Pemphigus and COVID ‐19: Critical overview of management with a focus on treatment choice

Abstract

COVID-19 is a serious multisystem disease caused by severe acute respiratory syndrome coronavirus 2. Due to the COVID-19 crisis, that still keeps its impacts worldwide, numerous scheduled medical activities have been postponed and this interruption has a potential to modify the management of many cutaneous conditions including pemphigus. This narrative review aims to discuss the management of pemphigus in the era of COVID-19, considering the necessity to balance suitable pemphigus treatment with minimal risk of COVID-19-related mortality and morbidity. The data on the effect of treatments used for pemphigus on COVID-19 are limited. However, the evidence to manage patients properly is evolving and our knowledge is updated. Current expert recommendations include that patients with pemphigus should be informed clearly to avoid mismanagement and they should be monitored regularly for symptoms of COVID-19. Patients with mild disease can be managed with topical or intralesional corticosteroids, dapsone, or doxycycline. Systemic corticosteroids should be tapered to the lowest effective dose during the pandemic. Prednis(ol)one ≤10 mg/d can be continued in patients with COVID-19 while prednis(ol)one >10 mg/d may be reduced considering the activity of the disease. Conventional immunosuppressive therapies should only be discontinued in confirmed cases of COVID-19. Postponing rituximab treatment should be considered on a case by case basis. Intravenous immunoglobulin is not likely to increase the risk of infection and may be considered a safe option in patients with COVID-19. Given the psychological burden brought by COVID 19, online or face-to-face psychological support programs should be considered.

Intravenous immunoglobulin as an important adjunct in the prevention and therapy of coronavirus 2019 disease

“…Table 3 shows other COVID-related autoimmune disease treated with IVIg. [109][110][111][112][113][114][115] Finally, it is important to pay attention to the post-COVID (ie short-term) and long-COVID (ie long-term) manifestations appearing in people recovering from the SARS-CoV-2 infection. Any organ system can be involved, in particular immune system.…”

“…Table 3 shows other COVID‐related autoimmune disease treated with IVIg. 109 , 110 , 111 , 112 , 113 , 114 , 115 …”

“…Five patients required vasoactive amine support, and all were treated with at least one infusion of IVIg (2g/ kg), two received a second dose of IVIg, five received methylprednisolone 2 mg/kg/day (two patients started with 30 mg/kg/day for 3 days). 107 Pouletty et al 108 Arthritis (not infectious) 92 Systemic vasculitis 92 Antiphospholipid antibodies 92 Kawasaki disease 91,93 Multisystem Inflammatory Syndrome in Children (MIS-C) [91][92][93][94][95][96][97][98][99][100][101][102][103][104][105] Exacerbation Antiphospholipid Syndrome 92 Systemic Lupus Erythematosus 92 Rheumatoid Arthritis 92 Organ specific autoimmune diseases New onset Immune thrombocytopenic purpura 92,93 Autoimmune idiopathic haemolytic anaemia 92 Evans syndrome 92,111 Pemphigus vulgaris 112 Guillain-Barré syndrome [91][92][93] Miler-Fisher Syndrome [91][92][93] Acute disseminated encephalomyelitis Devic syndrome 92 Goodpasture's syndrome 92 Exacerbation Myasthenia gravis Multiple sclerosis 92 patients. All patients had a positive test (serological or swab test) for SARS-CoV-2 and/or close contact with a positive COVID-19 individual.…”

Case Report: Complete and Fast Recovery From Severe COVID-19 in a Pemphigus Patient Treated With Rituximab

“…However, as it can lead to higher susceptibility to infections, concerns about its use during the pandemic have been raised (2). Some authors have suggested avoiding or temporarily postponing RTX during the pandemic due to the risk of SARS-CoV-2 infection (2,12).…”

The initial experience of COVID ‐19 vaccination in autoimmune blistering diseases patients from a reference care center in Italy

“… 1 However, because of the immunosuppressive background of the autoimmune disorder itself and the immunosuppressive drugs used in the treatment of these diseases, it is reasonable to think that these patients have a higher susceptibility to bacterial and viral infections. 2 , 3 For this reason, EADV guidelines recommend checking for an up‐to‐date vaccination status before starting an immunosuppressive treatment and regularly performing standard vaccinations (influenza, pneumococci, tetanus, pertussis, etc). The only contraindication is the use of live vaccines in patients treated with adjuvant immunosuppressants and rituximab.…”