Psoriasis and HIV infection

Use of ixekizumab in an HIV-positive patient with psoriatic arthritis

Psoriasis is a chronic immune-mediated disease of the skin. The incidence of psoriasis among people living with HIV (PLHIV) is higher than that in the general population. The mechanism is complex, the manifestations are varied, and the treatment is difficult. Biotherapy has greatly alleviated psoriasis, but clinical trials often exclude PLHIV, and evidence is limited to case reports. Here, we report a man living with psoriatic arthritis who had poor response to traditional treatments. After receiving the anti-interleukin (IL)-17 monoclonal antibody (ixekizumab), the arthritis symptoms were significantly relieved, while CD4⁺ T cell count increased and the viral load of HIV-1 remained undetectable in combination with antiretroviral therapy (ART). In conclusion, anti-IL-17 monoclonal antibody is a promising and safe treatment for psoriatic arthritis in HIV-positive patients.

Retrospective study of psoriasis in people living with HIV: Thailand's experience

Psoriasis in people living with HIV (PLHIV) has been reported as having particular clinical characteristics. However, most of the source data was derived from descriptive studies in Europe and the USA. This study was conducted to compare the characteristics of psoriasis in PLHIV to general psoriasis patients. We retrospectively reviewed the records of 73 cases of psoriasis in PLHIV and of 232 general psoriasis patients who visited a psoriasis clinic in Bangkok, Thailand. Psoriasis in PLHIV predominated in males (78.1%), with an older age of onset, significantly lower rates of nail involvement and psoriatic arthritis, but higher rates of co-infectious diseases than for general psoriasis patients. A low nadir CD4 T-cell count (<100 cells/μl) and CD4 T-cell count at psoriasis diagnosis were associated with a high body surface area (BSA) involvement. The mean BSA involvement in PLHIV was 24. Although 64.4% (47/73) of the PLHIV had moderate-to-high psoriasis severity, 29.8% of those (14/47) only received topical treatment. Acitretin was the most common drug used. Other therapies were rarely used, and no biologics were administered. In conclusion, psoriasis in PLHIV has several clinical features that differ from general psoriasis. PLHIV tend to receive substandard care for psoriasis, even in upper-middle-income countries.

Experience of using ustekinumab in the treatment of a patient with HIV-associated psoriasis and anogenital warts

The article presents an analysis of the literature of patients with HIV infection suffering from psoriasis. The clinical picture, laboratory data, and treatment of a patient suffering from psoriasis, psoriatic arthritis, anogenital venereal warts associated with HIV infection are described. Against the background of the use of an IL 12.23 inhibitor, regression of anogenital warts, resolution of psoriatic rashes, and relief of articular syndrome were noted.

The Use of Apremilast in Psoriasis: An Indian Perspective on Real-World Scenarios

Apremilast, an oral phosphodiesterase-4 inhibitor, is approved for use in the management of psoriasis and psoriatic arthritis. Although its efficacy and safety have been well established in clinical studies, in real-world settings, different practice scenarios have been reported. This review paper serves to evaluate clinical real-world scenarios and aspects of treatment for which the information in the literature was considered to be lacking or controversial. Following a literature review, a panel of five dermatologists with expertise in psoriasis considered five scenarios; namely, the positioning of apremilast in psoriasis, its use in difficult-to-treat areas, special conditions and populations, safety, dose titration and dose in maintenance therapy. These were then assessed with psoriasis experts in India using a web-based questionnaire. A total of 28 questions were discussed regarding these scenarios. According to the responses, apremilast is effective in stable mild to moderate psoriasis as monotherapy and in severe psoriasis in combination. Also, a positive response was received with regard to its effectiveness in difficult locations such as the scalp, palms and soles. To reduce adverse effects, prolonged titration therapy over 4 weeks is required and lower doses can be prescribed to maintain remission. Apremilast therapy should be continued for a minimum of 8 weeks once initiated to achieve the desired results, and the total duration of therapy should be about 24 weeks for better efficacy. It is also effective in many other cases, such as obese patients, patients with hepatitis B or C and HIV, or patients on polypharmacy. It was also reported that apremilast requires less prescreening and monitoring than other conventional and biologic systemic therapies. Overall, apremilast is an attractive option for the individualized treatment of psoriasis owing to its favorable safety profile, its ease of oral administration without the need for screening or ongoing laboratory monitoring, and its positive impact on symptoms and lesions in difficult-to-treat areas.

