1.1

It is not known with certainty if having psoriatic disease meaningfully alters the risks of contracting SARS-CoV-2 (the virus which 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.

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.

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 which 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.

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).

2.3

Chronic systemic steroids should be avoided if possible for the management of psoriatic arthritis. If patients require chronic systemic steroids for management of psoriatic arthritis, the dose should be tapered to the lowest dose necessary to achieve the desired therapeutic effect. Chronic systemic steroid use for the treatment of psoriatic disease at the time of acute infection with SARS-CoV-2 may be associated with worse outcomes from COVID19 illness.It is important to note, however, that steroids may improve outcomes for COVID19 when initiated in hospitalized patients requiring oxygen treatment.

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 shared decision making).

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 COVID19 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 COVID19 pandemic and a discussion of a patient’s individual circumstances and preferences should guide decision making.

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.

3.2

The following patients should be considered for in-person care if pandemic conditions allow (i.e., the clinical practice is open to see patients in person) and Standard Operating Procedures are observed (i.e. social distancing, hand washing and masking). Patients at risk for melanoma and non-melanoma skin cancer should be seen in person at a frequency consistent with 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.

3.3

Providers recommend the recent guidelines published by Lim et al on how to optimize safety of office phototherapy for the patients and staff in the setting of the pandemic.

4.1

Patients should be advised to follow measures that prevent infection with SARS-CoV-2. These preventative measures include: To practice good hand hygiene, to maintain physical distancing from non-household 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.

4.2

Patients with psoriatic disease should follow measures to prevent infection with SARS-CoV-2 in the workplace. If the work place environment does not allow for 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 whom, due to age or underlying health conditions, are at especially high risk for poor COVID-19 outcomes.

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.

4.4

Patients with psoriatic disease should receive the seasonal inactivated (e.g. killed) influenza vaccine when it becomes available. 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 COVID19 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.

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 COVID19 vaccine. 

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).

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 between the patient, researcher, and provider.

4.8

In most cases, patients should take the first mRNA-based COVID-19 vaccine currently approved by emergency use authorization for which they are eligible and offered based on federal, state, and local guidance. Currently available vaccines include the mRNA vaccines (manufactured by Pfizer and Moderna, see recommendation 4.5) and a replication-incompetent adenovirus type 26-vectored vaccine encoding a stabilized variant of the SARS-CoV-2 S protein (Ad26.COV2.S, manufactured by Johnson & Johnson). Systemic medications for psoriasis or psoriatic arthritis are not a contraindication to any currently available COVID-19 vaccines (be they mRNA-based or adenovirus vectored vaccine).

4.9

It is recommended that patients who are to receive an Ad26.COV2.S vaccine continue their biologic or oral therapies for psoriasis and/or psoriatic arthritis in most cases. Patients 60 or older who have at least one comorbidity associated with an increased risk for poor COVID-19 outcomes,* and who are taking methotrexate with well-controlled psoriatic disease, may, in consultation with their prescriber, consider holding it for 2 weeks after receiving the Ad26.COV2.S vaccine in order to potentially improve vaccine response. Holding methotrexate for 2 weeks following influenza vaccination in patients with rheumatoid arthritis resulted in a modest improvement in antibody titer response, with unknown clinical significance. It is not known if holding methotrexate for 2 weeks following the Ad26.COV2.S vaccine will result in clinically meaningful benefits for vaccine efficacy. 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, see guidance 4.6 for continuation of biologic or oral therapies during mRNA vaccine administration).

* https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

4.10

Patients with psoriasis and or psoriatic arthritis who are taking certain medications that affect the immune system in a manner that may increase the risk of infections may not be fully protected even if fully vaccinated against COVID-19. Out of an abundance of caution, and until more data emerge, we recommend that patients with psoriatic disease taking abatacept, cyclosporine, leflunomide, glucocorticoids (e.g., prednisone), methotrexate, or tofacitinib continue masking and social distancing precautions (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html) when they are in contact with people who are not vaccinated against COVID-19 or whose vaccination status is not verifiable. 

4.11

Antibody testing is currently not recommended to assess immunity after COVID-19 vaccination or to inform medical decision making related to individual precautions. The accuracy of antibody testing to predict protection from SARS-CoV-2 infection and COVID-19 illness is not known. Individuals who are concerned about the efficacy of the COVID-19 vaccines due to their unique circumstances are referred to guidance 4.10 and 5.2 for additional strategies to lower their risk of COVID-19.

4.12

Patients 18 and older# with psoriatic disease who received a second dose of the Pfizer-BioNTech or a Moderna COVID-19 vaccine five or more months ago* SHOULD get a booster shot.

