10.5826/dpc.1204a166
Introduction: Little is known about how much the impact of patient-driven issues on the treatment of psoriasis in the amid of COVID-19 pandemic.
Objectives: We aimed to investigate the COVID-19 knowledge of the patients with psoriasis receiving systemic therapy in the pandemic.
Methods: The patients who received systemic treatment for psoriasis presented to our dermatology outpatient clinic were enrolled in the study. A questionnaire measuring the level of knowledge about COVID-19 and psoriasis was administered to patients. Demographics and disease characteristics of patients were recorded.
Results: A total of 183 patients with psoriasis were enrolled in the study. Of the patients, 33.9% thought that psoriasis exposes them to a risk of getting COVID-19, 30.6% declared that psoriasis treatment exposes them to a risk of getting COVID-19, and 59.6% were worried about getting COVID-19. The treatment discontinuation rate was 42.1%. The patients with high scholarity level showed more anxiety and discontinued their treatment.
Conclusions: The patients with psoriasis did not have adequate knowledge of the effect of both psoriasis itself and its treatment on COVID-19 during the pandemic. The patients on biologic therapy tend to discontinue their treatment based upon the physician's recommendation, whereas those on conventional therapy mostly on their own will. Clinicians should provide patients with not only as much information as they need but also current evidence about both psoriasis and COVID-19.
text/xml
2160-9381
2142
en
Fatma Arzu Kılıç
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
psoriasis
COVID-19 Knowledge in Patients with Psoriasis Receiving Systemic Therapy: A Questionnaire Study
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2021-10-31
2022-10-31
2022-11-29
e2022166
Dermatol Pract Concept
Introduction: Little is known about how much the impact of patient-driven issues on the treatment of psoriasis in the amid of COVID-19 pandemic.
Objectives: We aimed to investigate the COVID-19 knowledge of the patients with psoriasis receiving systemic therapy in the pandemic.
Methods: The patients who received systemic treatment for psoriasis presented to our dermatology outpatient clinic were enrolled in the study. A questionnaire measuring the level of knowledge about COVID-19 and psoriasis was administered to patients. Demographics and disease characteristics of patients were recorded.
Results: A total of 183 patients with psoriasis were enrolled in the study. Of the patients, 33.9% thought that psoriasis exposes them to a risk of getting COVID-19, 30.6% declared that psoriasis treatment exposes them to a risk of getting COVID-19, and 59.6% were worried about getting COVID-19. The treatment discontinuation rate was 42.1%. The patients with high scholarity level showed more anxiety and discontinued their treatment.
Conclusions: The patients with psoriasis did not have adequate knowledge of the effect of both psoriasis itself and its treatment on COVID-19 during the pandemic. The patients on biologic therapy tend to discontinue their treatment based upon the physician's recommendation, whereas those on conventional therapy mostly on their own will. Clinicians should provide patients with not only as much information as they need but also current evidence about both psoriasis and COVID-19.
Fatma Arzu Kılıç
2022/10/31
10.5826/dpc.1204a166
e2022166
Department of Dermatology, Faculty of Medicine, Balıkesir University, Balıkesir, Turkey
2160-9381
psoriasis
en
e2022166
COVID-19 Knowledge in Patients with Psoriasis Receiving Systemic Therapy: A Questionnaire Study
https://dpcj.org/index.php/dpc/article/download/2142/1771
  COVID-19 Knowledge in Patients with Psoriasis
 Receiving Systemic Therapy: a Questionnaire Study
                                             Sinan Özçelik1, Fatma Arzu Kılıç2


1 Department of Dermatology, Faculty of Medicine, Başkent University, Adana Dr. Turgut Noyan Application and Research Center,
  Adana, Turkey
2 Department of Dermatology, Faculty of Medicine, Balıkesir University, Balıkesir, Turkey



Key words: COVID-19, coronavirus, pandemic, psoriasis
Citation: Özçelik S, Kılıç FA. COVID-19 Knowledge in Patients with Psoriasis Receiving Systemic Therapy: A Questionnaire Study.
Dermatol Pract Concept. 2022;12(4):e2022166. DOI: https://doi.org/10.5826/dpc.1204a166
Accepted: January 17, 2022; Published: October 2022
Copyright: ©2022 Özçelik et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Sinan Özçelik, MD, Başkent University, Adana Dr. Turgut Noyan Application and Research Center, Department of
Dermatology, Adana, Turkey. Phone: 90-322-458-6868, E-mail: sinozc@gmail.com




