National Psoriasis Foundation COVID-19 Task Force Guidance for Management of Psoriatic Disease During the Pandemic: Version 1

Objective:To provide guidance about management of psoriatic disease during the coronavirus disease 2019 (COVID-19) pandemic. Study design: A task force (TF) of 18 physician voting members with expertise in dermatology, rheumatology, epidemiology, infectious diseases, and critical care was convened. The TF was supplemented by nonvoting members, which included fellows and National Psoriasis Foundation (NPF) staff. Clinical questions relevant to the psoriatic disease community were informed by questions received by the NPF. A Delphi process was conducted.Results: The TF approved 22 guidance statements. The average of the votes was within the category of agreement for all statements. All guidance statements proposed were recommended, 9 with high consensus and 13 with moderate consensus.Limitations: The evidence behind many guidance statements is limited in quality.Conclusion: These statements provide guidance for the management of patients with psoriatic disease on topics ranging from how the disease and its treatments impact COVID-19 risk and outcome, 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 and what they should do if they develop COVID-19.

## National psoriasis foundation covid-19
Task Force Guidance for Management of Psoriatic Disease During the Pandemic: Version 1
Key words: biologics; COVID-19; psoriasis; psoriatic arthritis; SARS-CoV-2.
Severe acute respiratory coronavirus 2 (SARS-CoV-2), a single-stranded RNA virus that binds to the angiotensinconverting enzyme 2 receptor and causes the illness called coronavirus disease 2019 (COVID- , has precipitated devastating personal, economic, and societal repercussions worldwide. 1-4 SARS-CoV-2 usually causes a mild, self-limited illness, but approximately 15% of affected individuals have a more severe, sometimes lifethreatening course, with the risk of poor outcomes increasing with age and comorbidities. [bib_ref] Clinical characteristics of coronavirus disease 2019 in China, Guan [/bib_ref] [bib_ref] Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in..., Cummings [/bib_ref] [bib_ref] Epidemiology of COVID-19: a systematic review and meta-analysis of clinical characteristics, risk..., Li [/bib_ref] Diffuse alveolar damage and acute respiratory distress syndrome are the most common presentations in severe COVID-19. Additionally, thromboembolic events, along with direct and indirect viralinduced injury, may target the skin, gastrointestinal tract, kidney, heart, and brain, with devastating consequences. [bib_ref] Extrapulmonary manifestations of COVID-19, Gupta [/bib_ref] [bib_ref] COVID-19: the vasculature unleashed, Teuwen [/bib_ref] [bib_ref] COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection, Al-Samkari [/bib_ref] The type 1 interferon response, which is required to clear the virus, is often insufficient in the early phase of SARS-CoV-2 infection, but a delayed persistent elevation may develop as the illness progresses. [bib_ref] Impaired type I interferon activity and inflammatory responses in severe COVID-19 patients, Hadjadj [/bib_ref] Profound dysregulation of innate and acquired immunity can occur with more severe COVID-19, including significant lymphopenia as a direct result of viral-induced apoptosis and necrosis of lymphocytes in the spleen and lymph nodes. [bib_ref] Immunology of COVID-19: current state of the science, Vabret [/bib_ref] The persistent interferon response can result in systemic hyperinflammation, also known as cytokine storm. [bib_ref] On the alert for cytokine storm: immunopathology in COVID-19, Henderson [/bib_ref] [bib_ref] In the eye of the COVID-19 cytokine storm, Vaninov [/bib_ref] Several of the cytokines elevated in severe COVID-19 patients (tumor necrosis factor [TNF], interleukin 6, and interleukin 17) are also elevated in patients with psoriatic disease. [bib_ref] New therapies for psoriasis and psoriatic arthritis, Ritchlin [/bib_ref] [bib_ref] Pathophysiology, clinical presentation, and treatment of psoriasis: a review, Armstrong [/bib_ref] [bib_ref] Psoriatic arthritis, Ritchlin [/bib_ref] The current model of COVID-19 is that immune suppression in early infection may be harmful by allowing uncontrolled SARS-CoV-2 replication and dissemination but may be helpful in severe illness by limiting organ damage from a dysregulated hyperimmune response. [bib_ref] Immune response in COVID-19: