Brazilian Consensus on Psoriasis 2020 and Treatment Algorithm of the Brazilian Society of Dermatology

onia Sofia Ocampo-Garza: Conception and design of the tudy; acquisition of data; analysis and interpretation; draftng the article; final approval of the version submitted. Maira Elizabeth Herz-Ruelas: Conception and design of he study; analysis and interpretation; revising the article; nal approval of the version submitted. Sonia Chavez-Alvarez: Conception and design of the tudy; revising the article; final approval of the version subitted. David Marcelo de la Fuente-Rodriguez: Acquisition of ata; final approval of the version submitted. Jorge Ocampo-Candiani: Conception and design of the tudy; analysis and interpretation; revising the article; final pproval of the version submitted. with frontal fibrosing alopecia: a case series. Br J Dermatol. 2018;179:1402--3. 5. Marks DH, Manatis-Lornell A, Hagigeorges D, De Yu J, Senna MM. No difference in relevant potential allergens in SPF-containing facial moisturizers: implications in frontal fibrosing alopecia. Drugs Ther Perspect. 2019;35:347--9. 6. Thompson CT, Chen ZQ, Kolivras A, Tosti A. Identification of titanium dioxide on the hair shaft of patients with and without frontal fibrosing alopecia: A pilot study of 20 patients. Br J Dermatol. 2019;181:216--7. 7. Rudnicka L, Rokni GR, Lotti T, Wollina U, Fölster-Holst R, Katsambas A, et al. Allergic contact dermatitis in patients with frontal fibrosing alopecia: An international multi-center study. Dermatol Ther. 2020;33:e13560.

The elucidation of pathophysiological mechanisms and the development of new treatments for psoriasis require periodic updates in the publication of consensuses, algorithms and treatment guides.
In Brazil, the ethnic composition, increased longevity, in addition to climatic and insolation characteristics may imply unique epidemiological data and different regional prevalence rates of psoriasis, in addition to influence dis-ଝ How to cite this article: Romiti  ease severity and therapeutic response. Recent data from the Brazilian Society of Dermatology estimate the prevalence of psoriasis in Brazil at 1.31%, with 1.15% (95% CI 0.90% to 1.43%) in women and 1.47% (95% CI 1.11% to 1.82%) in men (p = 0.22). An increase in the prevalence of psoriasis (p < 0.01) was identified in relation to age groups, which was 0.58% (95% CI 0.31% to 0.84%) under the age of 30; 1.39% (95% CI 1.10% to 1.74%) between 30 and 60 years old; and 2.29% (95% CI 1.71% to 2.84%) in individuals over 60 years. The geographical regions of the country differed in terms of disease prevalence (p = 0.02), with higher indicators in the South and Southeast regions, in contrast to the Midwest, North and Northeast regions. 1 In parallel, 73.4% of Brazilian patients with moderate to severe psoriasis report impaired health-related quality of life. 2 The Brazilian Consensus on Psoriasis 2020 and the Treatment Algorithm of the Brazilian Society of Dermatology (SBD), created with the collaboration of experts from all regions of Brazil is shown below (Fig. 1).
In preparing this consensus, the stratification of the levels of evidence and their grade of recommendation was used, Grade of recommendation and strength of evidence 3 A: Experimental or observational studies of higher consistency.
B: Experimental or observational studies of lower consistency.
C: Case reports (uncontrolled studies). D: Opinion without critical evaluation consensus based, physiological studies or animal models.
In this document, we use the Delphi tool to obtain answers to non-consensual questions in the literature, through the anonymous collection of data among specialists on the subject. The Delphi method is defined as ''a data collection technique used to obtain consensus from a group of experts on a particular subject''. 4 Thus, a new treatment flowchart for severe psoriasis was validated and strategies were defined for the migration of therapies, designed for adoption in the Brazilian public or private health context, based on hearing the opinions of experts engaged in these health systems (Fig. 2).
Two rounds were held with the participation of 66 dermatologists who authored this consensus, from all regions of the country, with experience in the treatment of psoriasis. The online voting system (Survey Monkey ® ) was used, and the agreement of at least 70% of the experts was considered a consensus. The data obtained were statistically analyzed. The sample was obtained by appointment and submitted to a randomness test, which resulted in the non-rejection of randomness, with a significance of 5%. The results are shown in Table 1.
Mediated by the Brazilian Society of Dermatology, this instrument represents progress in the standardization of conduct, whether in public or private care, based on what we have available or aspire for the treatment of severe psoriasis. The existence of dissensus stimulates further debate on controversial and unanswered topics in the medical literature.
The high percentage of agreement in the other topics provides subsidies to professionals working in the area for the best therapeutic choices, instead of decisions based solely on the prescriber's experience. Such transparency is essential for everyone involved, whether managers of the supplementary health system or the Brazilian Unified Health System (SUS), physicians, patients, their families, and patient associations. 5

Financial support
Brazilian Society of Dermatology (SBD).

Authors' contributions
Ricardo Romiti: Design and planning of the study; data collection, or data analysis and interpretation; statistical analysis; drafting and editing of the manuscript or critical review of important intellectual content; collection, analysis, and interpretation of data; effective participation in research orientation; critical review of the literature; approval of the final version of the manuscript.
André Vicente Esteves de Carvalho: Design and planning of the study; data collection, or data analysis and interpretation; statistical analysis; drafting and editing of the manuscript or critical review of important intellectual content; collection, analysis, and interpretation of data; effective participation in research orientation; critical review of the literature; approval of the final version of the manuscript.  Table 1 Classification of respondents' opinions, per question, Brazil ---2020. Source: Study data.

Questions
Answers with the highest percentage of agreement

86.4% of agreement Consensus
Gleison V Duarte: Design and planning of the study; data collection, or data analysis and interpretation; statistical analysis; drafting and editing of the manuscript or critical review of important intellectual content; collection, analysis, and interpretation of data; effective participation in research orientation; critical review of the literature; approval of the final version of the manuscript.