Use of Systemic Therapies for Treatment of Psoriasis in People Living with Controlled HIV: Inference-Based Guidance from a Multidisciplinary Expert Panel

Background

People living with human immunodeficiency virus (PLHIV) have a similar prevalence of psoriasis as the general population, though incidence and severity correlate with HIV viral load. Adequately treating HIV early renders the infection a chronic medical condition and allows PLHIV with a suppressed viral load (PLHIV-s) to live normal lives. Despite this, safety concerns and a lack of high-level data have hindered the use of systemic psoriasis therapies in PLHIV-s.

Objectives

We aim to provide a structured framework that supports healthcare professionals and patients discussing the risks and benefits of systemic psoriasis therapy in PLHIV-s. Our goal was to address the primary question, are responses to systemic therapies for the treatment of psoriasis in PLHIV-s similar to those in the non-HIV population?

Methods

We implemented an inference-based approach relying on indirect evidence when direct clinical trial data were absent. In this instance, we reviewed indirect evidence supporting inferences on the status of immune function in PLHIV. Recommendations on systemic treatment for psoriasis in PLHIV were derived using an inferential heuristic.

Results

We identified seven indirect indicators of immune function informed by largely independent bodies of evidence: (1) functional assays, (2) vaccine response, (3) life expectancy, (4) psoriasis manifestations, (5) rate of infections, (6) rate of malignancies, and (7) organ transplant outcomes.

Conclusions

Drug-related benefits and risks when treating a patient with systemic psoriasis therapies are similar for non-HIV patients and PLHIV with a suppressed viral load and normalized CD4 counts. Prior to initiating psoriasis treatment in PLHIV, HIV replication should be addressed by an HIV specialist. Exercise additional caution for patients with a suppressed viral load and discordant CD4 responses on antiretroviral therapy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00722-0.

People living with human immunodeficiency virus (PLHIV) develop psoriasis as often as everyone else. We asked: what are effective and safe treatments when PLHIV need systemic therapy (pills or injections) for their psoriasis?

HIV infection attacks the immune system. When HIV is not treated, the immune system declines. A less effective immune system makes it harder for the body to fight infections and certain cancers. Psoriasis is a skin condition caused by overactive immune cells. Effective psoriasis treatments reduce immune-cell activity. There are some concerns that treatments for psoriasis may not work and could worsen infections or cancers.

To answer the question, we gathered 11 dermatologists and 4 HIV specialists. We reviewed the international scientific literature on PLHIV and psoriasis. The absence of direct evidence and volume of information to review made the process challenging. The end results were worthwhile.

We concluded that people who are diagnosed early and take antiretroviral therapy to control their HIV infection (PLHIV-c) can live long, healthy lives. Accordingly, we determined that PLHIV-c can likely expect the same safety and efficacy for systemic psoriasis treatments as the general population. Treatment decisions should be made on a case-by-case basis through consultation with the patient and treating physician(s).

Pillars of modern medicine are evidence-based care and collaborative decision-making. Too often, neither care provider nor patient are adequately informed. We have tried to fill one information gap for PLHIV and psoriasis. This process may help answer questions in other disease populations where direct evidence is scarce or absent.

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.

Comparison of guidelines for the use of Ustekinumab for psoriasis in the United States, Europe, and the United Kingdom: A critical appraisal and comprehensive review

The aim of this review is to compare and contrast evidence-based clinical practice guidelines from global dermatological organizations for the use of ustekinumab in psoriasis. Clinical practice guidelines from the American Academy of Dermatology, National Psoriasis Foundation, British Association of Dermatologists, and European S3 were reviewed and compared. Practice guidelines from the three dermatological organizations are similar with regards to treatment dosage and initiation but differ in their recommendations for baseline screening and interval laboratory monitoring, treatment in patients undergoing surgery or receiving live vaccines, and treatment contraindications. Ustekinumab is an effective and well-tolerated systemic treatment for patients with psoriasis and should be considered in the line of therapy that dermatologists discuss with their patients. Consideration should be given to evidence-based practice guidelines of global dermatology organizations to effectively guide treatment decisions in patients with psoriasis.