addressing a pharmacological challenge by targeting pathways triggered..., Catanzaro [/bib_ref] Many treatments used for psoriatic disease directly or indirectly impact immune pathways involved in COVID-19. [bib_ref] Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the..., Menter [/bib_ref] [bib_ref] Joint AAD-NPF guidelines of care for the management and treatment of psoriasis..., Menter [/bib_ref] [bib_ref] American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of psoriatic..., Singh [/bib_ref] Patients and providers are concerned about the safety of immunomodulating agents in the setting of the COVID-19 pandemic. These concerns are particularly relevant given that many of the comorbidities associated with psoriasis and psoriatic arthritis, including obesity, diabetes, and cardiovascular disease, are risk factors for the development of severe COVID-19. [bib_ref] Recognizing and managing comorbidities in psoriatic arthritis, Ogdie [/bib_ref] [bib_ref] Psoriasis and comorbid diseases: epidemiology, Takeshita [/bib_ref] To address the questions posed by patients and providers, the National Psoriasis Foundation (NPF) commissioned a COVID-19 task force (TF) to develop scientifically based guidance that promotes optimal management of psoriatic disease during the pandemic.

# Methods
See the Online Supplement for detailed methods, available via Mendeley Data, V2, at https://doi.org/ 10.17632/x4mxnjmc76. [fig_ref] Table I: National Psoriasis Foundation COVID-19 Task Force Guidance for Management of Psoriatic Disease... [/fig_ref] Mendeley Data, V1, at https://doi.org/10.17632/ 2cbs7r7z72.1). The TF was supplemented by nonvoting members, which included 4 trainees in dermatology, rheumatology, and infectious diseases, 1 postdoctoral fellow in epidemiology, as well as senior staff from the NPF.

## Establishment of the tf

## Evidence synthesis
The TF co-chairs completed weekly literature searches for COVID-19 in relation to psoriatic disease. TF members also recommended papers of broad importance to COVID-19 related to its basic biology, epidemiology, and treatment. Additional sources of data were obtained from the Centers for Disease Control and Prevention (CDC), World Health Organization, the United States Food and Drug Administration, and the National Institutes of Health.

## Development of clinical questions
The TF met every 2 weeks to discuss the developments in the literature and clinical experience. Clinical questions relevant to the psoriatic disease community were iterated and informed by questions received by the NPF from the broader patient and clinical community. The questions were subdivided into 5 categories, and work groups with balanced expertise were formed. Each TF work group convened to draft responses to the clinical questions based on the available evidence. These responses were reviewed and drafted into guidance statements.

## Modified delphi process
The guidance statements were presented to the 18 TF members using a modified Delphi process, including 2 rounds of voting with discussion in between. The Delphi approach was based on the RAND appropriateness method, which has been extensively validated. [bib_ref] American College of Rheumatology Guidance for the Management of Rheumatic Disease in..., Mikuls [/bib_ref] [bib_ref] The reproducibility of a method to identify the overuse and underuse of..., Shekelle [/bib_ref] [bib_ref] Assessing the predictive validity of the RAND/UCLA appropriateness method criteria for performing..., Shekelle [/bib_ref] [bib_ref] Appropriateness criteria for coronary angiography in angina: reliability and validity, Hemingway [/bib_ref] [bib_ref] Validity of criteria used for detecting underuse of coronary revascularization, Kravitz [/bib_ref] TF members were asked to report their level of agreement anonymously with each guidance statement on a scale of 1 to 9. A rating of 1 corresponded to ''complete disagreement,'' 5 corresponded to ''uncertain or neutral,'' and 9 corresponded to ''complete agreement.'' The members were able to provide anonymous written comments. Median vote ratings of 1 to 3, 4 to 6, and 7 to 9 were defined a priori as disagreement, uncertainty/neutral, and agreement, respectively. Panel consensus was determined to be ''low'' when $5 votes fell into the 1 to 3 rating range with $5 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 along with an independent analysis of the data by a nonvoting member of the TF, which yielded identical results.

