PUVA therapy is preferable to UVB phototherapy in the management of HIV-associated dermatoses

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.

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.

HIV-associated pruritus: etiology and management

With the advent of highly active antiretroviral therapy (HAART), life-threatening opportunistic infection has become less common in patients with HIV infection and longevity has increased dramatically. With increased longevity, the problems of living with a chronic disease have become more prominent in this patient population. Disorders such as fat redistribution and metabolic abnormalities can result from antiviral medications and from HIV disease itself. Pruritus is one of the most common symptoms encountered in patients with HIV. The spectrum of skin diseases in such patients encompasses dermatoses of diverse etiologies; a few are peculiar to patients with HIV while others are not. Some of these conditions may cause severe and sometimes intractable pruritus that provokes scratching, picking, disfigurement, sleep loss, and significant psychological stress. Moreover, the expense of ongoing medical treatments can be daunting. Skin rash can sometimes be the initial presentation of HIV infection or serve as a harbinger of disease progression. Causes of pruritus include skin infections, infestations, papulosquamous disorders, photodermatitis, xerosis, drug reactions, and occasionally lymphoproliferative disorders. Drug eruptions are particularly common in patients who are HIV positive, presumably as a result of immune dysregulation, altered drug metabolism, and polypharmacy. Itching can also result from systemic diseases such as chronic renal failure, liver disease, or systemic lymphoma. Workup of pruritus should include a careful examination of the skin, hair, nails, and mucous membranes to establish a primary dermatologic diagnosis. If no dermatologic cause is found, a systemic cause or medication-related etiology should be sought. Idiopathic HIV pruritus is a diagnosis of exclusion and should only be considered when a specific diagnosis cannot be established. The management of HIV-associated pruritus should be directed at the underlying condition. Phototherapy has been found to be useful in the treatment of several HIV-associated dermatoses and idiopathic pruritus as well. Unfortunately, some of the treatments that have been suggested for patients with HIV are anecdotal or based on small uncontrolled studies. The last decade has seen a surge in the utilization of HAART which, to some degree, reconstitutes the immune system and ameliorates some dermatologic diseases. On the other hand, some skin diseases flare temporarily when HAART is started. Unless frank drug allergy is suspected, HAART does not need to be stopped.

HIV and AIDS in inpatient dermatology. Approach to the consultation

In the inpatient setting, the dermatologic consultant is called on to address the whole spectrum of cutaneous disease seen in HIV/AIDS patients, with severity varying from severe life-threatening to less serious conditions that dramatically affect quality of life. Rather than reviewing a "laundry list" of conditions associated with HIV/AIDS or the most severe conditions, this article aims to demonstrate a systematic approach to inpatient dermatology consultation in HIV/AIDS patients and to briefly review several common and interesting topics frequently addressed in the inpatient setting (e.g., medications issues, and phototherapy in HIV-infected patients).

Spectroscopic detection of photoproducts in lecithin model system after 8-methoxypsoralen plus UV-A treatment

Photoreactions of 8-methoxypsoralen (8-MOP) in the presence of synthetic lecithins esterified at the beta-position with linoleic/oleic and gamma-palmitic acid (PCd2/d1pal) have been studied. Following UV-A (320-400 nm) irradiation, the photoproducts separated by thin-layer chromatography are analysed by UV absorption spectroscopy, nuclear magnetic resonance and mass spectroscopy. The new isolated products are lecithin double cyclobutane adducts, PC-(8-MOP)2, fatty acid-8-MOP split adducts from phosphatidylcholine and lecithin adducts with photo-oxidized 8-MOP. The photolysis performed in the presence of 8-MOP is related to the previously reported lecithin cyclobutane adducts with psoralen. A hypothetical scheme of lecithin photolysis under PUVA (psoralen + UV-A) treatment is proposed. We suggest that photolysis of lecithin may have a significant role in the chain of reactions triggered in cell membrane submitted to PUVA treatment.

HIV-positive patients differ from HIV-negative patients in indications for and type of UV therapy used

BACKGROUND

Treatments using UV, UVB, or oral psoralen and UVA (PUVA) have been advocated for the care of HIV-infected persons with skin diseases. Concerns about the safety of these treatments exist.

OBJECTIVE

We attempted to determine the characteristics of HIV infected persons receiving UV therapy and establish the reasons for and type of treatment administered.

METHODS

During two 2-week periods, we prospectively ascertained basic information on all patients treated at 40 phototherapy clinics and detailed clinical information on patients known to be infected with HIV.

RESULTS

We identified 3716 persons receiving UV therapy, including 311 known to be infected with HIV. When compared with patients not known to be infected with HIV, HIV-positive patients were significantly more likely to be treated with UVB rather than PUVA and were more likely to be treated for pruritic conditions rather than psoriasis.

CONCLUSION

There were great variations in the relative reliance on UVB and PUVA among centers. There appears to be no agreement as to which type of UV therapy is optimal for patients infected with HIV. Most patients known to the treating clinician to be HIV positive are in the advanced stages of HIV disease. The number of persons with less advanced HIV disease receiving treatment remains unquantified but may be even more clinically important.

Ultraviolet therapy of HIV-infected individuals: a panel discussion

Patients infected with the human immunodeficiency virus (HIV) frequently develop skin diseases that are responsive to ultraviolet (UV) radiation. Studies on the effects of UV on HIV and on the immune system in vitro and in transgenic animals have raised questions regarding the safety of UV exposure in these patients. In this article, invited experts address issues concerning the safety of ultraviolet therapy in HIV-infected patients by discussing their clinical and/or research experience.