Psoriasis and Covid-19 – Increased Risks in Autoimmunity

There are many things that increase your risk of contracting Coronavirus Disease 2019 (or simply Covid-19). Psoriasis and Covid-19 however present unique and combined risks(1) for co-morbid fatalities when this viral, pneumonia-like infection takes hold.

Psoriasis and Covid-19 – Increased Risks in Autoimmunity | TreatPsoriasis.com

Covid-19 is transmitted through contact with wet membranes and bodily fluids. The most common of these are the eyes, mouth, nose, and sweat(2). These are challenging times, especially when your psoriasis flares happen on the top half of your body.

Some evidence in extremely rare cases exists that Covid-19 can be transmitted through blood and feces(3) but conclusive research remains lacking in larger studies.

What are some symptoms of Covid-19?

Symptoms vary, and have varying degrees of severity.

Those with mild-to-moderate symptoms are said to recover without lingering effects, while those with the most serious or severe symptoms may develop Covid-19 pneumonia-like symptoms, a potentially fatal form of the viral infection.

Psoriasis and Covid-19 – Increased Risks in Autoimmunity | TreatPsoriasis.com
Symptoms and severity of Covid-19 infection (4)

DID YOU KNOW?
Covid-19 is the seventh known Coronavirus to infect humans

Source: Nature.com (5)

How Covid-19 infects your body

SARS-CoV-2, the virus that causes the novel (or new) COVID-19 infection, is part of the Coronavirus thread of infections, which are classified under four strains. Within these four classifications, seven (known) viruses can infect human beings.

  • alpha
  • beta
  • gamma
  • delta

Covid-19 is not a new type of virus, simply a new strain of other, similar viral threats such as MERS (Middle East Respiratory Syndrome) or SARS (Severe Acute Respiratory Syndrome). Both MERS and SARS are classified as beta strains of the Coronavirus, as is the Covid-19 variant(6).

Psoriasis and Covid-19 – Increased Risks in Autoimmunity | TreatPsoriasis.com
A Century of Coronaviruses (Sources: 7, 8, 9, 10)

An airborne contagion, Covid-19 relies on breathing patterns and air expelled from breathing pathways (the nose and mouth) to attach to wet molecules from another breather within range of the expelled (and moist) molecules in the air. Covid-19 viral molecules attach to the moist particles in the air and are breathed in when you inhale, immediately binding themselves to healthy cells.

When you inhale moist viral particles or are exposed to them via wet membranes (such as the eyes), the two separate sub-units of the viral molecule perform the following actions(11):

  • Sub-unit 1 binds to the angiotensin-converting enzyme 2 (or ACE2)
  • Sub-unit 2 forms a six-helical structure that instigates a structural change to the ACE2 molecule, allowing Covid-19 to bind with the cell.

Angiotensin-converting enzyme 2 (or ACE2) is a vital enzyme found on the surface of human cells that attaches to cell membranes in your arteries, heart, intestines, kidneys, and lungs. ACE2 regulates body processes such as blood pressure, inflammation, and wound healing. At its most basic, ACE2 is produced in reaction to sodium levels in the bloodstream and kidneys(12).

Why “wet” skin lesions increase your risk of Covid-19

In autoimmune skin diseases that present with “wet” skin lesions (such as psoriasis, eczema, or rosacea) on the face, neck, scalp, hands, or upper trunk of the body, the risks of contracting Covid-19 are increased ten-fold because these areas of the body are within range of exhaled moist Covid-19 molecules and are constantly touched – either to relieve the itch or to treat it.

As it is, humans touch their faces upwards of 20 times an hour(13)! That’s once every 3 minutes. Do you know where your hands were 3 minutes ago, and who touched that item in store before you?

Autoimmune diseases such as pustular psoriasis or severe rosacea (where blisters have burst open) create a wet, welcoming environment for viral and bacterial infections to flourish.

In chronic wounds, hospitalization or clinical treatments further increase your risk of infection. Psoriasis, of course, presents with multiple co-morbid conditions that may also exacerbate your open wounds, healing, and recovery time(14).

In addition to this, Covid-19 also results in skin rashes of varying degrees of severity(15). It may not be easy to tell the difference between your psoriasis and an unrelated rash. If your flares seem different or you develop an unrelated skin rash that seems peculiar in any way, seek immediate medical attention.

The link between psoriasis and Covid-19, and other co-morbid conditions

ACE2 is a zinc- and protein-based enzyme that’s predominantly found in your blood vessels, kidneys, intestines, and lungs. Covid quite specifically seeks out this enzyme, which acts as a receptor for the virus in these specific locations within your body, resulting in symptoms such as those seen above.

In psoriasis and other autoimmune conditions, chronic inflammation(16) is the normal state of being for most cells within the affected body. And although research(17) is still relatively new regarding the effects of psoriasis on your lungs, preliminary results indicate that psoriasis puts you at increased risk for chronic obstructive pulmonary disease (or COPD).