# Results
The NPF COVD-19 TF Delphi was completed over a 2-week period (Supplemental E- Patients with psoriatic disease appear to have similar rates of infection with SARS-CoV-2 and COVID-19 outcomes 33-37 as the general population (Guidance 1.1). However, uncertainty remains regarding this question. First, a few reports suggest that patients with psoriasis may be more prone to infection with COVID-19 or have worse outcomes. [bib_ref] Dermatological diseases presented before COVID-19: are patients with psoriasis and superficial fungal..., Kutlu [/bib_ref] [bib_ref] Factors associated with COVID-19-related death using OpenSAFELY, Williamson [/bib_ref] [bib_ref] Psoriasis and risk of the COVID-19: is there a role for angiotensin..., Shahidi-Dadras [/bib_ref] For example, a United Kingdom study with more than 17 million patients found a small but statistically increased risk of death from COVID-19 (fully adjusted hazards ratio, 1.19; 95% confidence interval, 1.11-1.27) in individuals with psoriasis, rheumatoid arthritis, or lupus. [bib_ref] Factors associated with COVID-19-related death using OpenSAFELY, Williamson [/bib_ref] It is unknown from this study the degree to which the observed finding is driven by psoriasis, its severity, or treatment. Additionally, patients with psoriatic disease may be prone to thrombotic complications that can also occur in COVID-19. [bib_ref] The risk of stroke in patients with psoriasis, Gelfand [/bib_ref] [bib_ref] Risk of myocardial infarction in patients with psoriasis, Gelfand [/bib_ref] [bib_ref] Prevalence of metabolic syndrome in patients with psoriasis: a populationbased study in..., Langan [/bib_ref] [bib_ref] Patients with severe psoriasis are at increased risk of cardiovascular mortality: cohort..., Mehta [/bib_ref] [bib_ref] Objective measures of psoriasis severity predict mortality: a prospective population-based cohort study, Noe [/bib_ref] [bib_ref] Risk of venous thromboembolism in patients with psoriatic arthritis, psoriasis and rheumatoid..., Ogdie [/bib_ref] [bib_ref] Risk of major cardiovascular events in patients with psoriatic arthritis, psoriasis and..., Ogdie [/bib_ref] [bib_ref] Risk of moderate to advanced kidney disease in patients with psoriasis: population..., Wan [/bib_ref] [bib_ref] Psoriasis and the risk of diabetes: a prospective population-based cohort study, Wan [/bib_ref] [bib_ref] Thrombosis in hospitalized patients with COVID-19 in a New York City health..., Bilaloglu [/bib_ref] [bib_ref] Cardiovascular manifestations and treatment considerations in COVID-19, Kang [/bib_ref] [bib_ref] Neutrophil subsets, platelets, and vascular disease in psoriasis, Teague [/bib_ref] [bib_ref] Platelet P-selectin reflects a state of cutaneous inflammation: possible application to monitor..., Garbaraviciene [/bib_ref] [bib_ref] Platelet activation: a link between psoriasis per se and subclinical atherosclerosisda caseecontrol..., Saleh [/bib_ref] [bib_ref] Endothelial cell-, platelet-, and monocyte/macrophage-derived microparticles are elevated in psoriasis beyond cardiometabolic..., Takeshita [/bib_ref] There was unanimous agreement that severity of COVID-19 is driven by risk factors such as older age and comorbidities (Guidance 1.2). [bib_ref] Epidemiology and outcomes of novel coronavirus 2019 in patients with immune-mediated inflammatory..., Gianfrancesco [/bib_ref] [bib_ref] Covid-19 in immunemediated inflammatory diseases-case series from New York, Haberman [/bib_ref] [bib_ref] Clinical course of COVID-19 in 41 patients with immune-mediated inflammatory diseases: experience..., Allocca [/bib_ref] [bib_ref] Factors associated with COVID-19-related death using OpenSAFELY, Williamson [/bib_ref] [bib_ref] COVID-19 and older adults: what we know, Shahid [/bib_ref] [bib_ref] Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia..., Chen [/bib_ref] [bib_ref] Clinical Characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in..., Wang [/bib_ref] Psoriatic diseasedparticularly severe psoriasisdis associated with many of the comorbidities that drive COVID-19 mortality. [bib_ref] Objective measures of psoriasis severity predict mortality: a prospective population-based cohort study, Noe [/bib_ref] [bib_ref] Psoriasis and the risk of diabetes: a prospective population-based cohort study, Wan [/bib_ref] [bib_ref] Psoriasis severity and the prevalence of major medical comorbidity: a populationbased study, Yeung [/bib_ref] Category 2: What are the effects of psoriasis or psoriatic arthritis treatment on SARS-CoV-2 infection and COVID-19 illness?