Individuals who are eligible for a booster dose may choose which vaccine they receive as a booster. Some people may prefer the vaccine type that they originally received, and others may prefer to get a different booster. In most situations, Pfizer-BioNTech or Moderna COVID-19 vaccines are preferred over the Johnson & Johnson COVID-19 vaccine for primary and booster vaccination.

If receiving a booster dose with a Moderna vaccine, this should be half of the dose that is given for the primary series (i.e., first 2 doses).

# Children 12-17 years old can get a Pfizer-BioNTech COVID-19 vaccine booster 5 months after completing their primary COVID-19 vaccination series with a Pfizer-BioNTech COVID-19 vaccine.

*Patients with psoriatic disease treated with immunosuppressive or immune-modulating therapies such as corticosteroids, leflunomide, methotrexate, tofacitinib, upadacitinib, apremilast, and biologics that target the cytokines TNF, IL-12/23, IL-17, and IL-23 or T cells (e.g., abatacept), are ELIGIBLE for a 3rd dose “mRNA COVID-19 vaccine as per the CDC, as soon as 28 days after the second dose of an mRNA vaccine. This eligibility applies to patients ages 5 and older (Pfizer-BioNTech vaccine) or in patients ages 18 and older (Moderna vaccine and Pfizer-BioNTech vaccine). Most patients receiving systemic treatment for psoriatic disease are not moderately to severely immunocompromised and would not require a 3rd dose at 28-days. Patients taking abatacept, cyclosporine, leflunomide, glucocorticoids (e.g., prednisone), methotrexate, upadacitinib or tofacitinib who have additional risk factors for poor COVID-19 outcomes may benefit from a 3rd dose of a mRNA COVID-19 vaccine. Patients who elect to get a 3rd dose of an mRNA vaccine may then receive a booster dose 5 months after the 3rd dose. Shared decision-making between clinician and patient is recommended to guide discussions about use of 3rd doses of mRNA COVID-19 vaccines and booster doses of COVID-19 vaccines.

Patients 18 and older with psoriatic disease who received a single dose of the Johnson & Johnson COVID-19 vaccine two or more months ago SHOULD get a booster shot. This booster vaccine can be a Pfizer-BioNTech COVID-19 vaccine or a Moderna (half dose) COVID-19 vaccine which are preferred over the Johnson & Johnson COVID-19 vaccine.

The following patients most likely to BENEFIT from a COVID-19 booster vaccine:

• People aged 50 or older

• People taking abatacept, cyclosporine, leflunomide, glucocorticoids (e.g., prednisone), methotrexate, upadacitinib or tofacitinib

• People who received their second dose of an mRNA vaccine over 6 months ago

• People who received a single dose of the Johnson & Johnson vaccine over 2 months ago

• People with underlying co-morbidities known to increase the risk of severe COVID-19, such as being overweight, being a current or former smoker, or having diabetes, cardiovascular disease, chronic lung, liver, or kidney disease.

• People who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting; or who have routine contact with unvaccinated individuals (i.e., children) or routine contact with those at high risk for severe COVID-19 or infection (i.e., an elderly or immunocompromised household member).

It is recommended that patients who are to receive COVID-19 booster vaccine continue their biologic or oral therapies for psoriasis and/or psoriatic arthritis in most cases. Patients who are taking methotrexate with well-controlled psoriatic disease, may, in consultation with their prescriber, consider holding it for 2 weeks after receiving a booster vaccine in order to potentially improve vaccine response.

4.13

Adults and adolescents (12 years of age and older weighing at least 40 kg) with psoriatic disease who are not currently infected with SARS-CoV-2, who have not had a known recent exposure to an individual infected with SARS-CoV-2, and who are treated with immunosuppressive or immune-modulating therapies such as corticosteroids, leflunomide, methotrexate, tofacitinib, apremilast, and biologics that target the cytokines TNF, IL-12/23, IL-17, and IL-23 or T cells (e.g., abatacept) and may not mount an adequate immune response to COVID-19 vaccination may be eligible for Evusheld™ (tixagevimab co-packaged with cilgavimab), a SARS-CoV-2 spike protein-directed attachment inhibitor, for the pre-exposure prophylaxis (prevention) of coronavirus disease 2019 (COVID-19).

Most patients receiving systemic treatment for psoriatic disease are not moderately to severely immunocompromised, are expected to mount an adequate immune response to COVID-19 vaccination, and would therefore not benefit from Evusheld™. However, patients taking abatacept, cyclosporine, leflunomide, glucocorticoids (e.g., prednisone), methotrexate, tofacitinib, or upadacitinib who have additional risk factors for poor COVID-19 outcomes may possibly benefit from Evusheld™. Shared decision-making between clinician and patient is recommended to guide discussions about use Evusheld™.

