Atopic dermatitis patients may be at higher risk of COVID-19 because of comorbidities

Adult patients with atopic dermatitis (AD) have a small, increased risk of contracting COVID-19 which is likely due to higher rates of other comorbidities such as obesity or hypertension. On the other hand, AD patients using systemic dupilumab have a lower risk of contracting COVID-19 infection compared to those using other systemic medications. Read: Possible dupilumab-atopic dermatitis interaction These two findings come from a study published in the Journal of the American Academy of Dermatology (JAAD). “Patients with AD have skin-barrier dysfunction and immune system dysregulation, which increases risk of infection. Studies have shown an association between AD and both cutaneous and non-cutaneous infections, including influenza and pneumonia,” said lead author Dr. Jashin Wu, founder of the Dermatology Research and Education Foundation, an organization that conducts research on inflammatory skin diseases. On top of this, “AD has been associated with many established COVID-19 risk factors such as cardiovascular disease, cerebrovascular disease, hypertension, and obesity. Read: New Canadian evidence-based overview of atopic dermatitis management Lastly, individuals with moderate-to-severe AD may be exposed to immunosuppressive medications, for which the risk of COVID-19 is uncertain,” he told the Medical Post in an email. Researchers conducted the retrospective study using the internationally accessible COVID-19 Research Database. Data were extracted for all subjects, with at least two diagnoses of AD prior to Jan. 1, 2020, and were included in the AD cohort. Subjects with no record of AD diagnosis before that date, were randomly selected in a 10:1 size ratio into the control group and compared to AD group. Laboratory confirmed cases of COVID-19 from both groups between Jan. 1, 2020 and April 17 2021 were identified. A total of 39,417 and 397,293 subjects were included in the AD and non-AD cohorts, respectively. The mean age of the AD group was 54.9 years and 57.3 years for the non-AD group. An initial analysis, without controlling for demographic characteristics and comorbidities, showed COVID-19 incidence was about 41% higher in the adults with AD compared to adults without AD. However, further analysis showed that adults with AD had a higher prevalence of baseline comorbidities known to be COVID-19 risk factors than adults who did not have AD. Indeed, significant percentages of the AD patients had asthma (8.7%), rhinitis (13.5%), diabetes mellitus (10.6%), obesity (6.6%) and hypertension (22.5%). This compared to the rates in non-AD which were much lower for asthma (1.4%), rhinitis (1%), diabetes mellitus (7.4%), obesity (2.8%) and hypertension (14.2%). Other risk factors such as COPD and heart failure also stood out in the AD cohort. Read: Dupixent for moderate-to-severe atopic dermatitis in adults “The results of our study suggest that comorbidities may be driving the increased COVID-19 risk associated with AD in adults. However, further studies are needed to confirm this and to investigate which comorbidities are the strongest COVID-19 risk factors for patients with AD,” said study co-author Amylee Martin, a fourth-year medical student at the University of California. A limitation of the study is that researchers were unable to ensure all participants were tested for COVID-19 and it was possible the study did not capture asymptomatic cases. There were also some differences in risk found within the AD population, a key one being that the use of dupilumab for AD was associated with lower risk of contracting COVID-19 compared to no systemic medication. “In recent years, dupilumab has steadily increased in popularity for the treatment of patients aged six years or older with moderate-to-severe AD, not adequately controlled with topical therapies,” said Dr. Wu. “It is possible that dupilumab may have a protective role against COVID-19 infections by blocking interleukin-4, which has been associated with severe COVID-19 infections. However, this is just speculative at this point and there isn't strong evidence to support this theory currently,” he said. Other systemic treatments that are used for AD include prednisone, cyclosporine, azathioprine and methotrexate, but are being used less often for the treatment of moderate-to-severe AD. Read: Non-melanoma skin cancer rates up 30% in Ontario from 2003 to 2017 These other systemic treatments may be prescribed for patients with moderate-to-severe AD not adequately controlled by topical treatments for a variety of reasons such as patient age, patient preference and resistance/intolerance to dupilumab. The paper noted that IL-4 activity which is blocked by dupilumab, “has been associated with severe COVID-19 infections,” and concluded that “based on the current evidence, dupilumab does not appear to increase COVID-19 risk for patients with AD.” Dr. Maxwell Sauder, a dermatologist and assistant professor of medical at the University of Toronto found the findings of interest. “I am not surprised at these results. People with atopic dermatitis have a decreased skin barrier function to protect against pathogens leading to more infections.” He was not involved in the study. “Further, while the evidence of immunosuppression with prednisone, cyclosporine (CsA) and azathioprine is clear, this article supports the notion that dupilumab is more an immuno-modulating medication than immunosuppressive,” he said. Read: Skin across the spectrum: Dermatology education resources turn attention to caring for people with skin of colour In another dermatological element, a review published in Dermatologic Clinics in October 2021 by U.S. researchers found that current data suggest biologics do not seem to increase the risk of COVID-19 infection or worsen COVID-19 outcomes. The review included a variety of biologics in in patients with inflammatory skin conditions and was not limited to AD.

Atopic dermatitis patients may be at higher risk of COVID-19 because of comorbidities

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