The existing literature suggests that treatments for psoriasis or psoriatic arthritis, or both, do not meaningfully alter the risk of acquiring SARS-CoV-2 infection or having worse COVID-19 outcomes (Guidance 2.1). [bib_ref] Psoriasis, biological drugs and coronavirus disease 2019: real life experience of two..., Vispi [/bib_ref] [bib_ref] Covid-19 in immunemediated inflammatory diseases-case series from New York, Haberman [/bib_ref] [bib_ref] Clinical course of COVID-19 in 41 patients with immune-mediated inflammatory diseases: experience..., Allocca [/bib_ref] Cyclosporine, the most broadly immunosuppressive of psoriasis treatments, was not found to alter the risk of COVID-19 in 130 patients in Italy with psoriasis or atopic dermatitis (2 became infected with SARS-CoV-2 and recovered without hospitalization). [bib_ref] Covid-19 infection in psoriasis patients treated with cyclosporin, Lernia [/bib_ref] This study lacked a comparison group and was too small to reach definitive conclusions. One study suggested that patients with psoriasis on biologics were more likely to be hospitalized for COVID-19 but did not adjust for risk factors known to drive poor COVID-19 outcomes. [bib_ref] Biologics increase the risk of SARS-CoV-2 infection and hospitalization, but not ICU..., Damiani [/bib_ref] The rheumatology literature also suggests that treatments used for psoriatic disease, such as TNF inhibitors and methotrexate, do not negatively impact COVID-19, 87-90 with 1 large registry (600 case reports from 40 countries) finding that TNF inhibitors are associated with a reduced adjusted odds of COVID-19 hospitalization compared with patients with rheumatic conditions not treated with TNF inhibitors. [bib_ref] Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data..., Gianfrancesco [/bib_ref] Similarly, adverse effects of TNF inhibitors on COVID-19 were not observed in large registries of patients with inflammatory bowel disease. [bib_ref] but not TNF antagonists, are associated with adverse COVID-19 outcomes in patients..., Brenner [/bib_ref] [bib_ref] Impact of anti-TNF and thiopurines medications on the development of COVID-19 in..., Khan [/bib_ref] Small case series have reported poor COVID-19 outcomes in patients on Janus kinase inhibitors for psoriatic arthritisand secukinumab for ankylosing spondylitis [bib_ref] COVID-19 in rheumatic disease patients on immunosuppressive agents, Sharmeen [/bib_ref] ; however, these isolated reports could be due to selection bias, chance, or underlying comorbidity. By contrast, an analysis of approximately 1400 patients from the It is not known with certainty whether 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. rheumatology, gastroenterology, and dermatology literature concluded that biologic or targeted synthetic disease-modifying antirheumatic drug therapy has not been associated with more severe COVID-19 outcomes. [bib_ref] Epidemiology and outcomes of novel coronavirus 2019 in patients with immune-mediated inflammatory..., Gianfrancesco [/bib_ref] Given these data, patients who are not infected with SARS-CoV-2 should continue their biologic or oral therapies for psoriasis or psoriatic arthritis in most cases (Guidance 2.2). Nevertheless, the existing literature is largely based on small case series or large registries of spontaneous reports, and therefore, shared decision-making between clinician and patient is recommended (Guidance 2.2, 2.4, and 2.5). By contrast, studies in the rheumatology and gastroenterology literature have observed that long-term use of oral corticosteroids is associated with worse COVID-19 outcomes (ie, hospitalization or a composite outcome of any or all of intensive care unit admission, ventilator use, or death). [bib_ref] Epidemiology and outcomes of novel coronavirus 2019 in patients with immune-mediated inflammatory..., Gianfrancesco [/bib_ref] [bib_ref] Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data..., Gianfrancesco [/bib_ref] [bib_ref] but not TNF antagonists, are associated with adverse COVID-19 outcomes in patients..., Brenner [/bib_ref] Chronic systemic corticosteroids should be avoided, if possible, for the management of psoriatic arthritis (Guidance 2.3). Category 3: How should medical care be delivered to patients with psoriatic disease to lower their risk of infection with SARS-CoV-2 while still ensuring quality of care?