Effect of sofosbuvir plus daclatasvir for treatment of chronic hepatitis C on patients with psoriasis

AIM

Until recently, clinicians caring for patients with psoriasis who were infected with hepatitis C virus (HCV) were concerned that treating one condition could exacerbate the other. We evaluated the outcome of treatment with direct-acting antiviral agents (DAAs) on patients with psoriasis having chronic hepatitis C (CHC) infection.

PATIENTS AND METHODS

This was an observational prospective cross-sectional study. It included CHC-naive patients with plaque psoriasis. All patients received sofosbuvir plus daclatasvir once daily for 12 weeks for treatment of CHC. Psoriasis area severity index (PASI) scores and the dermatology quality-of-life index were evaluated at the start of treatment with DAAs and then at 12 and 24 weeks after the end of HCV treatment. The primary end point was sustained virological response 12 weeks after treatment (SVR12).

RESULTS

A total of 34 CHC-naive patients were enrolled in this study. Most of them were of male sex (76.5%), and most of them had severe psoriasis, as the mean PASI score was 32. The primary and secondary end points (SVR12 and SVR24) for our patients were 100%. Regarding PASI and dermatology quality-of-life index scores, there was a highly significant difference before start of treatment and after treatment at 12 and 24 weeks. The most common adverse events are fatigue and headache.

CONCLUSION

Sofosbuvir plus daclatasvir is effective in the eradication of HCV and improvement of symptoms in patients with psoriasis having CHC infection. Future large series studies are needed to evaluate this promising effect of DAAs.

Case of coincident severe acne and psoriasis in AIDS patient successfully treated with antiretroviral therapy

Cutaneous disorders remain a major problem in HIV-infected patients, even under antiretroviral therapy (ART). Patients at any stage of HIV/AIDS may suffer from skin lesions. Acnes and psoriasis are both common chronic and inflammatory skin diseases, and the treatment becomes more challenging and complex when combined with HIV infection. Whether the incidence and severity of acne and psoriasis are related to HIV infection is still controversial. Here, we report a rare case of an AIDS patient who developed severe acne along with psoriasis. The patient had initially received multiple systemic and topical antipsoriatic and anti-acne treatments which failed. Ultimately, he achieved dramatic clinical improvement after initiation of ART for main treatment. An 8-year follow up demonstrated that the patient has been free of symptoms of both psoriasis and acne till now.

Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics

Psoriasis is a chronic, inflammatory multisystem disease that affects up to 3.2% of the US population. This guideline addresses important clinical questions that arise in psoriasis management and care, providing recommendations based on the available evidence. The treatment of psoriasis with biologic agents will be reviewed, emphasizing treatment recommendations and the role of the dermatologist in monitoring and educating patients regarding benefits as well as associated risks.

HIV-associated psoriasis: Epidemiology, pathogenesis, and management

People living with HIV (PLWH) are affected by a higher incidence skin disorders, which are often associated with high morbidity and mortality. In particular, psoriasis affects PLWH severely and for a longer time than the general population. Human immunodeficiency virus (HIV) infection is characterized by a progressive decrease in CD4⁺ T-cell count, and it could seem paradoxical that psoriasis exacerbations are more frequent in this subset of patients than the general population, even though it is commonly observed at any stage of infection. For a long time, there have been limited therapeutic choices for PLWH affected by psoriasis. The introduction of the combined antiretroviral therapy dramatically changed the natural course of both HIV and psoriasis in PLWH, leading to an improvement of quality and duration of life. However, the clinical severity of psoriasis in PLWH often requires the use of immunosuppressant drugs. Knowledge about their safety and efficacy are limited to case-reports, small case-series and studies, therefore their use has not yet entered the routine. Further studies are needed to determine if immunosuppressive drugs can be safely and effectively used in PLWH affected by psoriasis and other autoimmune disorders.

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.

