Western allopathic medicine—the profession of MDs and DOs—is based on the scientific method. Studying the root of disease and adapting to the best available evidence is responsible for the marvels of modern public health, medical devices, and drugs. These prescription medicines go through a rigorous period of scientific study, generating data that must be compelling enough to justify approving their safety and efficacy. Physicians and other medical providers weigh this evidence when deciding the best treatment course for any individual patient because every therapy—including not treating the disease at all—comes with risks and benefits, and we always want the benefits to outweigh the risks. This is true at any time, but the reality of the COVID-19 pandemic adds another factor to our calculations.
As a medical practitioner, there are three main risks to consider for any patient under the current threat of COVID-19: the risk of their underlying disease, the risk of their current medication, and the risk of stopping or modifying that medication. These factors all interact with each other, and a balance must be struck for each individual under our care. This is truly a commitment to personalized medicine!
Medication Factors to Consider:
First, the condition we’re treating plays a major role in evaluating someone’s risk. Patients with severe eczema (atopic dermatitis) can have significant viral skin infections, while those with psoriasis usually do not. Eczema patients often also have asthma, which was one of the early conditions known to increase the risk of COVID-19. Similarly, patients with uncontrolled autoimmune diseases like lupus are more susceptible to both viral and bacterial infections, so, somewhat paradoxically, being on immune-suppressing medications actually makes their ability to fight off viruses stronger. So, while we might consider changing a medication for a psoriasis patient, we might keep an eczema or lupus patient on that same drug because of their underlying condition.
Next, we need to consider the COVID-19-related risk of the medication itself: does it make someone more prone to viral infection, or a more severe infection if they get one? For this, It is helpful to consider our immune system medications on a spectrum. True immunosuppressives, like those taken to prevent organ transplant rejection, are probably riskiest because we know patients taking them are more likely to get severe infections. The biologic medications, which target only one or two immune system messengers, look rather safe in large part because we have years of studies documenting that patients on them do generally well. And the risk of newer pills can vary, where some seem very safe, and others may increase the risk of viral infections like shingles. We are much more likely to stop or change a strong immunosuppressive for COVID-19 concerns than medications that are more targeted.
Finally, patients and their clinical caregivers should consider the risk of stopping a medication that is working to treat the underlying condition. For many psoriasis patients, the risk is that their psoriasis comes back in several weeks, but others may have psoriatic arthritis where their joint damage and inflammation start up sooner. Patients with inflammatory scalp conditions risk permanent hair loss and disfiguring scars if they stop. As we already mentioned, those with eczema and asthma, or lupus, may put themselves at increased risk of COVID-19 itself if they discontinue their treatments. This dynamic again points out the necessity of an individual approach to each person’s unique situation.
Precautions During COVID-19
Fortunately, there are several guiding principles recommended by expert consensus from organizations such as the American Academy of Dermatology, the American College of Rheumatology, and others regarding best practices with immunomodulating medications and the current pandemic.1,2 Reducing the risk of transmission through social distancing, wearing masks, and guarding the most vulnerable remains the main thrust of protection. For those who are known COVID-19 positive, it is generally recommended to hold any medication that could worsen the disease; interestingly, those with severe COVID-19 may be entered into one of many trials that are testing whether these immune-modulating medicines actually help their outcomes. Otherwise, there are no specific recommendations to stop or change most of the oral or injectable medications we use in dermatology, and patients can re-start their treatment regimen after recovering from COVID-19 and discussing it with their prescriber.
At APDerm, we pride ourselves on providing the very best care to each and every individual patient. Our practices have exceeded CDC guidelines in providing a safe in-office experience during the current pandemic, and our clinicians are available via teledermatology for consults, including prescriptions and prescription refills in the safety and privacy of our patients’ homes. If you would like to discuss your condition and obtain personalized recommendations based on the most up-to-date information, please call (978) 315-6320 or fill out the form below to schedule an appointment.
- Mikuls, ER, Johnson, SR, et al. American College of Rheumatology Guidance for the Management of Adult Patients with Rheumatic Disease During the COVID-19 Pandemic. https://doi.org/10.1002/art.41301