LAUSR

Since the COVID-19 outbreak, different special measures have been applied in dermatological clinics, in order to reduce the spread of infection among both patients and physicians, with a reduction of face to face visits and an improved role given to the teledermatology (1). In this context, there is concern that patients on biologic treatment may be at risk because of COVID infection (2). However, recent articles oppose with this conclusions, showing the safety of biologics used for psoriasis during the COVID-19 era (3,4). As regards the patients treated with biological therapy for atopic dermatitis (AD), it has been showed that there is no evidence that dupilumab, human monoclonal antibody that inhibits the function of interleukin (IL)-4 and IL-13 used for AD, increase the risk of SARS-CoV-2 infection (5). The safety of dupilumab in COVID-19 patients has been reported also by Ferrucci et al. in two patients affected by both AD and COVID-19 (6). Herein we reported our experience of telephone consultations with adult AD patients under dupilumab who would have attended atopic care center of University of Naples Federico II from March 11 2020 to April 22 2020. The consultations were made to prevent patients from leaving their home and crowding the hospital and to continue to monitor their conditions even if they were not able to attend our clinic. The study population consisted of 200 patients (102 females, 51%; mean age 44.01 ± 19.2 years). None of the patients reported a COVID-19 infection confirmed with nasal swab or serological tests. Only 1% (n1⁄4 2) of interviewed patients told us that they have performed a nasopharyngeal swab for SARS-CoV-2 due to a recent contact with an infected patient, showing negative results. No one reported serious symptoms that required hospitalization. Only 3 out of 200 subjects (1.5%) related a positive medical history for fever and/or cough in the last month (mean duration 3.2 days, maximum T: 37.0 C) spontaneously solved without experiencing dyspnea. The 96.5% (n1⁄4 193) of patients regularly continued dupilumab treatment, while 5 (2.5%) patients extended the administration time to 3weeks due to a delay in drug supply. None of the interviewed patients developed or reported a worsening of AD manifestations. According to our experience dupilumab does not seem to expose patients to a higher risk of COVID-19 disease. The pathogenesis of COVID-19 is complex, characterized by an immune response mainly Th1/Th17 (7). The hyper-activation of these cells may cause the release of proinflammatory cytokines that may result in lungs impairment (7). Moreover, the pathways of IL-4 and IL13, which are Th2 cytokines, have not been implicated in host defense mechanism against viral infections (8). Indeed, viral infections, such as respiratory infections, have not been reported as a significant adverse event in clinical trials (8). Therefore, during SARS-CoV infection outbreak of 2002–2003, a significant increase of Th2 cytokines (IL-4, IL-5, IL-10) was observed in fatal cases when compared with recovered patients (9). Thus, biologic discontinuation may unnecessarily increase diseases burden and loss of efficacy of biologic treatments due to the formation of anti-drug antibodies (10). Current evidence suggests that treatment with dupilumab should not be discontinued during COVID-19 pandemic (11). Surely, a careful assessment is mandatory for each individual patient and further studies are needed in order to better characterize the immunologic responses against COVID-19 infection.