  ABSTRACT             Introduction: Little is known about the impact of patient behavior on the treatment of psoriasis in
                       the COVID-19 pandemic.
                       Objectives: We aimed to investigate the COVID-19 knowledge of the patients with psoriasis receiving
                       systemic therapy in the pandemic.
                       Methods: The patients who received systemic treatment for psoriasis presented to our dermatology
                       outpatient clinic were enrolled in the study. A questionnaire measuring the level of knowledge about
                       COVID-19 and psoriasis was administered to patients. Demographics and disease characteristics of
                       patients were recorded.
                       Results: A total of 183 patients with psoriasis were enrolled in the study. Of the patients, 33.9%
                       thought that psoriasis exposes them to a risk of getting COVID-19, 30.6% declared that psoria-
                       sis treatment exposes them to a risk of getting COVID-19, and 59.6% were worried about getting
                       COVID-19. The treatment discontinuation rate was 42.1%. The patients with high scholar level
                       showed more anxiety and discontinued their treatment.
                       Conclusions: The patients with psoriasis did not have adequate knowledge of the effect of both psori-
                       asis itself and its treatment on COVID-19 during the pandemic. The patients on biologic therapy tend
                       to discontinue their treatment based upon the physician’s recommendation, whereas those on conven-
                       tional therapy mostly on their own will. Clinicians should inform patients about current evidence of
                       COVID-19 and psoriasis.




Original Article | Dermatol Pract Concept. 2022;12(4):e2022166                                                                       1
Introduction                                                      whose score less than 10 was classified as mild psoriasis, and
                                                                  those with a score greater than 10 was classified as severe
Psoriasis is a chronic, immune-mediated disease that waxes        psoriasis. This was also carried out for DLQI scores. Types
and wanes with flareups. Most of the systemic therapies for       of psoriasis therapy were divided into conventional and bio-
psoriasis that are frequently used have immunosuppressive         logical treatments.
properties [1]. Since the World Health Organization (WHO)            Approval for the study was obtained from the local eth-
pronounced the COVID-19 (Coronavirus disease 2019) pan-           ics committee (Decision number 2020/111; 07/22/2020). All
demic on March 11, 2020, there have been health service           participants information was kept confidential and was used
disruptions in the follow-up of chronic diseases such as pso-     only for research purposes.
riasis. Transformation of many hospitals into a COVID-19
center during the pandemic, reassignment of health workers        Statistical Analysis
to COVID-19 services resulted in disruptions in treatment         Statistical analyses were performed using SPSS software
for chronic diseases [2]. Psoriasis patients faced difficulties   (­Version 22.0, IBM Corp). The variables were investigated us-
in accessing to medical care and routine follow-ups. Besides,     ing visual (histograms, probability plots) and analytical meth-
it is not difficult to guess that patients with psoriasis who     ods (Kolmogorov-Simirnov test with Lilliefors significance
are taking particularly certain systemic medications that af-     correction) to determine whether they are normally distrib-
fect the immune system might have concerns about getting          uted. Descriptive analyses were presented using means and
infected during the pandemic [3]. It has been observed that       standard deviations for normally distributed variables, me-
some patients on systemic therapy discontinued their treat-       dians, and minimum-maximum values for the non-normally
ment because of the fear of getting infected by COVID-19          distributed variables. The Chi-square test or Fisher exact test
[4]. However, there are few data showing how patients with        (when chi-square test assumptions do not hold due to low ex-
psoriasis receiving systemic treatment are affected by pan-       pected cell counts), where appropriate, was used to compare
demic and which way they prefer in their treatment decision       these proportions in different groups. A P of less than 0.05
making for psoriasis.                                             was considered to show a statistically significant result.


