Table I.

NPF COVID-19 TF guidance for management of psoriatic disease during the pandemic: Version 2

Guidance number	Guidance statement	Level of consensus
1.1	It is not known with certainty if having psoriatic disease meaningfully alters the risks of contracting SARS-CoV-2 (the virus that causes COVID-19 illness) or having a worse course of COVID-19 illness. Existing data, with some exceptions, generally suggest that patients with psoriasis and/or psoriatic arthritis have similar rates of SARS-CoV-2 infection and COVID-19 outcomes as the general population.	Moderate
1.2	The likelihood of poor outcomes from COVID-19 is driven by risk factors such as older age and comorbidities such as chronic heart, lung, or kidney disease and metabolic disorders such as diabetes and obesity. Patients with psoriatic disease are more prone to these comorbidities, particularly in those with more severe disease.	High
2.1	It is not known with certainty if treatments for psoriasis and/or psoriatic arthritis meaningfully alter the risks of contracting SARS-CoV-2 (the virus that causes COVID-19 illness) or having a worse course of COVID-19 illness. Existing data generally suggest that treatments for psoriasis and/or psoriatic arthritis do not meaningfully alter the risk of acquiring SARS-CoV-2 infection or having worse COVID-19 outcomes.	Moderate
2.2	It is recommended that patients who are not infected with SARS-CoV-2 continue their biologic or oral therapies for psoriasis and/or psoriatic arthritis in most cases. Shared decision making between clinician and patient is recommended to guide discussions about use of systemic therapies during the pandemic. (See guidance 2.5 for definition of shared decision making.)	High
2.3	Chronic systemic corticosteroids should be avoided if possible for the management of psoriatic arthritis. If patients require chronic systemic corticosteroids for the management of psoriatic arthritis, the dose should be tapered to the lowest dose necessary to achieve the desired therapeutic effect. Chronic systemic corticosteroid use for the treatment of psoriatic disease at the time of acute infection with SARS-CoV-2 may be associated with worse outcomes from COVID-19 illness. It is important to note, however, that corticosteroids may improve outcomes for COVID-19 when initiated in hospitalized patients requiring oxygen treatment.	High
2.4	Individuals newly diagnosed with psoriasis and/or psoriatic arthritis or who are currently not receiving treatment should be aware that untreated psoriatic disease is associated with serious impact on physical and emotional health and, in the case of psoriatic arthritis, can lead to permanent joint damage and disability. Shared decision making between clinician and patient is recommended to guide discussions about use of systemic therapies during the pandemic. (See guidance 2.5 for definition of shared decision making.)	High
2.5	Providers recommend shared decision making with patients. Shared decision making between clinician and patient should be guided by several factors, including the potential benefits of treatment, the activity of skin and/or joint disease and response to previous therapies, as well as the patient's underlying risk for poor COVID-19 outcomes and ability to maintain measures to prevent infection with SARS-CoV-2 such as hand hygiene, wearing of masks, and physical distancing as required by pandemic conditions. A review of known benefits of treatment accompanied by acknowledgment of the uncertainty related to the COVID-19 pandemic and a discussion of a patient's individual circumstances and preferences should guide decision making.	Moderate
3.1	Telemedicine should be offered to manage patients wherever possible when local restrictions or pandemic conditions limit the ability for in-person visits. The following patients can be managed with telemedicine: Patients who are clinically stable and previously started on psoriatic disease treatment. Patients requiring a follow-up visit and refills for medication. New patients without timely access to in-person visits. Patients diagnosed with COVID-19 who are experiencing a significant flare. If telemedicine visits become inadequate to monitor patients' disease progress or manage new or evolving symptoms or signs of skin and joint disease, clinicians and patients should consider in-person visits.	Moderate
3.2	The following patients should be considered for in-person care if pandemic conditions allow (ie, the clinical practice is open to see patients in person) and standard operating procedures are observed (ie, social distancing, hand washing, and masking): Patients at risk for melanoma and nonmelanoma skin cancer should be seen in person at a frequency consistent with the standard of care for a full skin examination. New patients establishing care. Patients experiencing unstable psoriatic disease/flares. Patients requiring a thorough skin/or joint examination and a full physical examination for rheumatology patients.	Moderate
3.3	Providers recommend the recent guidelines published by Lim et al35 on how to optimize safety of office phototherapy for the patients and staff in the setting of the pandemic. See Supplemental Table V for details.	High
4.1	Patients should be advised to follow measures that prevent infection with SARS-CoV-2. These preventative measures include the following: to practice good hand hygiene, to maintain physical distancing from nonhousehold members, and to wear a face covering of the nose and mouth when indoors (except in their own home) and when outdoors but unable to maintain physical distancing. Face coverings should not be used in children under 2 years old due to risk of suffocation. See Supplemental Table VI for details.	High
4.2	Patients with psoriatic disease should follow measures to prevent infection with SARS-CoV-2 in the workplace. If the workplace environment does not allow for the maintenance of prevention measures, a shared decision-making process between the patient and his/her clinician is recommended to determine if specific accommodations are medically necessary, especially for individuals who, due to age or underlying health conditions, are at especially high risk for poor COVID-19 outcomes.	Moderate