The pandemic has disrupted the ability of patients and providers ability to meet in person due to personal protective equipment shortages, measures implemented to lower risk of SARS-CoV-2 transmission, and patients' personal and economic hardships. [bib_ref] Dermatologists and SARS-CoV-2: the impact of the pandemic on daily practice, Gisondi [/bib_ref] [bib_ref] Teledermatology in the wake of COVID-19: advantages and challenges to continued care..., Gupta [/bib_ref] [bib_ref] Critical supply shortagesthe need for ventilators and personal protective equipment during the..., Ranney [/bib_ref] Patients express concern about being exposed to SARS-CoV-2 in the clinical setting either directly or indirectly (ie, on public transportation). Telemedicine can achieve similar outcomes for psoriasis patients compared with in-person care with a dermatologist 98-100 ; however, limited information is available on the management of psoriatic arthritis with telemedicine. [bib_ref] Telerheumatology in COVID-19 era: a study from a psoriatic arthritis cohort, Costa [/bib_ref] [bib_ref] Outcomes, Satisfaction, and costs of a rheumatology telemedicine program: a longitudinal evaluation, Wood [/bib_ref] Telemedicine should be considered when pandemic conditions limit inperson visits (Guidance 3.1).However, there are limitations of telemedicine, and therefore, some patients should be evaluated in person (Guidance 3.2). Office-based phototherapy remains an important option for patients with psoriasis (Guidance 3.3, [fig_ref] Table II ,: available via Mendeley Data, V1, at https [/fig_ref]. [bib_ref] Recommendations for phototherapy during the COVID-19 pandemic, Lim [/bib_ref] [bib_ref] Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the..., Elmets [/bib_ref] Category 4: What should patients with psoriatic disease do to protect themselves from becoming infected with SARS-CoV-2?