Biologic Treatment of 4 HIV-Positive Patients: A Case Series and Literature Review

The management of psoriatic disease in human immunodeficiency virus (HIV)-positive patients is challenging. Psoriasis in HIV-positive patients is often severe, progressive, and resistant to first- and second-line therapies, including topical treatments, phototherapy, highly active antiretroviral therapy (HAART), and oral retinoids. Other systemic agents used to treat psoriasis, such as methotrexate and cyclosporine, are immunosuppressants and thus many dermatologists may not feel comfortable prescribing them to HIV-positive patients who are already immunocompromised. Biologic agents, which target specific aspects of overactive immune pathways in psoriasis, have revolutionized the management of moderate-to-severe psoriasis. However, data is limited regarding their safety and efficacy in HIV-positive patients.

OBJECTIVE

Report four cases of HIV-positive patients managed on biologic therapy and summarize the cases of psoriasis in HIV-positive patients managed on biologic therapy that have been published in dermatologic literature to date.

METHODS

We searched PubMed and Embase databases using the terms HIV and psoriasis or HIV and psoriatic arthritis combined with one of the eleven biologics currently approved for treating psoriasis.

RESULTS

We identified 48 cases of anti-psoriasis biologic therapy (including adalimumab, infliximab, etanercept, ustekinumab, and guselkumab) in HIV-positive patients and added four. While data is limited, the evidence available suggests biologic agents are safe and efficacious in moderate-to-severe psoriasis and may even have a favorable effect on CD4 and HIV viral counts when used with concomitant HAART.

CONCLUSION

Further research would be helpful to establish practical guidelines for the use of anti-psoriasis biologic therapy in the HIV population, including that of newer agents.

Psoriasis in HIV infection: an update

Psoriasis is a prevalent systemic immune-mediated disease with cutaneous manifestations. In HIV-infected patients, psoriasis may have a higher incidence, present atypical and more exuberant clinical features, and is frequently recalcitrant to treatment. Despite this aggravated severity, treatment options for psoriasis in HIV-infected individuals remain limited due to the risk of fatal immunosuppression associated with both classical immunosuppressants and new biological drugs. Notwithstanding, drug therapy in psoriasis has been undergoing major advances for the last few years, with novel drugs approved, which could significantly add to the management of HIV-infected patients. It is therefore our aim to present a review of the available literature to highlight the updated evidence on psoriasis in HIV-infected individuals, particularly in regards to its epidemiology, proposed pathophysiology, clinical presentation, currently available therapeutic options, and future perspectives.

Hydroxyurea for the Treatment of Psoriasis with an Emphasis on HIV-Infected Psoriasis Patients: A Review

Hydroxyurea is a drug that has been long forgotten for the treatment of psoriasis. In addition to its anti-psoriatic effects, it has also been shown to have antiviral effects. This dual effect makes it a drug that dermatologists may want to consider when treating psoriasis in HIV-infected patients. Currently, no studies are available that discuss the safety and efficacy of hydroxyurea in the treatment of psoriasis in this immunocompromised group; however, numerous reports discuss the safety and efficacy of hydroxyurea in psoriasis and HIV separately. This review suggests that hydroxyurea is generally safe and effective. The main risk involves the hematologic adverse events (anemia, leukopenia, thrombocytopenia, and macrocytosis), which appear to be dose dependent. Because of the common hematologic adverse events, hydroxyurea may be considered a viable therapeutic option for patients with generalized psoriasis that is inadequately responsive to other safer options, whether or not the patient is HIV positive.