Objectives                                                        Results
We aimed to investigate the COVID-19 knowledge, attitude,         A total of 183 patients were included in the study. Ninety-one
and practice of the patients with psoriasis receiving systemic    of all patients were female (49.7%) and 111 were male
therapy in the COVID-19 pandemic.                                 (50.3%). The mean age of all patients was 45.85 ± 14.13
                                                                  years (Table 1). Demographic and disease characteristics of
Methods                                                           the patients are shown in Table 1. All patients completed
                                                                  the questionnaires (COVID-19 and DLQI). The distribution
The study was designed as a descriptive cross-sectional           of the answers given by the patients to the questionnaire is
study. The psoriasis patients receiving systemic therapy pre-     shown in Table 2.
sented to the dermatology outpatient clinic of our hospital          A small number of statistically significant differences
between March 2020 and June 2021 were enrolled in the             were found in the analysis of the effect of patients character-
study. A questionnaire consisting of 12 questions measuring       istics (gender, education level, working status, PASI, DLQI,
the level of knowledge about COVID-19 and their treatment         joint involvement, and type of treatment) on COVID-19
for psoriasis was administered to patients giving verbal con-     knowledge. Statistically significant differences between the
sent (Table 2). Sociodemographic (age, gender, education          groups in terms of the answers to the questionnaire are sum-
level, working status) and disease characteristics (duration,     marized in Table 3.
PASI (Psoriasis Area Severity Index), DLQI (Dermatology              No statistically significant difference was found between
Life Quality Index), joint involvement, type of treatment) of     those who work and those who do not in terms of having
the patients were recorded.                                       concerns about contracting COVID-19. No statistically
    It was investigated whether there was any effect of pa-       significant difference was found between certain groups in
tients’ characteristics (gender, education level, working sta-    terms of answers to questions 4, 7, 8, 9.
tus, PASI, DLQI, joint involvement, and type of treatment)           While most of the patients on biologic therapy discontin-
on COVID-19 knowledge. Education level was divided into           ued their treatment based upon physician recommendation,
two groups as: low scholarity (primary + middle school) and       those on conventional therapy made the decision mostly on
high scholarity (high school + university). All patients were     their own will (Table 3). Secukinumab and methotrexate were
divided into two groups based on PASI scores. The patients        the most frequently discontinued drugs in all patients (Table 4).


2                                                                     Original Article | Dermatol Pract Concept. 2022;12(4):e2022166
                 Table 1. Demographic and clinical characteristics of the patients (N = 183).
                                                  Characteristic
 Female, N (%)                                                                                           91 (49.7%)
 Male, N (%)                                                                                             92 (50.3%)
 Age (year), mean ± SD                                                                                   45.85±14.13
 Education level, N (%)
 Primary school                                                                                          71 (38.8%)
 Middle school                                                                                           27 (14.8%)
 High school                                                                                             43 (23.5%)
 University                                                                                               42 (23%)
 Employment status, N (%)
 Working                                                                                                 94 (51.4%)
 Nonworking                                                                                              89 (48.6%)
 Disease characteristics
 Duration of psoriasis (year), mean ± SD                                                                 13.32±9.41
 Psoriatic arthritis, N (%)                                                                              46 (25.1%)
 PASI, median (min-max)                                                                                  4.5 (0-35.3)
 DLQI, median (min-max)                                                                                   14 (2-36)
 Conventional therapies, N (%)
 Acitretin                                                                                               20 (10.9%)
 Methotrexate                                                                                            83 (45.4%)
 Cyclosporine                                                                                             9 (4.9%)
 Biologic therapies, N (%)
 Etanercept                                                                                               2 (1.1%)
 Infliximab                                                                                               6 (3.3%)
 Adalimumab                                                                                               12 (6.6%)
 Ustekinumab                                                                                              17 (9.3%)
 Secukinumab                                                                                              17 (9.3%)
 Ixekizumab                                                                                               17 (9.3%)

DLQI = Dermatology Life Quality Index; PASI = Psoriasis Area Severity Index; SD = standard deviation.


