A cross‐sectional study of dermatologists' attitudes towards COVID‐19 vaccination in patients with immunobullous diseases

Abstract

Dear Editor, International experts released recommendations regarding COVID‐19 vaccination for patients with autoimmune bullous diseases (AIBDs) in March 2021. 1 Here, we evaluated knowledge, perceptions and attitudes of dermatologists regarding usage of COVID‐19 vaccines for this patient cohort. Dermatologists taking care of AIBD patients, who were recruited from the database of the International Pemphigus and Pemphigoid Foundation, were asked to complete a COVID‐19 vaccination‐related, web‐based survey between 1 May 2022 and 30 June 2022. The online poll was adapted with minor modifications from Hasseli et al. 2 Electronic informed consent was obtained, and the questionnaire was completed anonymously. The study was granted an exemption by the Institutional Review Board of the University of Southern California. One hundred and eighty‐four emailed invitations were made to complete our survey, and valid questionnaires were collected from a total of 30 dermatologists (16.3%) [19 male and 11 female, aged 33–71 years (median 49.5)] from North America (n = 17, 56.7%), Europe (n = 7, 23.3%), Asia (n = 4, 13.3%), Africa (n = 1, 3.3%) and an unlisted location (n = 1, 3.3%). Workplaces included University hospital (n = 26, 86.7%), private practice (n = 3, 10%) or both (n = 1, 3.3%), with 29 (96.7%) physicians being involved in research. Work experience was 5–10 years (n = 4, 13.3%), 11–20 years (n = 10, 33.3%), 21–30 years (n = 10, 33.3%) and >30 years (n = 6, 20.0%). Twenty‐seven (90)% reported to be at least confident in handling issues of COVID‐19 vaccination, and 29 (96.7%) would recommend COVID‐19 vaccination (preferentially mRNA vaccines), although 12 (40.0%) believed in an association between SARS‐CoV‐2 vaccination and induction/triggering of AIBDs. The majority would continue systemic corticosteroids regardless of the dose during immunization, and half would recommend changes in certain immunomodulatory treatments (i.e. mainly rituximab, methotrexate, mycophenolate and azathioprine) before and/or after COVID‐19 vaccination (Table 1). TABLE 1 Results of the COVID‐19 vaccination questionnaire. Information sources for COVID‐19 vaccination (multiple selection possible) Communication among colleagues 27 (90%) Dermatologic societies (e.g. American Academy of Dermatology, European Academy of Dermatology and Venereology) 25 (83.3%) Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO) 23 (76.6%) Online research 21 (70.0%) General media (newspapers, television, radio) 14 (46.7%) Training 10 (33.3%) Patients asking for information about COVID‐19 vaccination Nearly every patient 13 (43.3%) >50% 10 (33.3%) <50% 6 (20.0%) None 1 (3.3%) Self‐assessment regarding handling COVID‐19 vaccination in AIBD patients Confident 18 (60.0%) Very confident 9 (30.0%) Uncertain/undecided 3 (10.0%) General recommendation of COVID‐19 vaccination for AIBD patients Yes 29 (96.7%) Uncertain 1 (3.3%) Self‐vaccination against COVID‐19 Yes 30 (100%) Preferred type of COVID‐19 vaccines for AIBD patients (multiple selection possible except for ‘no preference’) Pfizer‐BioNTech 23 (76.7%) Moderna 21 (70.0%) AstraZeneca 1 (3.3%) Johnson & Johnson 0 (0%) Other 3 (10.0%) No preference 5 (16.7%) Believe that COVID‐19 vaccines can induce a new‐onset AIBD or trigger a flare of an existing AIBD Yes 12 (40.0%) No 7 (23.3%) Uncertain 11 (36.7%) Recommendation of COVID‐19 vaccination for AIBD patients who are taking systemic corticosteroids such as oral prednisone/prednisolone Yes, regardless of the dose 20 (66.7%) Yes, depending on the dose 10 (33.3%) Recommendation or acceptance of the prednisone/prednisolone dose during COVID‐19 vaccination (multiple selection possible) <5 mg/day 6 (60.0%) 5–10 mg/day 7 (70.0%) 11–15 mg/day 6 (60.0%) >15 mg/day 5 (50.0%) Recommendation of any changes in at least one immunomodulatory treatment (i.e. azathioprine, colchicine, dapsone, doxycycline, immunoadsorption/plasmapheresis, intravenous immunoglobulins, methotrexate, mycophenolate, and/or rituximab) before and/or after COVID‐19 vaccination Yes 15 (50.0%) No 11 (36.7%) Uncertain 4 (13.3%) Changes in therapy due to COVID‐19 vaccination (i.e. pause before vaccination, pause after vaccination, pause before and after vaccination, dose reduction before vaccination, no changes, respectively; multiple selection possible except for ‘no changes’) Azathioprine 4 (26.7%), 1 (6.7%), 6 (40.0%), 0 (0%), 6 (40.0%) Colchicine 2 (13.3%), 0 (0%), 1 (6.7%), 1 (6.7%), 12 (80.0%) Dapsone 1 (6.7%), 0 (0%), 1 (6.7%), 1 (6.7%), 13 (86.7%) Doxycycline 0 (0%), 0 (0%), 1 (6.7%), 1 (6.7%), 14 (93.3%) Immunoadsorption/plasmapheresis 1 (6.7%), 2 (13.3%), 4 (26.7%), 1 (6.7%), 8 (53.3%) Intravenous immunoglobulins 2 (13.3%), 0 (0%), 2 (13.3%), 1 (6.7%), 11 (73.3%) Methotrexate 4 (26.7%), 4 (26.7%), 7 (46.7%), 1 (6.7%), 3 (20.0%) Mycophenolate 2 (13.3%), 2 (13.3%), 6 (40.0%), 1 (6.7%), 5 (33.3%) Rituximab 6 (40.0%), 3 (20.0%), 8 (53.3%), 1 (6.7%), 1 (6.7%) Although limited by a low number of participants and selection bias (i.e. dermatologists interested in AIBDs), this is the first survey research to investigate the opinion of dermatologists on COVID‐19 vaccines in AIBD patients. It shows that virtually all participating dermatologists across different countries supported SARS‐CoV‐2 vaccination for their AIBD patients, implicating that some concerns of potentially promoting immunobullous disease activity through vaccination were outweighed by the risk of contracting life‐threatening COVID‐19. 3 They advocated COVID‐19 vaccination also during immunosuppressive treatment with some restrictions including rituximab. Those attitudes are generally in accordance with the previously published expert recommendations for the management of AIBDs during the COVID‐19 pandemic. 1 Similar views were shared by rheumatologists regarding COVID‐19 vaccination in patients with inflammatory rheumatic diseases. 2 Surprisingly, however, several dermatologists preferred to temporarily terminate treatment with mycophenolate and azathioprine around the vaccination time to potentially improve the vaccine response. This has neither been specifically recommended for patients with AIBDs nor for those with rheumatic disorders because of the risk of disease exacerbation according to the respective international guidelines and experts' opinions. 1 , 4 In fact, discontinuation of an effective immunosuppressive treatment particularly by patients with chronic inflammatory immune‐mediated skin diseases has been a concern during the COVID‐19 pandemic. 5 In general, there is currently not enough evidence to support modifying treatment of systemic autoimmune diseases before or after SARS‐CoV‐2 vaccination with a few exceptions. 6 In detail, based on viewpoints of the Chinese Rheumatology Association, the American College of Rheumatology and The European League Against Rheumatism, a temporary hold of therapy in the perivaccination period has been limited to patients treated with methotrexate, JAK inhibitors, abatacept, cyclophosphamide (intravenous) and rituximab. 4 Taken together, our preliminary study indicates that basic recommendations on SARS‐CoV‐2 vaccination in AIBD patients were generally well perceived by international dermatologists, but also highlights the need for optimized decision‐making regarding modification of certain immunomodulatory therapies around COVID‐19 vaccination based on most current positions of scientific societies and newly generated objective data. FUNDING INFORMATION None. CONFLICT OF INTEREST R. Strong is a paid employee of the International Pemphigus and Pemphigoid Foundation; all other authors declared no conflicts of interest.