National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease during the pandemic: Version 2Advances in psoriatic disease management, COVID-19 vaccines, and COVID-19 treatments



# Results:
The TF updated evidence for the original 22 statements and added 5 new recommendations. The average of the votes was within the category of agreement for all statements, 13 with high consensus and 14 with moderate consensus.
Limitations: The evidence behind many guidance statements is variable in quality and/or quantity.
Conclusions: These statements provide guidance for the treatment of patients with psoriatic disease on topics including how the disease and its treatments affect COVID-19 risk, how medical care can be optimized during the pandemic, what patients should do to lower their risk of getting infected with severe acute respiratory syndrome coronavirus 2 (including novel vaccination), and what they should do if they develop COVID-19. The guidance is a living document that is continuously updated by the TF as data emerge. ( J Am Acad Dermatol 2021;84:1254-68.) Key words: biologics; COVID-19; psoriasis; psoriatic arthritis; SARS-CoV-2; vaccines.
The COVID-19 pandemic has substantially worsened since the publication of Version 1 of the National Psoriasis Foundation (NPF) COVID- [bib_ref] Prevalence, severity and mortality associated with COPD and smoking in patients with..., Alqahtani [/bib_ref] Task Force (TF) recommendations on September 4, 2020. [bib_ref] National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease..., Gelfand [/bib_ref] In just the ensuing 15 weeks alone, there have been more than an additional 11,100,000 cases and 125,000 COVID-19 deaths in the United States and an additional nearly 50,000,000 cases and more than 800,000 deaths worldwide.Similar to the exponential growth of COVID-19 cases, basic biological and epidemiologic knowledge related to this pandemic have expanded dramatically. In just a few months since our initial recommendations, there have been major advances in the understanding of how to prevent and treat COVID-19 as well as a substantial increase in data to inform management decisions for patients with psoriatic disease during the pandemic. Therefore, this TF is providing updated scientifically based guidance to promote optimal management of psoriatic disease during the pandemic.

# Methods
The methods have been described in detail previously. [bib_ref] National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease..., Gelfand [/bib_ref] Briefly, the COVID-19 TF includes physicians, fellows, and senior NPF staff with a variety of expertise relevant to decision making in the pandemic. The TF reviews COVID-19 literature weekly in relation to psoriatic disease and meets every 2 to 4 weeks to address 5 core questions related to the pandemic. Existing recommendations were updated based on evolving science and were approved by unanimous consent. New recommendations were generated by using a modified Delphi process based on the RAND appropriateness method, including 2 rounds of voting with discussion in between.(Only 1 round was used for new recommendations that achieved high consensus on the first round.) Panel consensus was determined to be low when 5 or more votes fell into the 1-to-3 rating range with 5 or more votes concurrently falling into the 7-to-9 rating range. Consensus was interpreted as high if all 18 votes fell within a single tertile, with all other combinations considered as moderate levels of consensus. The results were analyzed by the NPF with an independent analysis of the data by a nonvoting member of the TF.

# Results
The TF reaffirms the initial 22 guidance statements with updated data and has issued 5 new recommendations [fig_ref] Table I: NPF COVID-19 TF guidance for management of psoriatic disease during the pandemic [/fig_ref] Patients with psoriasis are more prone to thrombosis and comorbidities that portend worse COVID-19 outcomes and may be more susceptible to infection, which raised concerns that they could be at increased risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and worse COVID-19 outcomes. [bib_ref] Psoriasis severity and the prevalence of major medical comorbidity: a populationbased study, Yeung [/bib_ref] [bib_ref] Risk of serious infection, opportunistic infection, and herpes zoster among patients with..., Takeshita [/bib_ref] [bib_ref] The risk of stroke in patients with psoriasis, Gelfand [/bib_ref] [bib_ref] Risk of venous thromboembolism in patients with psoriatic arthritis, psoriasis and rheumatoid..., Ogdie [/bib_ref] [bib_ref] Activated platelets induce endothelial cell inflammatory response in psoriasis via COX-1, Garshick [/bib_ref] Nevertheless, patients with psoriatic disease appear to have similar rates of infection with SARS-CoV-2 and COVID-19 outcomes as the general population, with multiple new studies from Italy, which primarily focused on patients with psoriasis receiving oral or biologic treatment, supporting our initial recommendation (guidance 1.1). [bib_ref] Characteristic of chronic plaque psoriasis patients treated with biologics in Italy during..., Talamonti [/bib_ref] [bib_ref] Incidence rates of hospitalization and death from COVID-19 in patients with psoriasis..., Gisondi [/bib_ref] Additional new studies of patients with psoriatic arthritis (PsA) nested within cohorts of patients with rheumatic disease also suggest that they have similar rates of infection with SARS-CoV-2 and COVID-19 outcomes as the general population. [bib_ref] COVID-19 in French patients with chronic inflammatory rheumatic diseases: clinical features, risk..., Costantino [/bib_ref] [bib_ref] Coronavirus disease 2019 (COVID-19) in autoimmune and inflammatory conditions: clinical characteristics of..., Montero [/bib_ref] [bib_ref] Clinical course, severity and mortality in a cohort of patients with COVID-19..., Nuno [/bib_ref] However, the risk of COVID-19 in autoimmune diseases was higher than in control patients (odds ratio [OR], 2.19; 95% confidence interval [CI], 1.05-4.58) in a meta-analysis of 7 case-control studies. [bib_ref] Prevalence and clinical outcomes of COVID-19 in patients with autoimmune diseases: a..., Akiyama [/bib_ref] The severity of COVID-19 continues to be primarily driven by risk factors such as current smoking, male sex, older age, and underlying comorbidities (guidance 1.2). [bib_ref] Male sex identified by global COVID-19 meta-analysis as a risk factor for..., Peckham [/bib_ref] [bib_ref] Comorbidities and the risk of severe or fatal outcomes associated with coronavirus..., Zhou [/bib_ref] [bib_ref] Rapid epidemiological analysis of comorbidities and treatments as risk factors for COVID-19..., Mckeigue [/bib_ref] [bib_ref] Prevalence, severity and mortality associated with COPD and smoking in patients with..., Alqahtani [/bib_ref] New data confirm that age, male sex, and pre-existing comorbidities are also important drivers of poor COVID-19 outcomes in patients with psoriasis. [bib_ref] Factors associated with adverse COVID-19 outcomes in patients with psoriasisd insights from..., Mahil [/bib_ref] Category 2: What are the effects of psoriasis or PsA treatment on SARS-CoV-2 infection and COVID-19 illness?
The evolving literature reaffirms the TF conclusion that treatments for psoriasis and/or PsA do not appear to meaningfully alter the risk of acquiring SARS-CoV-2 infection or having worse COVID-19 outcomes; therefore, patients who are not infected with SARS-CoV-2 should continue their biologic or oral therapies for psoriasis and/or PsA in most cases (guidance 2.1 and 2.2). COVID-19 hospitalization was more frequent in patients using nonbiologic systemic therapy than in those using biologics (OR, 2.8; 95% CI, 1.3-6.2) in a registry of 374 patients with psoriasis from 25 countries. [bib_ref] Factors associated with adverse COVID-19 outcomes in patients with psoriasisd insights from..., Mahil [/bib_ref] A cohort of 6501 patients with psoriasis on biologics at northern Italian centers showed that the standardized incidence ratio of hospitalization and death in patients with psoriasis compared with those in the general population was 0.94 (95% CI, 0.57-1.45) and 0.42 (95% CI, 0.07-1.38), respectively. [bib_ref] Incidence rates of hospitalization and death from COVID-19 in patients with psoriasis..., Gisondi [/bib_ref] In a study of 12,807 patients with psoriasis on biologics from 33 Italian dermatology centers, 26 (0.25%) had confirmed SARS-COV-2 infection (similar to general population in Italy [0.31%]). [bib_ref] Characteristic of chronic plaque psoriasis patients treated with biologics in Italy during..., Talamonti [/bib_ref] In a study of patients with psoriasis (100 on topical treatment, 80 on biologics) from a single Italian dermatology center, COVID-19 symptoms were more common, but not statistically significant, in the biologic group (OR, 1.22; 95% CI, 0.58-2.58). [bib_ref] Does therapy with biological drugs influence COVID-19 infection? Observational monocentric prevalence study..., Brazzelli [/bib_ref] [bib_ref] Clinical outcomes of COVID-19 in patients taking tumor necrosis factor inhibitors or..., Yousaf [/bib_ref] Similarly, the use of immunosuppressive/ immunomodulating therapy was not associated with an increased risk for COVID-19 in a cohort of 5302 patients with inflammatory bowel disease. [bib_ref] Immunosuppressive therapy and risk of COVID-19 infection in patients with inflammatory bowel..., Burke [/bib_ref] This finding was supported by the Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD) registry, which showed no increase in severe outcomes in patients on TNFi or antieinterleukin (IL) 12/23 monotherapy. [bib_ref] Effect of IBD medications on COVID-19 outcomes: results from an international registry, Ungaro [/bib_ref] Patients with rheumatic disease do not appear to be at higher risk of contracting SARS-CoV-2 infection or of developing severe COVID-19 when on anti-TNF therapy. [bib_ref] Prevalence and clinical outcomes of COVID-19 in patients with autoimmune diseases: a..., Akiyama [/bib_ref] [bib_ref] Antecedent immunosuppressive therapy for immune-mediated inflammatory diseases in the setting of a..., Veenstra [/bib_ref] [bib_ref] Incidence of COVID-19 in a cohort of adult and paediatric patients with..., Michelena [/bib_ref] Nevertheless, uncertainty remains based on the quality of the existing data and lack of detailed analysis of patients at high risk because of age and/or 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 inperson visits.

