Psoriasis, Vaccination, and COVID-19
The COVID-19 pandemic raised urgent questions about whether patients on immunosuppressive biologic therapy were at increased risk of severe infection and whether their treatments would impair vaccine responses.
30.1 COVID-19 Risk on Biologics
Multiple studies and registries found that patients on biologic therapy for psoriasis were not at increased risk of severe COVID-19, and may even have had somewhat better outcomes than the general population. The PsoProtect global registry study found that biologic use was associated with lower odds of COVID-19 hospitalisation (adjusted OR 0.42, 95% CI 0.18-0.98) compared with non-biologic systemic therapy, with 93% of biologic-treated patients fully recovering (Mahil et al., 2021). The leading hypothesis is that patients on biologics had lower baseline systemic inflammation, which may have reduced their risk of the hyperinflammatory phase of COVID-19. The severe COVID-19 cytokine storm is driven primarily by IL-6, IL-1β, and TNF-α. By dampening chronic inflammation, biologics may have inadvertently provided partial protection.
IL-17 and IL-23 inhibitors appeared particularly favourable: large cohort studies showed that these drugs were not associated with increased risk of serious infections. BADBIR registry data had previously established that infliximab specifically carries a higher incidence of serious infections compared with other biologics and non-biologic systemics (Yiu et al., 2019), and the OpenSAFELY platform analysis confirmed that broader immunosuppression was associated with worse COVID-19 outcomes in immune-mediated inflammatory diseases (MacKenna et al., 2022). If you’re on a biologic, current guidelines don’t recommend stopping it during respiratory infections unless your doctor advises otherwise on a case-by-case basis.
30.2 Vaccine Response
A key concern was whether immunosuppressive therapy would impair vaccine responses. The evidence is nuanced:
- Biologics (anti-TNF, anti-IL-17, anti-IL-23): A longitudinal cohort study found that seroconversion after a completed two-dose COVID-19 vaccination course was achieved in 100% of participants on targeted biological therapies, comparable to healthy controls. Antibody titres were numerically slightly lower but not significantly different. Cellular immune responses (T-cell function) were largely unaffected (Mahil et al., 2022).
- Methotrexate was the exception. It consistently impaired antibody responses: only 62% of methotrexate-treated patients achieved adequate antibody response after vaccination, and up to one-third lacked CD8+ T-cell activation (Haberman et al., 2021). Follow-up data confirmed that both methotrexate and TNF inhibitors were associated with reduced long-term immunogenicity (Haberman et al., 2022). Some guidelines recommend temporarily pausing methotrexate for 1-2 weeks after each vaccine dose to optimise response, though this must be weighed against the risk of psoriasis flare.
Current NPF (National Psoriasis Foundation) Delphi consensus recommendations advise continuing biologic therapy without modification when receiving non-live vaccines (including all COVID-19 vaccines) and considering temporary interruption of methotrexate (Gelfand et al., 2021). Live vaccines should generally not be given to patients on biologic therapy, though the risk is primarily theoretical for IL-17 and IL-23 inhibitors.
30.3 Practical Vaccination Guidance for Psoriasis Patients
Based on the evidence above, here is drug-by-drug guidance reflecting current consensus for COVID-19 and other non-live vaccinations:
- IL-23 inhibitors (risankizumab, guselkumab, tildrakizumab) and IL-17 inhibitors (secukinumab, ixekizumab, brodalumab, bimekizumab): Continue without modification. No evidence of impaired vaccine response.
- TNF-α inhibitors (adalimumab, etanercept, infliximab, certolizumab): Continue without modification. Antibody titres may be slightly lower than in untreated individuals but seroconversion rates remain high.
- Ustekinumab: Continue without modification. No significant impairment of vaccine response demonstrated.
- Methotrexate: Consider holding for 1-2 weeks after each vaccine dose to optimise antibody response. This must be balanced against the risk of psoriasis flare during the drug holiday. Patients with stable, well-controlled disease may tolerate the temporary interruption better than those with active disease.
- Apremilast and deucravacitinib: No specific data suggest impaired vaccine response. Continue without modification.