                    Table 2. Distribution of answers given by patients to the questionnaire.
                                   Questions                                                 Answers    Patient, N (%)
 1. Do you think having psoriasis put you at risk for COVID-19?                   Yes                     62 (33.9)
                                                                                  No                      90 (49.2)
                                                                                  Don’t know              31 (16.9)
 2. Do you think psoriasis treatment put you at risk for COVID-19?                Yes                     56 (30.6)
                                                                                  No                      82 (44.8)
                                                                                  Don’t know              45 (24.6)
 3. Do you have any concern that you may contract COVID-19?                       Yes                     109 (59.6)
                                                                                  No                      74 (40.4)
 4. Where would you like to have your psoriasis treatment?                        Home                    120 (65.6)
                                                                                  Hospital                 42 (23)
                                                                                  Don’t know              21 (11.5)
 5. Do you think going to the hospital put you at increased risk of con-          Yes                     123 (67.2)
    tracting COVID-19?                                                            No                       44 (24)
                                                                                  Don’t know               16 (8.7)

                                                                                                         Table 1 continues



Original Article | Dermatol Pract Concept. 2022;12(4):e2022166                                                           3
           Table 2. Distribution of answers given by patients to the questionnaire. (continued)
                                Questions                                              Answers                 Patient, N (%)
 6. Has anyone in your family or friends had COVID-19?                       Yes                                   30 (16.4)
                                                                             No                                   144 (78.7)
                                                                             Don’t know                             9 (4.9)
 7. How is COVID-19 transmitted?                                             Respiratory                           108 (59)
                                                                             Contact                               16 (8.7)
                                                                             All (Respiratory+ Contact)            54 (29.5)
                                                                             Don’t know                             5 (2.7)
 8. What are the symptoms of COVID-19?                                       Fever                                154 (84.2)
                                                                             Sore throat                          121 (66.1)
                                                                             Cough                                127 (69.4)
                                                                             Dyspnea                              113 (61.7)
                                                                             Loss of smell                         108 (59)
                                                                             Fatigue                                97 (53)
                                                                             All                                   89 (48.6)
                                                                             Don’t know                             6 (3.3)
 9. Which symptom(s) do you have make you think that you might have          Fever                                  64 (35)
    COVID-19 and seek medical attention?                                     Sore throat                           29 (15.8)
                                                                             Cough                                 37 (20.2)
                                                                             Dyspnea                               26 (14.2)
                                                                             Loss of smell                         19 (10.4)
                                                                             Fatigue                                9 (4.9)
                                                                             All                                   85 (46.4)
                                                                             Don’t know                             6 (3.3)
 10. Has your psoriasis treatment been discontinued during the               Yes                                   77 (42.1)
     pandemic?                                                               No                                   106 (57.9)
 11. What was the reason for discontinuation of your treatment?              On my own will (patient)              35 (19.1)
                                                                             Physicianrecommendation               40 (21.9)
                                                                             Adverse effect                         2 (1.1)
 12. How long have you been without treatment?                               One week                                0 (0)
                                                                             Two weeks                              1 (0.5)
                                                                             Three weeks                            2 (1.1)
                                                                             Four weeks                             5 (2.7)
                                                                             Eight weeks                           15 (8.2)
                                                                             Twelve weeks                          36 (19.7)
                                                                             Over twelve weeks                     18 (9.8)




    The most common duration that patients remain with-          Many hospitals in our country have been transformed into
out treatment was 12 weeks, followed by over 12 weeks,           COVID-19 centers, health workers have been reassigned to
8 weeks, and 4 weeks (Table 5). No statistically significant     COVID-19 services, and it has been aimed to reduce the ad-
difference was found between the medications in terms of         mission of patients without urgent conditions to health in-
duration of treatment discontinuation.                           stitutions as much as possible. Therefore, there were health
                                                                 service disruptions in the follow-up of chronic diseases that

Conclusions                                                      require regular follow-up, such as psoriasis. In addition to
                                                                 pandemic measures and restrictions, many psoriasis patients
Since the beginning of the pandemic, the ability of health       discontinued their ongoing treatments or applied their treat-
systems to manage chronic diseases has been impacted.            ments improperly due to the fear of getting infected. Various