HIV-Associated Psoriasis

Human immunodeficiency virus (HIV) prevalence is increasing worldwide as people on antiretroviral therapy are living longer. These patients are often susceptible to debilitating inflammatory disorders that are frequently refractory to standard treatment. Psoriasis is a systemic inflammatory disorder, associated with both physical and psychological burden, and can be the presenting feature of HIV infection. In this population, psoriasis tends to be more severe, to have atypical presentations and higher failure rates with the usual prescribed treatments. Management of moderate and severe HIV-associated psoriasis is challenging. Systemic conventional and biologic agents may be considered, but patients should be carefully followed up for potential adverse events, like opportunist infections, and regular monitoring of CD4 counts and HIV viral loads.

Cytosolic RNA:DNA Duplexes Generated by Endogenous Reverse Transcriptase Activity as Autonomous Inducers of Skin Inflammation in Psoriasis

Psoriasis is a chronic skin disease of unknown ætiology. Recent studies suggested that a large amount of cytosolic DNA (cyDNA) in keratinocytes is breaking keratinocytes DNA tolerance and promotes self-sustained inflammation in the psoriatic lesion. We investigated the origin of this cyDNA. We show that, amongst all the possible DNA structures, the cyDNA could be present as RNA:DNA duplexes in keratinocytes. We further show that endogenous reverse transcriptase activities generate such duplexes and consequently activate the production of Th1-inflammatory cytokines. These observations open a new research avenue related to endogenous retroelements for the aetiology of psoriasis and probably of other human chronic inflammatory diseases.

Ostraceous and inverse psoriasis with psoriatic arthritis as the presenting features of advanced HIV infection

Knowledge of both the common and atypical presentations of human immunodeficiency virus (HIV)-associated dermatoses may be helpful in arousing suspicion of HIV, especially in patients with no reported risk factors. Herein, we report the case of an otherwise healthy, nonpromiscuous 29-year-old man who presented to our institution with an eight-week history of plaques with oyster shell-like scales on the trunk, extremities and genital area. The plaques were associated with fever, and intermittent knee pain and swelling. Initial diagnostic tests were suggestive of drug hypersensitivity syndrome, and the patient's condition improved with treatment using oral prednisone. However, the lesions recurred when the dose of prednisone was tapered, even after the culprit drug had long been discontinued. Repeat skin punch biopsy and arthrocentesis revealed a diagnosis of psoriasis vulgaris with psoriatic arthritis. Due to the atypical presentation of psoriasis, the patient was counselled to undergo HIV testing, which came back positive. Clinicians should be attuned to the skin signs heralding HIV/acquired immunodeficiency syndrome, in order to facilitate early diagnosis and treatment.

The impact of human immunodeficiency virus-related diseases on pigmented skin types

Infection with human immunodeficiency virus (HIV) remains a significant problem globally. Early diagnosis and treatment with antiretroviral drugs has considerably improved health outcomes and decreased disease-related morbidity. HIV infection is associated with a wide range of skin disorders enabling dermatologists to diagnose HIV as well as associated opportunistic infections early in the course of disease. Despite concerted efforts by international health organizations to limit disease incidence, the prevalence of HIV infection remains high and is highest in sub-Saharan Africa. The diagnosis of HIV-related skin diseases is challenging as immunosuppression often results in atypical disease presentation. In addition, the clinical presentation will vary in pigmented skin types. The aim of this article is to describe disease variation in pigmented skin types.

Psoriasis in patients with HIV infection: from the medical board of the National Psoriasis Foundation

BACKGROUND

Patients with psoriasis and HIV infection often present with more severe and treatment-refractory cutaneous disease. In addition, many of these patients have significant psoriatic arthritis. Many effective drugs for psoriasis and psoriatic arthritis are immunosuppressive. Therefore, therapy for the HIV-infected patient is more challenging, requiring both careful consideration of the potential risks and benefits of treatment and more fastidious monitoring for potential adverse events.