DID YOU KNOW?
Studies show that it’s possible to be re-infected by SARS-Cov viruses, due to a considerable reduction in antibodies post recovery

Source: medRxiv.org (18)

COPD presents with almost identical symptoms as the severe Covid-19 infection does. Once the ACE2 receptor has been used to gain viral entry to cells, the receptor is destroyed and viral molecules are replicated. ACE2 has also been identified as the main reason that Covid-19 is so contagious(19).

Broadly speaking, ACE2s role in the human body is to generate Ang 1-7, which regulates and controls inflammation and wound healing, and is a powerful antioxidant and a vasodilator that opens blood vessels and allows blood to flow more freely through the body’s arterial system. 

ACE2 counters the effects of ACE(1), which elevates sodium levels in the kidneys, constricts arteries, and impairs kidney function. ACE2 also regulates pancreatic activity and is closely tied to the development of insulin resistance. Psoriatic patients have a 49-56% elevated risk of developing diabetes.

Diabetes Mellitus is a common co-morbid condition of psoriatic disease, however it is unclear whether psoriasis is an underlying cause of diabetes (in patients with autoimmunity) or vice-versa. Research suggests that a psoriatic patient is six times more likely to develop diabetes (and other metabolic syndrome conditions) than those who do not have psoriasis.

While the CDC reckons that a compromised immune system(20) (enter psoriasis and other autoimmune conditions) might increase your risk of contracting severe Covid-19 disease, results from a UK study in 2020 seem to establish that Covid-19 actually triggers diabetes in previously healthy individuals(21).

Related reading: 8 Health Conditions Linked To Psoriasis

Covid-19, psoriasis, and co-morbid conditions

Estimates place the prevalence of diabetes as a co-morbid condition in 20-50% of all reported cases of Covid-19 patients(22), who are at elevated risk for multi-organ failure, hyperglycaemia, and death. Diabetes also increases levels of inflammatory and chronic pain, elevates immune markers in structural pain, and puts you at risk for just about any infection out there(23).

The role of ACE2 in insulin production is undisputed. A 2020 study published by the Institute of Endocrinology, Diabetes and Metabolism in Israel determined that when ACE2 is downregulated or destroyed in the viral infection stage of Covid-19, the loss of ACE2 triggers insulin resistance and causes acute diabetes in Covid-positive patients. This follows on from a 2009 study on Severe Acute Respiratory Syndrome (SARS), which occurred in 2003.

A 2011 study published in the research journal PLOS ONE indicates that “ACE2 gene deletion promotes age-dependent oxidative stress, autonomic dysfunction and hypertension”(24). In brief, these conditions present as follows:

  • Oxidative stress: An imbalance between free-radical molecules and antioxidant defense molecules that lead to tissue damage.
  • Autonomic dysfunction: A nervous-system disorder that occurs when core nerve fibers that help you survive are damaged, typically presenting with symptoms such as dizziness, chest pain, low blood pressure, either fast, slow, or an irregular heartbeat, being unable to stay upright, and problems with the gastrointestinal system.
  • Hypertension: Otherwise known as high blood pressure, a condition where the blood in your system is forced against artery walls at such high pressure that it leads to stroke or heart disease.

Psoriasis – as an inflammatory, immune-mediated skin condition – is triggered automatically once these immune markers are triggered. A December, 2020, study published in Experimental and Therapeutic Medicine highlights the fact that dermatological complications may worsen in diabetics, and skin diseases such as psoriasis tend to manifest more severely in these instances, when Covid-19 is present in the human body(25)

The British Journal of Dermatology (2020) notes that there is no clear evidence to support the theory that Covid-19 plays a role in inflammatory dermatological conditions like psoriasis. Inconclusively, it is unknown whether skin‐associated changes in patients with Covid‐19 are due to the viral infection or if adverse reactions to Covid‐19 drug management is the cause for these changes(26)

However, Covid-19 certainly creates favourable conditions for inflammatory skin diseases like psoriasis, and may even trigger more severe psoriatic flares. Much more research is needed to verify this, as noted by the authors.

An article published in June 2020 discusses preliminary reports that indicate Covid-19 may present with cutaneous rashes (noticeable changes to your skin color or texture), urticaria (which are usually classified as hives or swelling), and chickenpox-like blisters(27).

Whilst no empirical evidence exists to support the theory that psoriatic patients are at increased risk of contracting Covid-19, the common consensus is that all medications should be maintained whilst no Covid-19 infection is present, and that managed care of comorbid conditions is essential in the fight to remain Covid-19 disease-free.

Diabetic control drugs like Metformin have anti-inflammatory properties to reduce inflammation biomarkers in people with diabetes seem promising in the Covid fight, though more research is needed to confirm this(28).

Immunosuppressive drugs and corticosteroids such as those used in inflammatory bowel disease (or IBD) and psoriasis may be key in limiting the infection severity in Covid-19 patients, however specialists caution against the random use of these drugs.