- Cyclosporine: Broad immunosuppression may reduce vaccine efficacy. No specific holding guidance; consider checking post-vaccination antibody titres in immunosuppressed patients.
Timing of vaccination relative to biologic dosing isn’t considered critical for non-live vaccines, though some clinicians prefer to administer vaccines at the midpoint between biologic doses when practical. If you’re about to start biologic therapy, it’s advisable to complete vaccinations (including COVID-19 boosters, influenza, pneumococcal, and herpes zoster vaccines) before initiating treatment where possible.
30.4 General Vaccination Guidance for Immunosuppressed Patients
The lessons from COVID-19 vaccination have reinforced and refined broader vaccination principles for psoriasis patients on immunosuppressive therapy. The National Psoriasis Foundation Medical Board developed 22 consensus statements on vaccination for psoriasis patients, and similar guidance has been issued by the British Association of Dermatologists and European Academy of Dermatology and Venereology (Gelfand et al., 2024).
Key Principles
Vaccination schedules should mirror the general population. Psoriasis patients should receive all age-appropriate vaccinations recommended by national immunisation programmes, including annual influenza, COVID-19 boosters, and routine adult vaccinations. Being on biologic therapy is not a reason to skip or delay non-live vaccines.
Live-attenuated vaccines are generally advised against during biologic treatment. Live vaccines, including MMR (measles, mumps, rubella), varicella, BCG, oral polio, and live-attenuated influenza (nasal spray), carry a theoretical risk of causing disease in immunosuppressed patients. If a live vaccine is required, temporary interruption of biologic therapy is recommended, with timing dependent on the drug’s half-life:
| Biologic Class | Recommended Hold Before Live Vaccine | Restart After Vaccine |
|---|---|---|
| TNF-α inhibitors | 3-5 half-lives (varies by agent) | 2-4 weeks after vaccination |
| IL-17 inhibitors | 3-5 half-lives | 2-4 weeks |
| IL-23 inhibitors | 3-5 half-lives (12+ weeks for risankizumab) | 2-4 weeks |
| Methotrexate | 2 weeks before and after | 2 weeks |
Not all biologics are equally immunosuppressive. IL-17 and IL-23 inhibitors target narrow components of the immune system and carry lower overall infection risk than broad immunosuppressants (e.g., cyclosporine, high-dose corticosteroids). This distinction matters for risk counselling and clinical decision-making.
Specific Vaccine Recommendations
- Influenza: Annual vaccination recommended for all psoriasis patients on systemic therapy. Inactivated (injected) vaccine preferred over live-attenuated (nasal) formulation.
- Pneumococcal: PCV15 or PCV20 followed by PPSV23 (if PCV15 used). Recommended at earlier ages than the general population for patients on immunosuppressive therapy, given increased pneumonia risk.
- Herpes zoster (shingles): The recombinant (non-live) vaccine Shingrix is recommended for patients aged 50+ in the general population, but for immunocompromised patients (including those on biologics) ACIP recommends it from age 19+. Shingrix is safe to administer during biologic therapy. The older live vaccine (Zostavax) should be avoided in immunosuppressed patients.
- Hepatitis B: Pre-treatment screening is mandatory before starting biologics (Section 12). Vaccination is recommended for non-immune patients. Post-vaccination antibody titre testing is advised to confirm seroconversion.
- HPV (human papillomavirus): Recommended per standard age-based guidelines. No specific concerns with biologic co-administration.
Pre-Treatment Vaccination Strategy
The optimal approach is to complete all recommended vaccinations before starting biologic therapy when clinically feasible. This is particularly important for live vaccines (e.g., varicella, MMR boosters if non-immune) and for vaccines where biologic therapy may impair response (e.g., pneumococcal in methotrexate-treated patients). A “vaccination catch-up” visit with your GP or practice nurse before biologic initiation is a good idea.
Research stage: Established. Evidence strength: High. NPF Delphi consensus, BAD guidelines, and post-COVID-19 immunogenicity studies provide robust evidence for these recommendations.