NICE COVID-19 guidelines on treatment for dermatological conditions

NICE has published guidelines on treating dermatological conditions with drugs affecting the immune response during the COVID-19 pandemic. Here, Univadis provides a summary of the key recommendations:

General recommendations

• Be aware that patients taking drugs that affect the immune system may have atypical presentations of COVID‑19, for example, patients taking prednisolone may not develop a fever.
• Communicate with patients, their families and carers about their increased risk of severe COVID-19.
• Support their mental health needs, alleviating anxiety and fear.
• Minimise face-to-face contact whenever possible.
• For face-to-face appointments, first screen for COVID-19 symptoms by phone. Advise that they should contact NHS 111 if they think they have COVID‑19. They should also inform the dermatology team for advice about their immunosuppressive therapies.
• Ask patients to attend face-to-face consultations alone if possible and to avoid public transport.
• Minimise time in the waiting area.
• Consider the resource implications of treatment decisions.

Starting or continuing treatment

When deciding whether to start or continue treatment with drugs affecting the immune response, consider:

• Is it essential to continue or start this drug immediately?
• Is there an alternative treatment with a better risk profile?
• Are monitoring and review feasible?
• Can monitoring be done remotely or less often?
• Are there any changes to the dose, route of administration or mode of delivery that could reduce risk?

Risk stratification

The British Association of Dermatologists has published a risk stratification grid.

The following are considered high risk for COVID-19:

•  Any two agents within the following classes: immunosuppressive medications (e.g. ciclosporin, azathioprine as below), biologics/monoclonals (e.g. anti-TNFs, IL17 agents as below) or novel small molecule immunosuppressants (e.g.apremilast), with exceptions.
• Corticosteroid dose of ≥20 mg (or 0.5 mg/kg) prednisolone (or equivalent) per day for >4 weeks.
• Corticosteroid dose of ≥5 mg prednisolone (or equivalent) per day for >4 weeks plus ≥1 other immunosuppressant, biologic/monoclonal or novel small molecule immunosuppressants (e.g. JAK inhibitors).
• Cyclophosphamide at any dose orally or if received IV dose within last 6 months.
• Rituximab or infliximab when prescribed primarily for skin conditions.

Topical treatment

• In patients with known or suspected COVID‑19, continue topical treatments.
• Consider treating new-onset conditions with topical treatments rather than new systemic treatments that affect the immune system.

Systemic treatment

In patients with known or suspected COVID‑19:

• do not suddenly stop oral corticosteroids.
• continue hydroxychloroquine, chloroquine, mepacrine, dapsone and sulfasalazine.
• consider pausing all other oral immunosuppressive therapies, novel small-molecule immunosuppressants, biological therapies and monoclonal antibodies.

When deciding whether to stop treatment, discuss the risks and benefits with the patient, or their parent or carer

Support

• Provide acute and emergency dermatology advice to GPs to avoid unnecessary hospital attendances.
• Consider pooling resources with other specialities and NHS trusts.