OBJECTIVE

A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options. Our aim was to arrive at a consensus on therapy for psoriasis in patients with HIV.

METHODS

A MEDLINE search of the terms "psoriasis," "psoriatic arthritis," "human immunodeficiency virus (HIV)," and "HIV skin diseases" was performed and literature relevant to HIV-associated psoriasis and the treatment of HIV-associated psoriasis were reviewed.

RESULTS

Based on a review of the literature, 29 reports were included as evidence in this review. Topical therapy is the first-line recommended treatment for mild to moderate disease. For moderate to severe disease, phototherapy and antiretrovirals are the recommended first-line therapeutic agents. Oral retinoids may be used as second-line treatment. For more refractory, severe disease, cautious use of cyclosporine, methotrexate, hydroxyurea, and tumor necrosis factor-alpha inhibitors may also be considered.

LIMITATIONS

There are no randomized, placebo-controlled trials evaluating the therapeutic efficacy or safety of treatments for patients with HIV-associated psoriasis; consequently, the evidence supporting this review consists mainly of case reports or case series.

CONCLUSIONS

HIV-associated psoriasis is often refractory to traditional treatments. Treatment is challenging and requires careful consideration and should be tailored to patients based on disease severity and the input from an infectious disease specialist. Close monitoring for potential adverse events is necessary.

Etanercept for the treatment of human immunodeficiency virus-associated psoriatic arthritis

Etanercept may play an important role in modulating the inflammatory activity and progression of human immunodeficiency virus (HIV)-associated psoriasis and psoriatic arthritis. We report the case of a 45-year-old homosexual man with a CD4 cell count of less than 0.05 x 10(9)/L and an HIV viral load of 4200 copies/mL (while receiving highly active antiretroviral therapy) who developed extensive psoriatic plaques, 4.5-kg weight loss, onychodystrophy, and psoriatic arthropathy with severe periarticular bone demineralization. The arthritis progressed despite the use of several disease-modifying medications, including corticosteroids, hydroxychloroquine, and minocycline. Because of uncontrolled, progressive, and disabling arthritis and resulting profound disability, he was treated with etanercept. Within 3 weeks, his psoriasis had improved dramatically and his joint inflammation had stabilized. For the next 4 months, immunologic and viral parameters remained stable, but his clinical course was complicated by frequent polymicrobial infections. Etanercept was thus discontinued despite continued improvements in his psoriasis, psoriatic arthritis, and functional status. While both cutaneous and joint manifestations of psoriasis improved dramatically, the experience with this patient dictates that caution and careful follow-up must be exercised when prescribing etanercept in the setting of HIV infection.

A retrospective survey of mucocutaneous manifestations of HIV infection in Malaysia: analysis of 182 cases

A retrospective analysis of 182 HIV positive Malaysians was done in two centers, the University Hospital Kuala Lumpur (UHKL) and the General Hospital Kuala Lumpur (GHKL) from March 1997 to February 1998. Demographic and clinical data were analyzed. The analysis showed that 130 out of 182 patients had mucocutaneous disorders (71.4%). In the study there were 125 males (96.2%) and 5 females (3.8%). The majority of the patients were in the age group from 20 to 50 years. The patients who presented with mucocutaneous disease also had low CD4+ T lymphocyte counts, and most of them had AIDS defining illnesses. The number of cases with generalized hyperpigmentation was very high (35.7%), followed by papular eruptions (29.1%) and xerosis (27.5%). Seborrheic dermatitis was seen in 19.2% of the cases and psoriasis in 7.7%. The most common infections were oral candida 35.7%, tinea corporis and onychomycosis 9.9%, and herpes infection 4.3%. However, mucocutaneous manifestations of Kaposi's sarcoma were rare. The results suggested that mucocutaneous findings are useful clinical predictors of HIV infection or a sign of the presence of advanced HIV infection.