4.14

A second booster dose of the Pfizer-BioNTech COVID-19 vaccine or Moderna COVID-19 vaccine may be administered to individuals 50 years of age and older at least 4 months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine (see 4.12 for recommendations for a first booster). The original booster/3rd vaccine dose continues to offer strong protection against hospitalization and death from COVID-19, although there is some evidence that this protection wanes over time, particularly in people 60 years of age or older. New safety signals have not been identified in patients receiving a second booster, however, patients who had rare serious side effects from previous COVID-19 vaccines may consider deferring a second booster. Shared decision making is recommended when considering a second booster (see recommendation 2.5 regarding shared decision making).

The following patients with psoriatic disease are most likely to BENEFIT from a second COVID-19 booster vaccine:

• People 60 years of age or older

• People taking abatacept, cyclosporine, leflunomide, glucocorticoids (e.g., prednisone), methotrexate, upadacitinib, or tofacitinib

• People with underlying co-morbidities known to increase the risk of severe COVID-19, such as being overweight, being a current or former smoker, or having diabetes, cardiovascular disease, chronic lung, liver, or kidney disease.

• People who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting; or who have routine contact with unvaccinated individuals (i.e., children) or routine contact with those at high risk for severe COVID-19 or infection (i.e., an elderly or immunocompromised household member).

It is recommended that patients who are to receive COVID-19 booster vaccine continue their biologic or oral therapies for psoriasis and/or psoriatic arthritis in most cases. Patients who are taking methotrexate with well-controlled psoriatic disease, may, in consultation with their prescriber, consider holding it for 2 weeks after receiving a booster vaccine in order to potentially improve vaccine response.

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.

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 with consideration of the following:

For high risk** outpatients infected with SARS-CoV-2:

• Paxlovid (nirmatrelvir 300 mg plus ritonavir 100 mg) orally twice daily for 5 days

Paxlovid is available only by prescription. To locate a pharmacy that has Paxlovid, the following website can be searched: https://covid-19-therapeutics-locator-dhhs.hub.arcgis.com/.

If Paxlovid is not available or is contraindicated, additional treatment options can be found at: https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/nonhospitalized-adults--therapeutic-management/.

For hospitalized patients infected with SARS-CoV-2:

• Dexamethasone (systemic steroids) for patients meeting specific criteria

• Remdesivir treatment for patients meeting specific criteria

• Baricitinib (or tofacitinib if baricitinib is not available), with or without remdesivir, for patients meeting specific criteria

• Tocilizumab (or sarilumab if tocilizumab is not available), in combination with dexamethasone, 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, and are recommended by National Institute of Health COVID-19 treatment guidelines.

** For definition of high risk patient see: https://www.covid19treatmentguidelines.nih.gov/therapies/statement-on-patient-prioritization-for-outpatient-therapies/

5.3

Systemic steroids for the management of COVID-19 in with psoriatic disease are not contraindicated and should not be withheld due to the concern of potentially flaring psoriasis upon withdrawal of steroids when evidence demonstrates the effectiveness for treating COVID19 illness.

5.4.1

Hydroxychloroquine or chloroquine are not recommended for the prevention or treatment of COVID19 in patients with psoriatic disease outside of a clinical trial. Cases of psoriasis flare have been reported in patients on anti-malarial medications, but the clinical significance is not well understood.

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.

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.

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 symptoms. In those who have had a severe hospital course, shared decision made on a case-by-case basis is recommended.

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.

5.7

Patients with psoriatic disease who become infected with SARS-CoV-2 should follow CDC guidance on home isolation and discuss with their healthcare providers when they can end home isolation. Patients receiving systemic treatment for psoriatic disease, including biologics that target TNF, IL12/23, IL17, or IL23, are not moderately to severely immunocompromised. These patients are expected to clear SARS-CoV-2 infection at similar rates to those not taking systemic treatment for psoriatic disease, and should follow CDC guidance on home isolation if infected with SARS-CoV-2 as described for the general public (https://www.cdc.gov/coronavirus/2019-ncov/your-health/quarantine-isolation.html). Patients taking abatacept, cyclosporine, leflunomide, glucocorticoids (e.g., prednisone), methotrexate, tofacitinib, or upadacitinib with COVID-19 may consider additional precautions in consultation with their medical provider, including:

• Use of a 3-ply surgical mask (or N95 or KN95 mask if advised by a healthcare provider) if ending isolation at day 5, and continuing to use a mask for a period of 10 to up to 20 days from the beginning of symptoms or receipt of a positive test (whichever came first).

• Antigen or PCR based testing at day five of isolation (recognizing that some patients may be persistently positive and not infectious)

• Extending the isolation period to at least 10 and up to 20 days