The NPF COVID-19 Task Force (TF) announces 22 key recommendations for the management of patients with psoriatic disease during the COVID-19 pandemic.
NPF COVID-19 Task Force
These 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.
Providers and patients are encouraged to visit the COVID-19 Resource Center regularly for the latest guidance from the TF in order to promote optimal care and outcomes for patients with psoriatic disease during the pandemic.
What are the effects of psoriatic disease itself on SARS-CoV-2 infection and COVID-19 illness?
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.
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.
What are the effects of psoriasis or psoriatic arthritis treatment on SARS-CoV-2 infection and COVID-19 illness?
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.
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).
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.
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).
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.
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?
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.
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.
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.
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. 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.
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 COVID19 outcomes.
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.
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.
What should patients with psoriatic disease do if they become infected with COVID-19?
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.
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* should be used, currently including supportive care for patients with mild disease, bamlanivimab for treatment of mild-to-moderate disease in adult and pediatric outpatients meeting specific criteria who are at high risk for progressing to severe COVID-19 and/or hospitalization, and dexamethasone (systemic steroids) and remdesivir treatment, if available, for hospitalized 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 COVID19 outcomes.
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.
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.
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.
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.
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. 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.
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 anti-malarial medications, but the clinical significance is not well understood.
The COVID-19 Task Force updated their guidance statements on October 16, 2020. A summary of the updates can be found here.
Publication including methodology, full results and discussion in preparation for submission (Gelfand & Ritchlin on behalf of the NPF COVID-19 Task Force 2020)
More Information and Resources
Our COVID-19 Resource Center has information and tools for both patients and health care professionals.