Erythroderma: a comparison between HIV positive and negative patients

Background Erythroderma has protean underlying causes. There have been isolated case reports suggesting an association between erythroderma and the human immunodeficiency virus (HIV).

OBJECTIVE

To describe and characterize further the prevalence, etiology, and metabolic sequelae of erythroderma in HIV positive and negative patients. In a subset of patients, clinicopathologic correlation was performed.

METHOD

One hundred and thirty-eight consecutive patients were prospectively recruited over a one and a half year period at the skin clinic of King Edward VIII Hospital. Demographic, clinical, biochemical, and histologic data were recorded.

RESULTS

Seventy-five per cent of the patients were black, 22.5% Indian, and 2.5% white. The men to women ratio was 1.9 : 1. The mean age was 34. 7 years (range, 1 month to 85 years). Forty-three per cent of patients were HIV positive, of whom 90% were black. The commonest causes of erythroderma in the total sample were atopic dermatitis (23.9%), psoriasis (23.9%), and drug reactions (22.5%). The commonest cause in the HIV positive group was drug reactions (40.6%), the commonest being ethambutol (30.8%). HIV positive patients had a significantly lower (P < 0.05) white cell count (7.6 vs. 10.5 x 109 /L), hemoglobin (11.1 vs. 12.6 g/dL), platelets (278.3 vs. 378.0 x 109 /L), and albumin (25.4 vs. 28.7 g/L) and significantly higher serum urates (0.6 vs. 0.4 mM/L) than HIV negative patients. HIV positive patients did not have a significant increase in the number of episodes of erythroderma. Clinicopathologic correlation was greatest with psoriasis in the HIV negative group and with psoriasis and drug reactions in the HIV positive group.

CONCLUSIONS

A large proportion of erythrodermic patients in this study were HIV positive. Inflammatory dermatoses were the commonest cause of erythroderma in all the patients studied. Drug reactions were the commonest cause in HIV positive patients. In the young black patient, erythroderma may be a marker for HIV infection.

Mucocutaneous manifestations of HIV infection: a retrospective analysis of 145 cases in a Chinese population in Malaysia

BACKGROUND

Mucocutaneous lesions directly related to human immunodeficiency virus (HIV) infection usually present as initial manifestations of immune deficiency. The most common mucocutaneous lesions are Kaposi's sarcoma, histoplasmosis, oro-esophageal candidiasis, oral hairy leukoplakia, and, in Asia, Penicillium marneffei infection. Non-HIV-related skin lesions, such as psoriasis, seborrheic dermatitis, and nodular prurigo, may be the initial presentation among HIV infected patients attending outpatient clinics.

METHODS

A retrospective analysis was performed on 145 HIV-positive Malaysians of Chinese descent from two centers at the University Hospital Kuala Lumpur (UHKL) and the General Hospital Kuala Lumpur (GHKL) from March 1997 to February 1998. Demographic data and clinical data were analyzed.

RESULTS

The analysis showed that 104 out of 145 patients had mucocutaneous disorders (71.7%). In the study, there were 100 men (96.2%) and four women (3.8%). The majority of patients were in the age group 20-50 years. The patients who presented with mucocutaneous disease also had low CD4+ T-lymphocyte counts and most had acquired immunodeficiency syndrome (AIDS) defining illness. The number of cases with generalized hyperpigmentation was very high in the group (35.9%), followed by nodular prurigo (29.7%) and xerosis (27.6%). Seborrheic dermatitis was seen in 20.7% of cases, with psoriasis in 8.3%. The most common infections were oral candidiasis (35.9%), tinea corporis and onychomycosis (9.7%), and herpes infection (5.5%); however, mucocutaneous manifestations of Kaposi's sarcoma were rare.

CONCLUSIONS

The results suggest that mucocutaneous findings are useful clinical predictors of HIV infection or signs of the presence of advanced HIV infection.