## Moderate
Continued J AM ACAD DERMATOL VOLUME 84, NUMBER 5 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. 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. . The evolving literature suggests that a short interruption of in-person patient-rheumatologist interactions had no major detrimental impact on the disease course of PsA as assessed by patient-reported outcomes. [bib_ref] Impact of the COVID-19 pandemic on the disease course of patients with..., Ciurea [/bib_ref] Nevertheless, reductions in in-person care during the pandemic may be associated with a delay in diagnosis and treatment of malignancies, including melanoma. [bib_ref] Impact of COVID-19 on cancer care: how the pandemic is delaying cancer..., Patt [/bib_ref] [bib_ref] Delayed melanoma diagnosis in the COVID-19 era: increased Breslow thickness in primary..., Ricci [/bib_ref] Universal masking for staff, clinicians, and patients; restrictions on visitation; and liberal reverse transcription polymerase chain reaction testing of symptomatic and asymptomatic patients are very effective in limiting SARS-CoV-2 spread, with nosocomial transmission exceptionally rare. [bib_ref] Hospital-acquired SARS-CoV-2 infection: lessons for public health, Richterman [/bib_ref] [bib_ref] Incidence of nosocomial COVID-19 in patients hospitalized at a large US academic..., Rhee [/bib_ref] Therefore, patients should be informed that in-person medical care, including phototherapy (guidance 3.3), can be delivered safely with minimal risk of COVID-19 transmission in the clinical setting when safeguards are maintained. [bib_ref] Recommendations for phototherapy during the COVID-19 pandemic, Lim [/bib_ref] [bib_ref] Clinical research after COVID-19: embracing a new normal, Gelfand [/bib_ref] Outbreaks in the clinical setting that have occurred have been due to lack of masking in patient care areas and a lack of distancing among staff while eating unmasked. [bib_ref] Hospital-acquired SARS-CoV-2 infection: lessons for public health, Richterman [/bib_ref] Thus, the TF updated guidance 3.2, emphasizing that standard operating procedures for social distancing, hand washing, and masking be observed in clinical settings.

## Category 4: what should patients with psoriatic disease do to protect themselves from becoming infected with sars-cov-2?