Patients should be advised to follow measures that prevent infection with SARS-CoV-2 (Guidance 4.1; E-Table VI, available via Mendeley Data, V2, at https://doi.org/10.17632/w5m8jf94m8).These prevention measures should be followed at work (Guidance 4.2) and school (Guidance 4.3). In cases where measures to prevent transmission of SARS-CoV-2 at work or school cannot be maintained, shared decision making is recommended to determine whether specific accommodations are medically necessary (Guidance 4.2 and 4.3). Psoriasis, even when involving the face or hands, is not a contraindication to face coverings and hand washing, respectively, and a variety of approaches can be applied to mitigate skin irritation (E-Table VII, available via Mendeley Data, V2, at https://doi.org/ 10.17632/w5m8jf94m8). [bib_ref] Preventing and treating occupationally induced dermatologic conditions during COVID-19. A guide to..., Thiers [/bib_ref] [bib_ref] Joint AAD-NPF Guidelines of care for the management and treatment of psoriasis..., Elmets [/bib_ref] Patients with psoriatic disease should receive the seasonal inactivated (eg, killed) influenza vaccine, which is of special importance to individual and public health during the COVID-19 pandemic (Guidance 4.4). Providers may consider temporary discontinuation of methotrexate for 2 weeks after the influenza immunization to

## 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 patients with psoriasis are on medications with immunosuppressive effects, we recommend a case-by-case approach to determining the length of home isolation. J AM ACAD DERMATOL improve the immunogenicity of the seasonal influenza vaccine. [bib_ref] Impact of temporary methotrexate discontinuation for 2 weeks on immunogenicity of seasonal..., Park [/bib_ref] Category 5: What should patients with psoriatic disease do if they become infected with SARS-CoV-2? Patients with psoriatic disease who become infected with SARS-CoV-2 should monitor their symptoms (Supplemental E- [fig_ref] Table II ,: available via Mendeley Data, V1, at https [/fig_ref] , discuss management of their psoriatic disease treatments with their health care providers, and should be prescribed and adhere to evidence-based COVID-19 treatments, if available (Guidance 5.1 and 5.2). [bib_ref] Severe COVID-19 outcomes in patients with psoriasis, Lima [/bib_ref] [bib_ref] Remdesivir for the treatment of Covid-19dpreliminary report, Beigel [/bib_ref] [bib_ref] Dexamethasone in hospitalized patients with Covid-19dpreliminary report, Recovery Collaborative Group [/bib_ref] The mortality benefit of initiation of corticosteroids in patients with severe COVID-19 outweighs the risks of potentially precipitating a psoriasis flare, and therefore, acute systemic corticosteroids are not contraindicated for the management of COVID-19 in patients with psoriatic disease (Guidance 5.3). [bib_ref] Dexamethasone in hospitalized patients with Covid-19dpreliminary report, Recovery Collaborative Group [/bib_ref] [bib_ref] Systemic steroids in the treatment of psoriasis: what is fact, what is..., Mrowietz [/bib_ref] On the basis of 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 final decision needs to be determined on a caseby-case basis.
Consistent with guidance from the Food and Drug Administration and the American College of Physicians, the use of hydroxychloroquine or chloroquine is not recommended to prevent or treat COVID-19 in patients with psoriatic disease outside of a clinical trial (guidance 5.4). [bib_ref] Infectious Diseases Society of America Guidelines on the Treatment and Management of..., Bhimraj [/bib_ref] [bib_ref] Update alert 2: should clinicians use chloroquine or hydroxychloroquine alone or in..., Qaseem [/bib_ref] [bib_ref] Hydroxychloroquine and tocilizumab therapy in COVID-19 patients-an observational study, Ip [/bib_ref] [bib_ref] Association of treatment with hydroxychloroquine or azithromycin with in-hospital mortality in patients..., Rosenberg [/bib_ref] [bib_ref] A case of exacerbation of psoriasis after oseltamivir and hydroxychloroquine in a..., Kutlu [/bib_ref] [bib_ref] Hydroxychloroquine effects on psoriasis: a systematic review and a cautionary note for..., Sachdeva [/bib_ref] Patients with psoriatic disease should be aware that infection with SARS-CoV-2 may result in a flare of psoriasis, which may occur due to discontinuation of psoriasis treatments, treatment of COVID-19 with antimalarial drugs, or due to triggering of inflammation as part of COVID-19 illness (Guidance 5.6). [bib_ref] A case of exacerbation of psoriasis after oseltamivir and hydroxychloroquine in a..., Kutlu [/bib_ref] [bib_ref] A case of severe psoriatic erythroderma with COVID-19, Ghalamkarpour [/bib_ref] [bib_ref] Covid-19 and exacerbation of psoriasis, Ozaras [/bib_ref] [bib_ref] Guttate psoriasis secondary to COVID-19, Gananandan [/bib_ref] Patients with psoriatic disease who become infected with SARS-CoV-2 should follow CDC guidance 130-133 on home isolation and discuss with their health care providers when they can end home quarantine (Guidance 5.7; Supplemental E- [fig_ref] Table I: National Psoriasis Foundation COVID-19 Task Force Guidance for Management of Psoriatic Disease... [/fig_ref]. [bib_ref] Universal masking to prevent SARS-CoV-2 transmissiondthe time is now, Brooks [/bib_ref] In the event someone with psoriatic disease has close contact (Supplemental E- with an individual with suspected or confirmed SARS-CoV-2 infection, they should quarantine for 14 days after the last contact, according to CDC guidelines (Guidance 5.8).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 or psoriatic arthritis 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 137 and may complicate the decision to restart psoriasis or psoriatic arthritis medications. Therefore, shared decision making is recommended (Guidance 2.5).