4.3	Youth with psoriatic disease should follow measures to prevent infection with SARS-CoV-2 while at school. These measures include maintaining 6 feet of physical distancing, consistently wearing masks if over the age of 2 years, and washing hands frequently. If the school environment is unable to ensure these prevention measures or families believe their child may not be able to adhere to these practices, we encourage discussion with the patient, caregivers, and his/her clinician to collectively develop a learning plan in the best interest and safety of the child.	High
4.4.	Patients with psoriatic disease should receive the seasonal inactivated (eg, killed) influenza vaccine. While this vaccine will not protect against SARS-CoV-2, influenza vaccine lowers the risk of infection from seasonal influenza, which is of special importance to individual and public health during the COVID-19 pandemic. Patients taking systemic medications for psoriasis or psoriatic arthritis should discuss the timing of influenza vaccination with respect to their systemic psoriatic medications with their health care provider in order to optimize the response to the influenza vaccine.	High
4.5	Patients with psoriatic disease who do not have contraindications to vaccination should receive an mRNA-based COVID-19 vaccine as soon as it becomes available to them based on federal, state, and local guidance. Systemic medications for psoriasis or psoriatic arthritis are not a contraindication to the mRNA-based COVID-19 vaccine. If vaccine supply is limited, the TF recommends following the CDC's prioritization guidelines for early vaccination for selected groups based on their comorbidities and work setting (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations-process.html).	High
4.6	It is recommended that patients who are to receive an mRNA-based COVID-19 vaccine continue their biologic or oral therapies for psoriasis and/or psoriatic arthritis in most cases. Shared decision making between clinician and patient is recommended to guide discussions about use of systemic therapies during the pandemic. (See guidance 2.5 for definition of shared decision making.)	High
4.7	For patients with psoriatic disease deciding whether or not to participate in a COVID-19 therapeutic or vaccine clinical trial, the TF recommends that the decision should be made on a case-by-case basis with shared decision making among the patient, researcher, and provider.	High
5.1	Patients with psoriatic disease who become infected with SARS-CoV-2 should monitor their symptoms and discuss the management of their treatments with their health care providers.	Moderate
5.2	Patients with psoriatic disease who become infected with SARS-CoV-2 should be prescribed and adhere to evidence-based COVID-19 therapies. Evidence-based therapies∗ currently include supportive care for all patients and the following: For outpatients: •Bamlanivimab for patients meeting specific criteria and who are at high risk for progressing to severe COVID-19 and/or hospitalization •Casirivimab and imdevimab to be administered together for patients meeting specific criteria and who are at high risk for progressing to severe COVID-19 and/or hospitalization	Moderate
	For hospitalized patients: •Dexamethasone (systemic steroids) for patients meeting specific criteria •Remdesivir treatment for patients meeting specific criteria •Baricitinib, in combination with remdesivir, for patients meeting specific criteria
	The care of the hospitalized patient should include consultation with rheumatologists, dermatologists, and/or infectious disease specialists as medically necessary. ∗Evidence-based therapies are those that have been tested in well-conducted randomized controlled clinical trials and have proven benefit on clinically relevant COVID-19 outcomes.
5.3	Systemic corticosteroids for the management of COVID-19 in patients with psoriatic disease are not contraindicated and should not be withheld due to the concern of potentially flaring psoriasis upon withdrawal of corticosteroids when evidence demonstrates the effectiveness for treating COVID-19 illness.	Moderate
5.4.1	Hydroxychloroquine or chloroquine are not recommended for the prevention or treatment of COVID-19 in patients with psoriatic disease outside of a clinical trial. Cases of psoriasis flare have been reported in patients on antimalarial medications, but the clinical significance is not well understood.	High
5.4.2	At this time, due to insufficient data to recommend for or against the use of convalescent plasma for the treatment of COVID-19 in patients with psoriatic disease, the TF recommends convalescent plasma to primarily be used in the setting of a clinical trial. Outside of a clinical trial, its use may be considered on a case-by-case basis with shared decision making between the patient and provider.	Moderate
5.4.3	Ivermectin is not recommended for the prevention or treatment of COVID-19 in patients with psoriatic disease outside of a clinical trial.	High
5.5	Resumption of psoriasis and/or psoriatic arthritis treatments held during SARS-CoV-2 infection should be decided on a case-by-case basis. Most patients can restart psoriasis and/or psoriatic arthritis treatments after complete resolution of COVID-19 symptoms. In those who have had a severe hospital course, shared decision making made on a case-by-case basis is recommended.	Moderate
5.6	Patients with psoriatic disease should be aware that infection with SARS-CoV-2 may result in a flare of psoriasis based on case reports. The clinical significance of the risk of COVID-19 flaring psoriasis is not known.	Moderate
5.7	Patients with psoriatic disease who become infected with SARS-CoV-2 should follow CDC guidance on home isolation and discuss with their health care providers when they can end home isolation. We recommend waiting a minimum of 10 days after COVID-19 symptom onset, along with fever resolution for 24 hours without antipyretics and improvement in other symptoms, before ending home isolation and returning to work, as patients are unlikely to be infectious after this point. In patients with severe cases of COVID-19 or when psoriasis patients are on medications with immunosuppressive effects, we recommend a case-by-case approach to determining the length of home isolation.	Moderate
5.8	Patients with close contact to someone with SARS-CoV-2 infection should quarantine themselves for 14 days after the last contact and discuss the management of their psoriatic disease treatment with their medical provider(s).	Moderate

CDC, Centers for Disease Control and Prevention; mRNA, messenger RNA; NPF, National Psoriasis Foundation; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; TF, Task Force.