Expert Recommendations for Managing Autoimmune Bullous Diseases in COVID-19 Era

For patients with autoimmune bullous diseases (AIBD), dapsone/sulfapyridine, doxycycline/tetracycline, or intravenous immunoglobulin (IVIG) may be preferable treatments during the COVID-19 pandemic because they are not believed to increase the risk of infection and, for some infections, may even decrease risk, according to recommendations published online in The Journal of the European Academy of Dermatology and Venereology.

The advice, from a panel of experts from academic centers in the United States, France, and Germany, focused on AIBD management amid the threat of COVID-19.
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“Since immunosuppressive therapy can generally inhibit antiviral immunity, AIBD patients undergoing immunomodulatory treatment, especially elderly patients with comorbidities, may be  at higher risk of worse outcomes should they develop COVID-19,” the panel wrote. “On the other hand, it has been postulated that immune system overactivation is responsible for the lung injury caused by SARS-CoV-2 and that a subgroup of patients might actually benefit from immunosuppressive drugs.”

Overall, the experts advised healthcare providers to maintain needed immunomodulatory therapy in patients because withdrawal can cause uncontrolled AIBD activity linked with high morbidity and mortality.

If patients with AIBD become infected with SARS-CoV-2, azathioprine, mycophenolate mofetil/sodium, cyclophosphamide, methotrexate, and cyclosporine can be stopped for the  duration of  COVID-19 symptoms, per recommendations. However, treatment with topical corticosteroids, prednis(ol)one ≤10 mg/d, dapsone/sulfapyridine, doxycycline/tetracycline, colchicine, and IVIG can continue.

Prednis(ol)one ≤10 mg/d can be reduced if collaboration between the dermatologist and physician overseeing COVID-19 care deems doing is so necessary in light of AIBD severity, COVID-19 severity, and patient age and comorbidities, according to the recommendations. Considerable dose reductions or abrupt termination of systemic corticosteroids should be avoided.

The experts also pointed out that patients with AIBD treated with rituximab within the last year may have more severe or prolonged COVID-19 infections.

—Jolynn Tumolo

Reference

Kasperkiewicz M, Schmidt E, Fairley JA, et al. Expert recommendations for the management of autoimmune bullous diseases during the COVID-19 pandemic [published online ahead of print April 25, 2020]. J Eur Acad Dermatol Venereol. doi:10.1111/jdv.16525