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.

2.6

TB Tests and mRNA COVID-19 Vaccines:

Until more data are available, decisions about the timing of latent tuberculosis infection (LTBI) screening to facilitate initiation of oral or biologic therapy should involve a risk-benefit discussion between individual patients and their prescribers, which should consider individual epidemiologic risk factors for LTBI, treatment-related risk of LTBI reactivation (e.g., higher with TNFi), and urgency to initiate therapy. If TST or IGRA is done within 6 weeks after the first COVID-19 mRNA vaccine dose and there is a concern for a false negative result*, the test can be repeated ≥ 4 weeks after the second COVID-19 mRNA vaccine dose.

* https://www.cdc.gov/tb/publications/letters/covid19-mrna.html

----------------------------

Supporting language:

According to the CDC, not enough is known about COVID-19 mRNA vaccines to say definitively whether mRNA vaccination could interfere with tuberculin skin test (TST) and interferon gamma release assays (IGRA, e.g., Quantiferon Gold) by causing a false negative result. Ideally, the CDC recommends waiting 4 weeks after completion of a 2-dose mRNA COVID-19 vaccine series prior to latent TB (LTBI) screening. There are no data to inform or suggest that either test will impact efficacy of COVID-19 vaccination, nor any data to suggest an impact of mRNA vaccination on reactivity of TST or IGRA.

At present, the TF does not feel there are enough data to raise concern for an interference between COVID-19 vaccines and TST/IGRA results, and that for most patients, LTBI screening for biologic planning should proceed as planned, rather than be delayed; this should not change standard of care designed to optimize disease  control of patients who would benefit from an oral or biologic treatment for psoriatic disease.

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 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 with psoriatic disease treated with immunosuppressive or immune-modulating therapies that affect the immune system in a manner that may make a patient more susceptible to infection, 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), are ELIGIBLE for a 3rd dose “booster” mRNA COVID-19 vaccine as per the CDC. This booster vaccine should be administered at least 28 days following the two-dose regimen of the SAME vaccine, and only to patients ages 12 and older (Pfizer-BioNTech vaccine) or in patients ages 18 and older (Moderna vaccine and Pfizer-BioNTech vaccine). CDC has not issued recommendations for boosters in patients who received the one dose Ad26.COV2.S vaccine manufactured by Johnson & Johnson.

At this time, it is not known whether these treatments for psoriatic disease affect the benefits of COVID-19 vaccines, which are proven to be highly effective in preventing severe COVID-19 illness in the general population. The COVID-19 vaccines are safe and, to date, neither the CDC nor the FDA have seen evidence of a safety signal for these vaccines in terms of flaring existing psoriasis. Shared decision-making between clinicians and patients is recommended to guide discussions about the use of a 3rd booster dose of an mRNA vaccine.

Studies demonstrate that a third dose of an mRNA vaccine increases immunogenicity in transplant recipients, but it is not known whether a 3rd booster dose of an mRNA vaccine will result in additional clinically important benefits for patients with psoriatic disease taking immunosuppressive or immune-modulating treatments. Patients taking an immunosuppressive or immune-modulating treatment for psoriatic disease are predicted to be more likely to benefit from a 3rd booster mRNA-based COVID-19 vaccine in the following circumstances:

1.      People aged 50 or older, based on data from Israel.*

2.      People taking abatacept, cyclosporine, leflunomide, glucocorticoids (e.g., prednisone), methotrexate, or tofacitinib, based on evidence of modest reduction in antibody responses to mRNA-based vaccines for some of these treatments, or theoretical concerns based on their mechanism of action.

3.      People who received their second dose of an mRNA vaccine over 6 months ago.*

4.      People with underlying comorbidities 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)*

*Based on data from the general population

4-13

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 3rd “booster” mRNA 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 a booster dose of a mRNA 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).

CDC Links:

• https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/immuno.html
• https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-07/07-COVID-Oliver-508.pdf
• https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

FDA Link:

• https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-vaccine-dose-certain-immunocompromised

References regarding benefits of a 3rd dose mRNA vaccine:

• https://www.acpjournals.org/doi/10.7326/L21-0282
• DOI: 10.1056/NEJMc2111462; PMCID: PMC8262620
• https://www.nejm.org/doi/full/10.1056/NEJMc2111462

References regarding subgroups likely to benefit from a 3rd dose of a mRNA vaccine:

• https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(21)00212-5/fulltext
• https://www.acpjournals.org/doi/10.7326/M21-1451
• https://ard.bmj.com/content/early/2021/08/09/annrheumdis-2021-220597
• https://onlinelibrary.wiley.com/doi/full/10.1111/bjd.20479
• https://jamanetwork.com/journals/jama/fullarticle/2779852
• https://www.medrxiv.org/content/10.1101/2021.04.05.21254656v2
• https://www.kidney-international.org/article/S0085-2538(21)00348-3/fulltext
• https://ard.bmj.com/content/early/2021/08/09/annrheumdis-2021-220272
• https://ard.bmj.com/content/80/8/1098
• https://gut.bmj.com/content/early/2021/04/25/gutjnl-2021-324789
• https://onlinelibrary.wiley.com/doi/10.1111/ced.14631
• https://www.reuters.com/world/middle-east/israel-expands-covid-vaccine-booster-campaign-over-50s-health-workers-2021-08-13/
• https://www.nejm.org/doi/full/10.1056/nejmc2103916
• https://www.nejm.org/doi/full/10.1056/NEJMoa2109072

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 exposed to or 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 post-exposure prophylaxis:

Casirivimab and imdevimab to be administered together for patients meeting specific criteria and who are at high risk for progression to severe COVID-19 and/or hospitalization and have been exposed to an individual infected with SARS-CoV-2 or who are at high risk of exposure to an individual infected with SARS-CoV-2 (for example, a resident of a nursing home where an outbreak may be occurring).

For outpatients infected with SARS-CoV-2:

• Sotrovimab for patients meeting specific criteria and who are at high risk for progressing to severe COVID-19 and/or hospitalization

• Casirivimab and imdevimab to be administered together for patients meeting specific criteria and who are at high risk for progressing to severe COVID-19 and/or hospitalization

For hospitalized patients infected with SARS-CoV-2:

• Dexamethasone (systemic steroids) for patients meeting specific criteria

• Remdesivir treatment for patients meeting specific criteria

• Baricitinib, with or without remdesivir, for patients meeting specific criteria

• Tocilizumab, 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.

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. 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.