clinicians have been facing difficulties concerning therapeutic management of chronic immune-mediated skin disease, above all psoriasis. Major challenges arisen were to understand the role of immunosuppression or immunomodulation on COVID-19 evolution, the benefit/risk ratio related to discontinuation or modification of ongoing treatment, and the appropriateness of initiating new treatments, the optimization of timing in vaccination administration to patients under immunomodulatory treatments, and finally how to find new strategy of patients’ management through remote assistance. In this comprehensive review, we present the current evidence about the course and management of psoriasis during the COVID-19 pandemic. The general message from dermatologists was that data did not suggest that having PSO or its treatment significantly increased risk of SARS-CoV-2 infection or more severe COVID-19 course, the vaccination is highly recommended in all psoriatic patients, beyond ongoing treatment, and that the telehealth experience was a success overall.

Biologics for Psoriasis During the COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19), a new form of acute infectious respiratory syndrome first reported in 2019, has rapidly spread worldwide and has been recognized as a pandemic by the WHO. It raised widespread concern about the treatment of psoriasis in this COVID-19 pandemic era, especially on the biologics use for patients with psoriasis. This review will summarize key information that is currently known about the relationship between psoriasis, biological treatments, and COVID-19, and vaccination-related issues. We also provide references for dermatologists and patients when they need to make clinical decisions. Currently, there is no consensus on whether biological agents increase the risk of coronavirus infection; however, current research shows that biological agents have no adverse effects on the prognosis of patients with COVID-19 with psoriasis. In short, it is not recommended to stop biological treatment in patients with psoriasis to prevent the infection risk, and for those patients who tested positive for SARS-CoV-2, the decision to pause biologic therapy should be considered on a case-by-case basis, and individual risk and benefit should be taken into account. Vaccine immunization against SARS-CoV-2 is strictly recommendable in patients with psoriasis without discontinuation of their biologics but evaluating the risk-benefit ratio of maintaining biologics before vaccination is mandatory at the moment.

Vaccines Against SARS-CoV-2 in Psoriasis Patients on Immunosuppressive Therapy: Implications of Vaccination Nationwide Campaign on Clinical Practice in Italy

More than 12 months have passed since the World Health Organization (WHO) declared Coronavirus Disease 19 (COVID-19), caused by the SARS-CoV2 virus, to be a pandemic on 11 March 2020. The entire world scientific community agrees that at this time vaccine is the most promising weapon to combat the infection and the severity of the disease. According to the document “Draft landscape of COVID-19 candidate vaccines” by WHO, 272 vaccines against SARS-CoV-2 virus are in development, although only four of these, produced by Pfizer-BioNTech (Pfizer, Inc. and BioNTech), Moderna, AstraZeneca, and Janssen companies, respectively, have been approved by European Medicines Agency and Italian Medicines Agency and subsequently distributed nationwide for use. These vaccines are the result of highly innovative procedures and are quite different from each other in terms of composition. Even clinicians in various medical fields may be unfamiliar with the effects of these vaccines. There is the strong emerging need for dermatologists to understand the crucial role of vaccines, with a focus on the need to vaccinate patients suffering from immune-mediated skin diseases, such as psoriasis, while taking the ongoing treatment into consideration regarding the timing of vaccination. Similarly, psoriasis patients aware of having an immune-mediated and inflammatory disease are increasingly asking the dermatologist information about the efficacy and safety of vaccines against SARS-CoV-2 virus. In this narrative review of the literature and critical analysis of the recommendations of the Italian Ministry of Health, we analyze the implications of the vaccination campaign on dermatological patients with psoriasis undergoing immunosuppressive treatment.

National Psoriasis Foundation COVID-19 Task Force Guidance for Management of Psoriatic Disease During the Pandemic: Version 1

Objective

To provide guidance about management of psoriatic disease during the coronavirus disease 2019 (COVID-19) pandemic.

Study design

A task force (TF) of 18 physician voting members with expertise in dermatology, rheumatology, epidemiology, infectious diseases, and critical care was convened. The TF was supplemented by nonvoting members, which included fellows and National Psoriasis Foundation (NPF) staff. Clinical questions relevant to the psoriatic disease community were informed by questions received by the NPF. A Delphi process was conducted.

Results

The TF approved 22 guidance statements. The average of the votes was within the category of agreement for all statements. All guidance statements proposed were recommended, 9 with high consensus and 13 with moderate consensus.

Limitations

The evidence behind many guidance statements is limited in quality.

Conclusion

These statements provide guidance for the management of patients with psoriatic disease on topics ranging from how the disease and its treatments impact COVID-19 risk and outcome, how medical care can be optimized during the pandemic, what patients should do to lower their risk of getting infected with severe acute respiratory syndrome coronavirus 2 and what they should do if they develop COVID-19. The guidance is intended to be a living document that will be updated by the TF as data emerge.