Author’s Note:

The views and opinions expressed in this article do not negate the fact that wearing a face mask is critical in the Covid-19 fight, as is regular hand-washing and sanitizing of surfaces and objects (such as your mobile phone or shared workspaces), and maintaining a safe social distance from others around you.

Psoriasis and Covid-19 Vaccines: What You Need To Know

There are many myths and a lot of dis-information about vaccinations against Covid-19 being shared online at this time(29). You can track the status of vaccines that have been approved, are in clinical trials, or have been discontinued in your region by visiting the McGill University Interdisciplinary Initiative in Infection and Immunity (MI4) Covid-19 Vaccine Tracker page(30).

Track the Covid-19 vaccine race here.

According to the International Federation of Psoriasis Associations (IFPA), immune-compromised individuals should steer clear of live (or activated) vaccines(31). These are vaccines that were created using a weakened form of a particular virus, such as the chickenpox and measles vaccines(32).

Non-active (or killed-virus) vaccines only use a portion of the bacteria or bacterial protein elements to create a vaccine, and may use different methods to deliver the vaccine. As approved vaccines currently being administered are non-live vaccines, they may safely be given to those using medicines that have an effect on the immune system – unless there are specific contraindications that indicate otherwise.

The National Psoriasis Foundation caught up with Dr. Joel Gelfand, M.D., MSCE, Dermatology and Epidemiology Professor at the University of Pennsylvania and Co-Chair of the NPF COVID-19 Task Force. Watch the brief Q and A video below for answers to commonly asked questions(34), including:

  • Will taking the COVID-19 vaccine weaken my immune system?
  • When I receive the COVID-19 vaccine, should I continue to take my oral or biologic treatment?
  • Will my overactive immune system cancel out the impact of the vaccine?
  • Could taking the vaccine make my psoriasis worsen?
  • Could the side effects from the vaccine impact my psoriasis?

“We recommend that patients with psoriatic disease get the vaccine as soon as it is available to them. Patients may continue their oral or biologic psoriasis or psoriatic arthritis treatment without interruption when receiving these immunizations”

Dr. Joel Gelfand(33)

Sources used in this article:

  1. https://www.healio.com/news/dermatology/20201222/2020-psoriasis-news-includes-covid19-guidelines-meeting-coverage
  2. https://www.forbes.com/sites/jvchamary/2020/09/29/coronavirus-infectious-sweat/?sh=2d717b9c2a85
  3. https://www.cidrap.umn.edu/news-perspective/2020/03/study-covid-19-may-spread-several-different-ways
  4. https://www.who.int/news-room/q-a-detail/q-a-coronaviruses
  5. https://www.nature.com/articles/s41401-020-0485-4
  6. https://www.cdc.gov/coronavirus/types.html
  7. https://eurekamag.com/research/013/304/013304856.php
  8. https://www.sciencedirect.com/science/article/pii/S2590093520300175
  9. https://www.the-scientist.com/news-opinion/a-brief-history-of-human-coronaviruses-67600
  10. https://en.wikipedia.org/wiki/History_of_coronavirus
  11. https://theconversation.com/what-is-the-ace2-receptor-how-is-it-connected-to-coronavirus-and-why-might-it-be-key-to-treating-covid-19-the-experts-explain-136928.
  12. https://academic.oup.com/ndt/article/27/5/1793/1842521
  13. https://www.researchgate.net/publication/271647859_Face_touching_A_frequent_habit_that_has_implications_for_hand_hygiene
  14. https://www.uptodate.com/contents/covid-19-issues-related-to-wound-care-and-telehealth-management
  15. https://www.uptodate.com/contents/covid-19-cutaneous-manifestations-and-issues-related-to-dermatologic-care?topicRef=128115&source=see_link
  16. https://www.ncbi.nlm.nih.gov/books/NBK493173/
  17. https://pubmed.ncbi.nlm.nih.gov/26458363/
  18. https://www.nature.com/articles/s41401-020-0485-4
  19. https://www.tandfonline.com/doi/full/10.1080/09546634.2020.1782819
  20. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
  21. https://www.thelancet.com/journals/landia/article/PIIS2213-8587%2820%2930315-6/fulltext
  22. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(20)30152-2/fulltext
  23. https://www.nature.com/articles/s41430-020-0652-1
  24. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0022682
  25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579812/
  26. https://onlinelibrary.wiley.com/doi/full/10.1111/bjd.19670
  27. https://www.tandfonline.com/doi/full/10.1080/09546634.2020.1782819
  28. https://www.diabetesresearchclinicalpractice.com/article/S0168-8227(20)30382-X/fulltext
  29. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html
  30. https://covid19.trackvaccines.org/trials-vaccines-by-country/
  31. https://ifpa-pso.com/covid-19/vaccines-and-psoriatic-disease/
  32. https://medlineplus.gov/ency/article/002024.htm
  33. https://www.psoriasis.org/covid-19-task-force-vaccine-statement/
  34. https://www.psoriasis.org/watch-and-listen/covid-19-vaccine-q-and-a/

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