Describing the burden of the COVID‐19 pandemic in people with psoriasis: findings from a global cross‐sectional study

Indirect excess morbidity in the COVID-19 pandemic may arise from public health risk-mitigation efforts such as stay-at-home orders and re-purposing of healthcare services1 . Increased mental health disorders and shortfalls in the care of long-term conditions are described.

Editor, Indirect excess morbidity in the COVID-19 pandemic may arise from public health risk-mitigation efforts such as stay-at-home orders and re-purposing of healthcare services. 1 Increased mental health disorders and shortfalls in the care of long-term conditions are described. 2,3 We used global self-reported crosssectional data to characterise the factors associated with worsening psoriasis in the pandemic, focussing on the impact of anxiety and depression.
Data from a cross-sectional survey (PsoProtectMe 4 ) were extracted on 15th January 2021. After excluding participants self-reporting COVID-19, the association between mental health and worsening psoriasis was assessed using a fully adjusted logistic regression model including covariates selected a priori as potentially influential on psoriasis severity and anxiety/depression. Participants scoring ≥3 in GAD-2 or PHQ-2 defined a positive mental health screen. 5 4043 people with psoriasis from 86 countries were included (Table 1) A fully adjusted regression model for worsening psoriasis estimated an odds ratio (OR) 2.01 (95% CI, 1.72-2.34) for those with a positive screen for anxiety or depression compared to those without a positive screen (Fig. 1 Table 1). The commonest reason was concern regarding complications related to COVID-19 (n = 217). Non-adherence was associated with worsening psoriasis (OR, 2.90, 95% CI, 2.31-3.63). A positive mental health screen was more common in those reporting non-adherence compared to those who were adherent (42.8% vs. 32.4%).
These data indicate a burden due to the COVID-19 pandemic in people with psoriasis; worsening psoriasis is common and is associated with poor mental health. We find that in the subset on systemic therapy, non-adherence is associated with worsening disease and is driven by concerns about immunosuppressant-related risks of COVID-19. This is an important observation since current guidelines (informed by reassuring data on drug-related risks of severe COVID-19 6 ) recommend continuing immunosuppression in people without COVID-19 to maintain disease control. 7 Our findings parallel data from the general population indicating an increased mental health burden during the pandemic, particularly in women. 8 People with psoriasisespecially those with severe psoriasis, and womenhave a high prevalence of anxiety and depression and may thus be particularly vulnerable to the adverse impact of the pandemic on mental health. 9 Whilst men are known to be at greater risk of severe outcomes from COVID-19, our data suggest that women may be more susceptible to indirect excess morbiditypoor mental health and worsening skin diseasethan men.
The generalisability of results is limited given the self-selecting bias of our study population towards UK white women. Individuals non-adherent to treatment, with low computer literacy or less anxiety, may be disinclined to participate, which may introduce ascertainment bias.
Our data underscore the importance of holistic models of care and indicate a need to provide access to psychological support. In those with worsening psoriasis, possible non-adherence should be explored. Evidence-based communication around medication-related COVID-19 risks and behavioural approaches for supporting adherence may help address fears, anxieties and confusion. 10 Attention given now to address this may mitigate a long-lasting detrimental impact of the pandemic on health outcomes in people with psoriasis. Ingelheim, Roche and Merck. Dr. Mason reports personal fees from LEO Pharma and Novartis, outside the submitted work. Ms. Moorhead reports personal fees from Abbvie, personal fees from Celgene, personal fees from Janssen, personal fees from LEO Pharma, personal fees from Novartis, personal fees from UCB, outside the submitted work. Dr. Puig reports grants and personal fees from AbbVie, grants and personal fees from Almirall, grants and personal fees from Amgen, grants and personal fees from Boehringer Ingelheim, personal fees from Bristol Myers Squibb, personal fees from Fresenius-Kabi, grants and personal fees from Janssen, grants and personal fees from Lilly, personal fees from Mylan, grants and personal fees from Novartis, personal fees from Pfizer, personal fees from Sandoz, personal fees from Sanofi, personal fees from Samsung-Bioepis, grants and personal fees from UCB, outside the submitted work. Dr. Mahil reports departmental income from Abbvie, Celgene, Eli Lilly, Janssen-Cilag, Novartis, Sanofi, UCB, outside the submitted work. Dr. Di Meglio reports grants and personal fees from UCB, personal fees from Novartis, personal fees from Janssen, outside the submitted work. Prof. Warren reports grants and personal fees from Abbvie, grants and personal fees from Celgene, grants and personal fees from Eli Lilly, grants and personal fees from Novartis, personal fees from Sanofi, grants and personal fees from UCB|, grants and personal fees from Almirall, grants and personal fees from Amgen, grants and personal fees from Janssen, grants and personal fees from Leo, grants and personal fees from Pfizer, personal fees from Arena, personal fees from Avillion, personal fees from Bristol Myers Squibb, personal fees from Boehringer Ingelheim, outside the submitted work. Prof. Smith reports grants from Abbvie, Sanofi, Novartis, and Pfizer and through consortia with multiple academic partners (psort.org.uk, BIOMAP-IMI.eu), outside the submitted work. Dr. Torres reports grants and personal fees from AbbVie, Almirall, Amgen, Arena Pharmaceuticals, Biogen, Biocad, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, LEO Pharma, MSD, Novartis, Pfizer, Samsung-Bioepis, Sandoz, during the conduct of the study. Dr. Waweru is on the Board of the International Federation of Psoriasis Associations who have received grants from Abbvie, Almi-