# Discussion
The NPF COVID-19 TF guidance statements serve to promote optimal management of psoriatic disease during the pandemic. There are several strengths to the approach taken. First, the TF assembled is a geographically diverse team that has expertise in adult and pediatric dermatology, rheumatology, critical care, infectious diseases, epidemiology, and basic and translational immunology, with experience managing surges in COVID-19. The TF also includes trainees in dermatology, rheumatology, and infectious disease, who are on the frontlines managing patients with COVID-19, as well as senior staff from the NPF who are in touch daily with patients and providers worldwide whose questions are brought to the TF. Second, we have established a robust process for staying up-to-date with the latest literature relevant to COVID-19 and the management of psoriatic disease resulting in the dissemination and evaluation of hundreds of peer reviewed publications by the TF.
Third, a validated Delphi approach enabled transparency and reproducibility of our process for evaluating consensus statements. [bib_ref] American College of Rheumatology Guidance for the Management of Rheumatic Disease in..., Mikuls [/bib_ref] [bib_ref] The reproducibility of a method to identify the overuse and underuse of..., Shekelle [/bib_ref] [bib_ref] Assessing the predictive validity of the RAND/UCLA appropriateness method criteria for performing..., Shekelle [/bib_ref] [bib_ref] Appropriateness criteria for coronary angiography in angina: reliability and validity, Hemingway [/bib_ref] [bib_ref] Validity of criteria used for detecting underuse of coronary revascularization, Kravitz [/bib_ref] Several limitations are acknowledged. First, the TF did not formally grade the strength of our recommendations. [bib_ref] GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables, Guyatt [/bib_ref] With the exception of guidance statements 4.4, 5.2, and 5.4, which are based on large-scale randomized controlled trials, the evidence behind many of the guidance statements was often limited in quality. For example, studies evaluating the safety of treatments for psoriasis and psoriatic arthritis in the setting of COVID-19 involve small case series or large collections of case reports and thus should be considered preliminary. Largescale, longer-term, population-based studies 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 not intended to be proscriptive or 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 biologic behavior of the disease and therapeutics.
Third, the TF does not have global representation of experts or direct inclusion of patients.
The guidance statements are intended to be part of 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-resourcecenter regularly for the latest guidance from the TF in order to promote optimal care and outcomes for patients with psoriatic disease during the pandemic.
[fig] Category 1: What are the effects of psoriatic disease itself on SARS-CoV-2 infection and COVID-19 illness? [/fig]
[table] Table II ,: available via Mendeley Data, V1, at https://doi.org/10.17632/ 2cbs7r7z72). Five categories of questions were explored (Supplemental E-Table III, available via Mendeley Data, V1, at https://doi.org/10.17632/ 2cbs7r7z72) with 100% complete voting on 22 guidance statements(Table I 32 and Supplemental E-Table IV, available via Mendeley Data, V2, at https://doi.org/ 10.17632/n78m9f3cpr). The median was within the category of agreement for all statements, with the number of votes outside the range of agreement being only 1 or 2 for statements where agreement was not unanimous. All guidance statements were recommended, 9 with high consensus, and the remainder with moderate consensus. [/table]
[table] Table I: National Psoriasis Foundation COVID-19 Task Force Guidance for Management of Psoriatic Disease During the Pandemic: Version 1 [/table]