Patients should follow recommended measures to prevent infection with SARS-CoV-2 (guidance 4.1, 4.2, and 4.3).In cases where measures to prevent the transmission of SARS-CoV-2 at work or school cannot be maintained, shared decision making is recommended to determine if specific accommodations are medically necessary (guidance 4.2 and 4.3). In the United States, adherence rates with methods to prevent COVID-19 were lowest among adults aged 18 to 29 years (73%) and highest among those aged older than 60 years (86%). [bib_ref] COVID-19 mitigation behaviors by age groupdUnited States, AprileJune 2020, Hutchins [/bib_ref] An international survey of patients with psoriasis found that rates of COVID-19 prevention measures were slightly higher in those receiving biologics for psoriasis than in those receiving nonbiologic systemic therapies. [bib_ref] Factors associated with adverse COVID-19 outcomes in patients with psoriasisd insights from..., Mahil [/bib_ref] Since our first recommendations, the major advance in protection from COVID-19 is the advent of highly effective vaccines using messenger RNA (mRNA) technology, which results in temporary expression of the SARS-CoV-2 spike protein in human cells after injection, triggering an immune response [fig_ref] Table I: NPF COVID-19 TF guidance for management of psoriatic disease during the pandemic [/fig_ref]. The regimen of 2 doses, 21 days apart, for BNT162b2 (manufactured by Pfizer and BioNTech) conferred 95% protection against COVID-19, with an excellent safety profile similar to that of other viral vaccines, and was granted Emergency Use Authorization (EUA) on December 11, 2020, by the US Food and Drug Administration (FDA). [bib_ref] Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine, Polack [/bib_ref] Similarly, the regimen of 2 doses, 28 days apart, for mRNA-1273 (manufactured by Moderna) conferred 94.5% protection against COVID-19 (FDA EUA pending).Therefore, the TF recommends that 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 (guidance 4.5). Additional vaccine platforms are undergoing testing [fig_ref] Table I: NPF COVID-19 TF guidance for management of psoriatic disease during the pandemic [/fig_ref]. [bib_ref] Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an..., Voysey [/bib_ref] The effect of psoriasis treatment on the efficacy of COVID-19 vaccines is unknown. Based on a review of the literature, methotrexate treatment with doses commonly used in patients with psoriatic disease lowers the humoral response to seasonal influenza and pneumococcal vaccines, and temporary discontinuation of methotrexate for 2 weeks after influenza immunization improves the immunogenicity of the seasonal influenza vaccine. [bib_ref] Impact of temporary methotrexate discontinuation for 2 weeks on immunogenicity of seasonal..., Park [/bib_ref] [bib_ref] A systematic review and metaanalysis of antirheumatic drugs and vaccine immunogenicity in..., Subesinghe [/bib_ref] TNFi and tofacitinib do not significantly affect the humoral immune response to influenza vaccination but have been reported to result in both reduced and sufficient immune responses to the pneumococcal vaccine. [bib_ref] A systematic review and metaanalysis of antirheumatic drugs and vaccine immunogenicity in..., Subesinghe [/bib_ref] [bib_ref] Effects of immunosuppression on immune response to pneumococcal vaccine in inflammatory bowel..., Fiorino [/bib_ref] [bib_ref] Immune responses following administration of influenza and pneumococcal vaccines to patients with..., Kaine [/bib_ref] [bib_ref] T-cell-mediated immune response to pneumococcal conjugate vaccine (PCV-13) and tetanus toxoid vaccine..., Winthrop [/bib_ref] [bib_ref] The effect of tofacitinib on pneumococcal and influenza vaccine responses in rheumatoid..., Winthrop [/bib_ref] Abatacept, [bib_ref] Antibody response to pneumococcal and influenza vaccination in patients with rheumatoid arthritis..., Alten [/bib_ref] ustekinumab,and antieIL-17 treatment [bib_ref] Immunogenicity and safety of vaccination against seasonal influenza vaccine in patients with..., Furer [/bib_ref] [bib_ref] Secukinumab does not impair the immunogenic response to the influenza vaccine in..., Richi [/bib_ref] [bib_ref] Response to tetanus and pneumococcal vaccination following administration of ixekizumab in healthy..., Gomez [/bib_ref] do not interfere with the immune response to either influenza or pneumococcal vaccination, although large prospective studies of vaccine efficacy are lacking. No data were available at the time of analysis for cyclosporine (as used for psoriasis and other inflammatory diseases), antieIL-23 biologics, apremilast, or acitretin on the efficacy of any approved vaccine.
