COVID-19 vaccination in psoriasis patients: Latest guidelines

Coronavirus disease 2019 (COVID-19) pandemic has affected every sphere of life and altered the management of dermatological disorders like psoriasis. Vaccines are the most important defence by healthcare professionals to fight against COVID-19 so far. There is no data on the eligibility of patients with psoriasis or on immunosuppressive or immunomodulating medications for COVID-19 vaccination. Recently a position statement regarding the same issue was published in the Indian Journal of Dermatology, Venereology and Leprology.

An extensive PUBMED search using keywords 'COVID-19'or 'SARS-CoV-2' and 'Vaccine' and 'Psoriasis' was done. A total of 23 abstracts were obtained. Articles for which full texts could not be accessed were excluded so a total of 14 articles were analysed arrive at this position statement.

Importance of vaccination in psoriasis patients

Available data suggests that the presence of psoriasis does not increase the risk of COVID-19 infection or impact the disease outcome. As it is well known that patients with psoriasis have strong association with obesity, diabetes mellitus and metabolic syndrome, it makes them vulnerable for severe COVID-19 infection.

Furthermore, psoriasis patients requiring systemic therapy are often treated with methotrexate, cyclosporine and biologicals, all of which may cause varying degrees of immunosuppression. Vaccines induce an immune response without causing the disease and therefore decrease the chance of natural infection or at least decrease the severity of illness, if infected.

Risk-benefit analysis of COVID-19 vaccination in psoriasis patients

The potential benefit from vaccination has to be weighed against vaccination induced adverse events. Since psoriasis patients may be immunocompromised, due to comorbidities or immunosuppressive treatments, they can develop severe

COVID-19 illness so potential benefit from vaccination could be substantial. The effect of vaccination on the clinical course of psoriasis is largely unknown. There are few initial reports of exacerbation of psoriasis after COVID-19 vaccination. The possibility of post-vaccination flare-up of psoriasis has been documented for influenza vaccination. However, there is a possibility that a live attenuated vaccine could overwhelm the weakened immune system of a patient on immunosuppressives. In addition administration of immunosuppressive medications could lead to decreased immune response to vaccination.

It is well known that live vaccines are contraindicated in patients on immunosuppressives including biologic therapy. Immunosuppressives should be stopped one–three months before giving a live vaccine. Therefore, all required vaccinations should be completed before initiation of biologic therapy, and for live vaccines, biologic therapy can be started two–four weeks after the administration of the live vaccine.

Mechanism of action of different types of COVID-19 vaccines in India

Inactivated vaccine

SARSCoV-2 is killed using chemicals, heat or radiation and when injected, presents the immune system with a whole, inactivated version of the coronavirus. Example of this is Covaxin (approved in India) and Sinovac and Sinopharm (not approved in India).

Live-attenuated vaccine, vaccines with protein subunit, vaccines with virus-like particle and replicating viral vector vaccine

There are at present no approved vaccines in all of these 4 categories.

Messenger ribonucleic acid vaccines

Ribonucleic acid introduced into the body codes for a SARSCoV-2 protein. Here,

the vaccinated person's own cells produce a specific part of the COVID-19 virus and the immune system produces antibodies to it. Pfizer/BioNTech (not yet approved in India) and Moderna vaccines (recently approved in India) belong to

this category. It is safe in immunocompromised patients.

Deoxyribonucleic acid

Recently, Zydus Cadila's (ZyCoV-D) COVID-19 vaccine, the world's first deoxyribonucleic acid vaccine against COVID-19, was approved for use in India for adults and children aged 12 years and above. This is the first vaccine approved in India in the 12–18 years age group. Here too, only the deoxyribonucleic acid is introduced which only produces a viral protein, hence is safe in the immunocompromised.

Non-replicating viral vector vaccine

Non-replicating engineered viruses carrying genetic code for proteins of the SARSCoV-2 virus are introduced which stimulate an immune response. The university of Oxford vaccine/AstraZeneca (approved in India as CoviShield) uses genetically altered chimpanzee adenovirus. The Sputnik V vaccine (approved in India) uses two different harmless adenoviruses. Janssen (Johnson & Johnson; recently approved in India) also uses a disabled adenovirus.

Vaccination for psoriasis patients on systemic therapy

At present, all the vaccines available in the market (whether approved or not approved in India) carry minimal to nil risk of vaccine-induced severe infection in psoriasis patients. Therefore, the possibility of less than expected vaccine-induced immunity is the main consideration for psoriasis patients on immunosuppressives.