4                                                                    Original Article | Dermatol Pract Concept. 2022;12(4):e2022166
             Table 3. Comparison of certain groups in terms of the answers to the questionnaire.
                           Answers                                                        Groups                                 P
 Q1: Yes, having psoriasis put me at risk for COVID-19.          Mild psoriasis                Severe psoriasis                0.04
                                                                 (PASI < 10)                   (PASI > 10)
                                                                 Psoriatic arthritis           Psoriatic arthritis             0.01
                                                                 (-)                           (+)
 Q2: Yes, psoriasis treatment put me at risk for                 Mild psoriasis                Severe psoriasis (PASI          0.04
 COVID-19                                                        (PASI < 10)                   > 10)
 Q2: No, I don’t think psoriasis treatment put me at risk        Severe psoriasis (DLQI        Mild psoriasis                  0.02
 for COVID-19                                                    > 10)                         (DLQI < 10)
                                                                 Conventional treatment        Biological treatment            0.01
 Q3. Yes, I have concerns about contracting COVID-19.            High scholarity               Low scholarity                  0.01
 Q5. Yes, going to the hospital put me at increased risk         Female                        Male                            0.03
 of contracting COVID-19.
 Q6. Yes, some of my family and friends have had                 Severe psoriasis (DLQI        Mild psoriasis                  0.01
 COVID-19.                                                       > 10)                         (DLQI < 10)
 Q10. Yes, my psoriasis treatment has discontinued               Biological                    Conventional                    0.01
 during the pandemic.                                            treatment                     treatment
 Q12. I discontinued treatment.                                  Conventional                  Biological                      < 0.01
                                                                 treatment                     treatment
                                                                 High scholarity               Low scholarity                  0.01
 Q12. My doctor recommended that I stop treatment                Biological                    Conventional                    < 0.01
                                                                 treatment                     treatment
                                                                 Low scholarity                High scholarity                 0.01
 The group in which a statistically significant difference was found in favor of itself is shown in bold.

DLQI = Dermatology Life Quality Index; PASI = Psoriasis Area Severity Index.


      Table 4. Distribution of the reasons for treatment discontinuation according to medications.
                                      Patient will         Physician recommendation           Adverse effect            TOTAL
 Acitretin                                  2                              3                          0                    5
 Methotrexate                              19                              9                          1                   29
 Cyclosporine                               2                              2                          0                    4
 Conventional (Total)                      23                             14                          1                   38
 Etanercept                                 0                              0                          0                    0
 Infliximab                                 1                              4                          1                    6
 Adalimumab                                 5                              4                          0                    9
 Ustekinumab                                2                              3                          0                    5
 Secukinumab                                3                              8                          0                   11
 Ixekizumab                                 1                              7                          0                    8
 Biological (Total)                        12                             26                          1                   39
 Total                                     35                             40                          2                   77


studies on psoriasis and COVID-19 are available in the liter-             In the present study, 33.9% of the patients stated that pso-
ature [5-7]. These studies primarily focus on the management          riasis exposes them to a risk of getting COVID-19, whereas
of psoriasis during the pandemic, and the effects of psori-           49.2% responded that there was no risk, and 16.9% did not
atic disease itself and systemic treatments on COVID-19.              know. In addition, mostly patients with mild psoriasis (PASI
There are few studies on the knowledge of psoriasis patients          <10 and without arthritis) declared that psoriasis exposes
about COVID-19. In this study, we aimed to investigate the            them to a risk of getting COVID-19. In a study including pso-
COVID-19 knowledge of the patients with psoriasis and how             riasis (N = 51), atopic dermatitis (N = 22), and hidradenitis
they address their psoriasis treatment during the pandemic.           suppurativa (N = 25) patients, 28.6% patients thought that



Original Article | Dermatol Pract Concept. 2022;12(4):e2022166                                                                          5
                      Table 5. Duration of treatment discontinuation according to drugs.
                              1 week       2 weeks       3 weeks       4 weeks       8 weeks        12 weeks        > 12 weeks
 Acitretin                        0            0             0             1             0               2                 2
 Methotrexate                     0            0             2             1             7              14                 5
 Cyclosporine                     0            0             0             1             0               1                 2
 Conventional (Total)             0            0             2             3             7              17                 9
 Etanercept                       0            0             0             0             0               0                 0
 Infliximab                       0            0             0             0             1               4                 1
 Adalimumab                       0            0             0             2             1               4                 2
 Ustekinumab                      0            0             0             0             3               2                 0
 Secukinumab                      0            1             0             0             1               5                 4
 Ixekizumab                       0            0             0             0             2               4                 2
 Biological (Total)               0            0             0             2             8              19                 9
 Total                            0            1             2             5            15              36               18