Extrapolating from this literature and based on current available evidence, the TF recommends that patients who are to receive an mRNA-based COVID-19 vaccine continue their biologic or oral therapies for psoriasis and/or PsA during the vaccination period (guidance 4.6). Many trials of COVID-19 treatment and vaccines have excluded Major advances have occurred in the management of SARS-CoV-2 since Version 1 of the TF recommendations. For outpatients meeting specific criteria and at high risk for progressing to severe COVID-19, the use of monoclonal antibodies specifically directed against the spike protein of SARS-CoV-2 are recommended (guidance 5.2). [bib_ref] Structural and functional properties of SARS-CoV-2 spike protein: potential antivirus drug development..., Huang [/bib_ref] [bib_ref] Prepare for the future: dissecting the spike to seek broadly neutralizing antibodies..., Vangelista [/bib_ref] [bib_ref] REGN-COV2, a neutralizing antibody cocktail, in outpatients with Covid-19, Weinreich [/bib_ref] For hospitalized patients meeting specific criteria, in addition to remdesivir and dexamethasone, baricitinib in combination with remdesivir is an option as because reduces recovery time and new infections in hospitalized patients with COVID-19 compared to remdesivir alone. [bib_ref] Baricitinib plus remdesivir for hospitalized adults with Covid-19, Kalil [/bib_ref] However, baricitinib had no mortality benefit, can be prothrombotic, and is recommended only when corticosteroids cannot be used. [bib_ref] Baricitinib plus remdesivir for hospitalized adults with Covid-19, Kalil [/bib_ref] Furthermore, the remdesivir efficacy is modest, and international trials did not find mortality benefit. [bib_ref] Remdesivir for the treatment of Covid-19dfinal report, Beigel [/bib_ref] [bib_ref] Covid-19: remdesivir has little or no impact on survival, WHO trial shows, Dyer [/bib_ref] Additional evidence suggests that hydroxychloroquine is not effective for the prevention or treatment of COVID-19; therefore, the TF emphasizes that its use be restricted to clinical trials (guidance 5.4.1). [bib_ref] Hydroxychloroquine as postexposure prophylaxis to prevent severe acute respiratory syndrome coronavirus 2..., Barnabas [/bib_ref] [bib_ref] A clusterrandomized trial of hydroxychloroquine for prevention of Covid-19, Mitj A [/bib_ref] [bib_ref] Hydroxychloroquine with or without azithromycin in mild-to-moderate Covid-19, Cavalcanti [/bib_ref] [bib_ref] Hydroxychloroquine in nonhospitalized adults with early COVID-19, Skipper [/bib_ref] The evidence that convalescent plasma is effective for COVID-19 is limited despite the FDA EUA; therefore, the TF recommends that it be used primarily in clinical trials (guidance 5.4.2). [bib_ref] Convalescent plasma in the management of moderate covid-19 in adults in India:..., Agarwal [/bib_ref] [bib_ref] A randomized trial of convalescent plasma in Covid-19 severe pneumonia, Simonovich [/bib_ref] Ivermectin has in vitro activity against SARS-CoV-2; however, doses up to 100 times higher than those approved for use in humans would be required to achieve antiviral effects against COVID-19, raising safety concerns even if therapeutic levels could feasibly be achieved. [bib_ref] The FDAapproved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro, Caly [/bib_ref] [bib_ref] COVID-19 and the rush for self-medication and self-dosing with ivermectin: a word..., Molento [/bib_ref] [bib_ref] Deaths associated with ivermectin treatment of scabies, Barkwell [/bib_ref] Therefore, the TF recommends ivermectin be used only in the setting of a clinical trial (guidance 5.4.3).
Based on limited available data and to be consistent with prescribing information, it may be prudent to hold treatments that target the immune system in the setting of suspected or confirmed SARS-CoV-2 infection, but the ultimate decision should be made case by case. Patients with psoriatic disease should be aware that infection with SARS-CoV-2 may result in a flare of psoriasis, including pustular flares (guidance 5.6). [bib_ref] A case of severe psoriatic erythroderma with COVID-19, Ghalamkarpour [/bib_ref] [bib_ref] A case of exacerbation of psoriasis after oseltamivir and hydroxychloroquine in a..., Kutlu [/bib_ref] [bib_ref] Covid-19 and exacerbation of psoriasis, Ozaras [/bib_ref] [bib_ref] Guttate psoriasis secondary to COVID-19, Gananandan [/bib_ref] [bib_ref] Hydroxychloroquine effects on psoriasis: a systematic review and a cautionary note for..., Sachdeva [/bib_ref] [bib_ref] Pustular psoriasis exacerbated by COVID-19 in a patient with the history of..., Shakoei [/bib_ref] [bib_ref] Generalized pustular psoriasis following COVID-19, Shahidi Dadras [/bib_ref] [bib_ref] New-onset pustular psoriasis in the setting of severe acute respiratory syndrome coronavirus..., Mathieu [/bib_ref] Patients with psoriatic disease who become infected with SARS-CoV-2 should follow Centers for Disease Control and Prevention guidance on home isolation and discuss with their health care providers when they can end home isolation (guidance 5.7; Version 1, Supplemental [fig_ref] Table I: NPF COVID-19 TF guidance for management of psoriatic disease during the pandemic [/fig_ref] Mendeley at https://doi.org/10.17632/w5m8jf94m8. 2). [bib_ref] National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease..., Gelfand [/bib_ref] [bib_ref] Universal masking to prevent SARS-CoV-2 transmissiondthe time is now, Brooks [/bib_ref] In the event that someone with psoriatic disease has close contact (Version 1, Supplemental with an individual with suspected or confirmed SARS-CoV-2 infection, he or she should follow local public health authority guidance for the recommended duration of quarantine. [bib_ref] National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease..., Gelfand [/bib_ref] The Centers for Disease Control and Prevention recommends a quarantine period of 14 days after last contact with a person who has COVID-19, assuming one remains asymptomatic, but offers an option to shorten quarantine to end after day 10 from last contact or day 7 with appropriately timed diagnostic testing (guidance 5.8).Individuals who have had COVID-19 within the past 3 months do not need to quarantine after close contact with someone who is infected, as long as they do not develop symptoms again. The decision regarding continuing or holding psoriasis treatments during a period of quarantine should be individualized on a case-by-case basis between patient and provider.