Few salient points regarding COVID-19 vaccination-

1. Patients on only topical therapy or non-immunosuppressive systemic therapies such as acitretin and apremilast or on phototherapy/photochemotherapy can receive any of the approved COVID-19 vaccines in India.
2. Ideally, psoriasis patients should be vaccinated before initiating on immunosuppressive systemic therapies and when the disease is well controlled and stable. However, immunosuppressive systemic therapies should not be withheld or interrupted for vaccination in a patient with active, worsening psoriasis who needs the treatment.
3. Secukinumab, an IL- 17 inhibitor, did not suppress humoral immune response after influenza vaccination even when used in combination with other disease modifying drugs among psoriasis and psoriatic arthritis patients.
4. Methotrexate and tofacitinib: In patients with well controlled disease, these medications can be stopped for one–two weeks after vaccination. If interruption of therapy is not possible because of disease activity, COVID-19 vaccination can take place while on treatment.
5. Interpretation of results of tuberculin skin test or an interferon gamma release assay (IGRA) should be performed before or at least four weeks after the administration of a messenger ribonucleic acid-based COVID-19 vaccine. If the tuberculin skintest or IGRA is performed less than four weeks after receiving a messenger ribonucleic acid-based COVID-19 vaccine, then the test should be repeated after completion of four weeks, to exclude a false-negative result before starting biologics. However, in India, tuberculin skin test and IGRA are not included in the diagnosis and work-up of a suspected HIV nonreactive tuberculosis patient according to National Tuberculosis Elimination Programme guidelines.
6. For psoriatic arthritis patients on systemic steroids consider tapering the steroid to a daily dose that is equivalent to <20mg of prednisolone wherever possible.

Vaccination in pregnant psoriatic patients:

Patient should be informed about the risks and benefits associated with the COVID-19 vaccines available in India. Based on the data available a pregnant woman may be offered any of the approved COVID-19 vaccine (Covaxin, CoviShield and Sputnik V) anytime during pregnancy. For impetigo herpetiformis patients on systemic steroids consider tapering the steroid to a daily dose that is equivalent to <20 mg of prednisolone wherever possible.

Vaccination in lactating psoriasis patients:

All lactating women are eligible to receive the COVID-19 vaccines any time after delivery.

Vaccination in children with psoriasis:

Zydus Cadila's (ZyCoV-D) COVID-19 deoxyribonucleic acid vaccine is approved for use in India for adults and children aged 12 years and above. Pfizer/BioNTech vaccine has been approved by the World Health Organisation for use by people aged 12 years and above. Specific data on COVID-19 vaccination of psoriasis patients in paediatric age group is yet to be available.

Therefore, the strategy outlined for adults is applicable for children above 12 years as well, till more data are generated. Children (12 years and older) with psoriasis who are being treated with immunosuppressive or immunomodulating therapies such as leflunomide, methotrexate, tofacitinib and biologics are eligible

for a third booster dose of messenger ribonucleic acid COVID-19 vaccine (Pfizer-BioNTech vaccine) according to the Centre for Disease Control, Atlanta. This booster dose should be administered at least 28 days following the two-dose regimen of the same vaccine.

Immune response to COVID-19 vaccine, counselling and advice:

Psoriasis patients on abovementioned immunosuppressives, the COVID-19 vaccine-induced immunity may be less than that of an immunocompetent individual. However, since COVID-19 illness can be life threatening the risk-benefit ratio analysis indicates that the vaccine should still be administered at the earliest opportunity for psoriasis patients on immunosuppressives. Patients can consider checking antibody titres after vaccination and take additional vaccinations, if needed, to boost the level of protective antibodies.

Guidelines regarding the interval between two doses and interval between recovery from COVID-19 illness and first or second dose of the vaccination should be the same in psoriasis patients as for the general population.

To conclude the currently available data suggests COVID-19 vaccines in India are safe to be administered to patients with psoriasis even if they are on systemic immunosuppressive agents or immune targeting therapy without altering their current treatment.

References

1. Parthasaradhi A, Ganguly S, Kar BR, Thomas J, Neema S, Tahiliani S, et al. Coronavirus disease 2019 vaccination in patients with psoriasis: A position statement from India by SIG psoriasis (IADVL Academy). Indian J Dermatol Venereol Leprol 2022;88:286-90.