A systematic review and meta-analysis of investigating the mutual impact of COVID-19 and psoriasis: Focusing on COVID-19 course in psoriasis and the opinion on biologics in this setting

IntroductionThis systematic review and meta-analysis aims to investigate the mutual impact of COVID-19 and psoriasis to inform clinical practice and future research.MethodsWe followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis protocol for systematic reviews and searched PubMed, Web of Science, Scopus, and Google Scholar until May 1, 2022. Eligibility criteria included full-text articles in English reporting COVID-19 treatment outcomes in psoriasis patients. Studies on animals, letters to editors, non-English studies, and studies with no access to full articles were excluded. Search results were screened and data were extracted by two groups of reviewers with any discrepancies resolved by the senior author. The risk of bias was assessed using ROBINS-I for nonrandomized studies. The hospitalization rate, Intensive Care Unit (ICU) admission rate, case fatality rate, odds ratios of COVID-19 infection and hospitalization rate in psoriasis patients were extracted and analyzed using random effects analysis to calculate pooled prevalence and odds ratios, as well as to explore heterogeneity.ResultsWe found 1980 records from four databases and included 20 studies after screening and removing duplicates. These studies evaluated 185,000 psoriasis patients and included eight retrospective cohort studies, one case-control study, three cross-sectional studies, and eight case series studies. The impact of the COVID-19 pandemic on psoriasis treatment and the outcome of COVID-19 infection in psoriasis patients receiving different forms of treatment were evaluated. The pooled data from included studies showed that the incidence rate of COVID-19 infection among psoriasis patients was 0.03% (confidence interval [CI]: 0.01-0.06), with a pooled odds ratio of 1.97 (CI: 0.69-5.60) compared to the general population. The hospitalization rate, ICU admission rate, and case fatality rate for psoriasis patients with COVID-19 were 0.17 (CI: 0.10-0.31), 0.06 (CI: 0.06-0.46), and 0.02 (CI: 0.01-0.04), respectively. Additionally, psoriasis patients receiving systemic nonbiologic therapy had a pooled odds ratio of 2.32 (CI: 1.18-4.57) for hospitalization compared to those using biologic agents.ConclusionStudies have shown that biologic therapy for psoriasis did not increase the risk of hospitalization due to COVID-19 infection and may have even offered some protection. Treatment adherence was higher in psoriasis patients receiving biologic therapies than those receiving conventional therapies. These findings suggest that psoriasis treatment did not negatively impact COVID-19 infection and that treatment could be continued on a case-by-case basis during the pandemic. The use of immunosuppressive treatments in patients with pre-existing immune-mediated diseases, such as psoriasis, who become infected with COVID-19 is a controversial issue.COVID-19 can cause cytokine storm in the body, which may exacerbate diseases with inflammation-based pathophysiology.Current information about the dynamic association between COVID-19 and pre-existing immune-mediated diseases, as well as the impact of COVID-19 infection and its treatments on the course of the underlying disease, is limited and controversial.There are concerns that discontinuing or altering routine medications due to COVID-19 may change the course of the underlying disease, and flare-ups may occur.However, evidence suggests that biologics and nonbiologic drugs may have desirable effects on overcoming the hyperinflammation state caused by COVID-19, and withholding biologics due to COVID-19 infection is not advisable.Patients who had discontinued their psoriasis medications prior or after being afflicted with COVID-19 were more likely to experience severe psoriasis flare-ups.Patients who had not missed their scheduled biologic administration were likely to experience mild COVID-19 symptoms while their psoriasis condition remained unchanged.Using glucocorticoids is one of the main therapeutic strategies in patients with severe COVID-19 symptoms, but in psoriatic patients, administration of glucocorticoids during the course of COVID-19 infection might affect the patient's psoriasis presentation. It is crucial to further investigate this matter, as there is still no general agreement.Infection with COVID-19 does not increase the possibility of exacerbation and flare-up of psoriasis.