Resumption of psoriasis and/or PsA treatments held during SARS-CoV-2 infection should be decided on a case-by-case basis (guidance 5.5). The persistence of 1 or more symptoms of COVID-19, such as fatigue or joint pain, beyond the acute phase of the illness can occur [bib_ref] Persistent symptoms in patients after acute COVID-19, Carf I [/bib_ref] and may complicate the decision to restart psoriasis or PsA medications. Therefore, shared decision making between the patient and provider(s) is recommended (guidance 2.5).

# Discussion
The NPF COVID-19 TF guidance statements serve to promote optimal management of psoriatic disease during the pandemic. Several limitations are acknowledged. First, the TF did not formally grade the strength of our recommendations. [bib_ref] GRADE guidelines: 1. IntroductiondGRADE evidence profiles and summary of findings tables, Guyatt [/bib_ref] With the exception of guidance statements 4.4, 4.5, 5.2, 5.4.1, and 5.4.2, which are based on large-scale randomized controlled trials, the evidence behind many guidance statements is limited in quality or quantity. Large-scale, longer-term, populationbased studies of patients with psoriatic disease (particularly those with increased COVID-19 risk due to age and/or comorbidity), with appropriate comparator groups, adjustment for relevant confounding variables, and complete ascertainment of clinically important COVID-19 outcomes are urgently needed.Second, the guidance is intended to be neither proscriptive nor comprehensive. The ultimate judgment regarding how these recommendations should be followed is best left with the treating clinician and the patient in light of the circumstances presented by the individual patient and the variability and biological behavior of the disease and therapeutics.
The recommendations are a living document that will be updated and amended when necessary by the rapidly evolving science of COVID-19. Readers are encouraged to visit https://www.psoriasis.org/ covid-19-resource-center regularly for the latest guidance from the TF to promote optimal care and outcomes for patients with psoriatic disease during the pandemic.

## Conflicts of interest
Dr Gelfand has served as a consultant for Bristol Myers Squibb, Boehringer Ingelheim, GlaxoSmithKline, Janssen Biologics, Novartis Corp, Regeneron, UCB (Data Safety and Monitoring Board), Sanofi, and Pfizer, receiving honoraria; has received research grants (to the Trustees of the University of Pennsylvania) from AbbVie, Janssen, Novartis Corp, Sanofi, Celgene, OrthoDermatologics, and Pfizer; has received payment for continuing medical education work related to psoriasis that was supported indirectly by Eli Lilly and Company and Ortho Dermatologics; is a copatent holder of resiquimod for treatment of cutaneous T-cell lymphoma; and is a deputy editor for the Journal of Investigative Dermatology, receiving honoraria from the Society for Investigative Dermatology. Dr Armstrong has served as a research investigator and/or scientific advisor to Leo, AbbVie, UCB, Incyte, Janssen, Lilly, Novartis, Ortho Dermatologics, Sun, Dermavant, Bristol Myers Squibb, Sanofi, Regeneron, Dermira, and Modmed. Dr Bell is an employee of the National Psoriasis Foundation. Dr Anesi is supported by the Agency for Healthcare Research and Quality (K12HS026372) and has received fees from
[table] Table I: NPF COVID-19 TF guidance for management of psoriatic disease during the pandemic: Version 2 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. [/table]