their disease expose them to a moderate-to-severe risk to con-     between patients with severe and mild psoriasis in terms of
tract COVID-19 [4]. It is not exactly known that the effects       having a family history of COVID-19. The patients with
of psoriasis on contracting COVID-19. However, existing lit-       severe psoriasis may have avoided seeking medical atten-
erature generally suggest that psoriasis patients have similar     tion because of increased anxiety since their relatives had
rates of COVID-19 infection as the general population [8].         COVID-19. Further investigation is needed on this issue.
    In our study, 30.6% of the patients declared that psori-          In our study, 59.6% of the patients were worried about
asis treatment exposes them to a risk of getting COVID-19,         contracting COVID-19. Bragazzi et al. reported that this rate
whereas 44.8% responded that there was no risk, and 24.6%          was 79.6% [4]. The relatively low rate in our study may
did not know. Patients on conventional therapies were more         be related to the limited knowledge of our patients about
than those on biologics among the patients who thought             COVID-19. Further, patients with high scholarity level were
that psoriasis treatments do not expose them to a risk of          more than those with low scholarity level among the patients
contracting COVID-19. Similarly, patients with high DLQI           who have concern about getting COVID-19 (P = 0.01). It
(> 10) were more than those with low DLQI (< 10) among             seems that the increase in knowledge affects attitude. The
the patients who thought that psoriasis treatments do not          patients with high scholarity may be looking up more infor-
expose them to a risk of contracting COVID-19. However,            mation on COVID-19.
patients with low PASI (< 10) were more than those with               In our study, 65.6% of the patients declared that they
high PASI (> 10) among the patients who thought that psori-        would like to have their psoriasis treatment at home, whereas
asis treatments expose them to a risk. Bragazzi et al. reported    23% prefer the hospital, and 11.5% did not know. In ad-
that 8.1% of patients thought that biologics expose them to        dition, 67.2% of patients stated that going to the hospital
a risk to contract COVID-19 [4]. In our study, this rate was       put them at increased risk of contracting COVID-19, 24%
13.1%. It remains unclear if treatments for psoriasis affect       responded that there was no risk, and 8.7% did not know. It
the risk of contracting COVID-19. Based on the available           may be related that the patients who have inadequate knowl-
evidence, treatments for psoriasis do not meaningfully alter       edge of COVID-19 and the low number of people around
the risk of contracting COVID-19 [8].                              them who had COVID-19 (16.4%).
    Our patients had not adequate knowledge of the effect of          Most of our patients had adequate knowledge and
both psoriasis itself and its treatment on COVID-19 to cope        awareness about the symptoms of COVID-19 and how it
with psoriasis during the pandemic. Doctors are the most           transmits (Table 2). This is most likely related that there has
reliable source of health information for patients. In addition    been a lot of easy-to-read information sharing on COVID-19
to the fact that doctor-patient interactions have been nega-       everywhere since the beginning of the pandemic.
tively impacted in the pandemic, the patients may not have            The treatment discontinuation rate was 42.1% and
requested information about COVID-19 from their physi-             physician recommendation was the most common reason
cians and/or the physicians may not have provided adequate         of the treatment discontinuation in our study (Table 2).
information.                                                       In our clinic, we tried to reach out to all our patients re-
    Thirty out of 183 patients had a history of COVID-19           ceiving immunosuppressive drugs at the beginning of the
in the family. A statistically significant difference was found    pandemic. Despite the lack of information on how exactly



6                                                                      Original Article | Dermatol Pract Concept. 2022;12(4):e2022166
immunosuppressive drugs should be used in the treatment            those on conventional therapy mostly on their own will.
of psoriasis in the early days of the pandemic, every patient      Clinicians should inform patients about current evidence of
who we reached out was evaluated for the risk: benefit ratio       psoriasis and COVID-19.
of immunosuppressive treatment. In this way, shared deci-
sion-making between clinician and patient was carried out.
The uncertainty in the early days of the pandemic may have         References
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Original Article | Dermatol Pract Concept. 2022;12(4):e2022166                                                                        7