Italian guidelines on the systemic treatments of moderate-to-severe plaque psoriasis

Psoriasis is a common disease, which has a considerable impact on the healthcare system. Therefore, appropriate use of therapeutic resources is very important. Management of psoriasis in daily clinical practice is highly variable because many issues are still debated and not definitely addressed by the evidence-based medicine. Moreover, the different availability and reimbursability of drugs in each country justifies national guidelines. Expert consensus can provide helpful guidelines for optimizing patient care. A total of 20 dermatologists from different areas of Italy and with large experience in the treatment of psoriasis agreed to participate in the guidelines expert panel who aimed to reach consensus on the factors influencing psoriasis severity, the indications for systemic treatments, the parameters to be considered in the choice of treatment, and the factors to be considered in the choice of biological treatment. The recommendations for the use, screening and monitoring of systemic therapies were based on the 2015 S3 European Dermatology Forum/European Academy of Dermatology and Venereology psoriasis guidelines. Recommendations on the treatment of psoriasis in special patient populations were also agreed. The final document was discussed in a meeting moderated by a facilitator with participation of the entire group and adopting a nominal group technique to reach consensus. A statement was regarded as consented when agreement was achieved by at least 75% of the voting experts according to the Delphi procedure.

Systematic review of the efficacy and safety of biological therapy for inflammatory conditions in HIV-infected individuals

Biologic therapies are injectable immunomodulatory agents directed against specific immune cell or chemical targets. They have transformed the lives of HIV-uninfected individuals with severe inflammatory conditions including psoriasis, rheumatoid arthritis, and ulcerative colitis. The perceived increased infection risk associated with these agents means that HIV-infected individuals have not been included in randomised control trials of these drugs. The literature for use of biologic therapies in HIV-infected populations is limited to case reports and case series. There are additional data on use of rituximab, a monoclonal antibody against B lymphocytes, in the setting of HIV-associated haematological malignancy. We performed a systematic review of efficacy and safety of biologic therapy for inflammatory conditions in HIV-infected individuals. Our systematic review identified 37 treatment episodes with six different biologic agents encompassing 10 different inflammatory conditions. Broadly, efficacy of the agents studied was comparable to reports from HIV-uninfected patients. Both infectious and non-infectious sequelae were also comparable with trial data from HIV-uninfected patients. HIV control, even for the minority of individuals not receiving anti-retroviral therapy (ART) at the time of biologic therapy, was not adversely affected. However, detail was limited concerning ART regimens and both immunological and virological parameters of follow-up. Overall available literature is of very low quality and likely subject to publication bias of successful cases. Firm conclusions are not possible regarding the efficacy and safety of biologic agents in HIV-infected individuals; however, there appear to be sufficient data to warrant inclusion of individuals with well-controlled HIV in future trial studies.

Erythrodermic psoriasis: pathophysiology and current treatment perspectives

Erythrodermic psoriasis (EP) is a rare and severe variant of psoriasis vulgaris, with an estimated prevalence of 1%-2.25% among psoriatic patients. The condition presents with distinct histopathologic and clinical findings, which include a generalized inflammatory erythema involving at least 75% of the body surface area. The pathogenesis of EP is not well understood; however, several studies suggest that the disease is associated with a predominantly T helper 2 (Th2) phenotype. Given the morbidity and potential mortality associated with the condition, there is a need for a better understanding of its pathophysiology. The management of EP begins with a comprehensive assessment of the patient's presentation and often requires multidisciplinary supportive measures. In 2010, the medical board of the US National Psoriasis Foundation published consensus guidelines advocating the use of cyclosporine or infliximab as first-line therapy in unstable cases, with acitretin and methotrexate reserved for more stable cases. Since the time of that publication, additional information regarding the efficacy of newer agents has emerged. We review the latest data with regard to the treatment of EP, which includes biologic therapies such as ustekinumab and ixekizumab.

Novel factors in the pathogenesis of psoriasis and potential drug candidates are found with systems biology approach

Psoriasis is a multifactorial inflammatory skin disease characterized by increased proliferation of keratinocytes, activation of immune cells and susceptibility to metabolic syndrome. Systems biology approach makes it possible to reveal novel important factors in the pathogenesis of the disease. Protein-protein, protein-DNA, merged (containing both protein-protein and protein-DNA interactions) and chemical-protein interaction networks were constructed consisting of differentially expressed genes (DEG) between lesional and non-lesional skin samples of psoriatic patients and/or the encoded proteins. DEGs were determined by microarray meta-analysis using MetaOMICS package. We used STRING for protein-protein, CisRED for protein-DNA and STITCH for chemical-protein interaction network construction. General network-, cluster- and motif-analysis were carried out in each network. Many DEG-coded proteins (CCNA2, FYN, PIK3R1, CTGF, F3) and transcription factors (AR, TFDP1, MEF2A, MECOM) were identified as central nodes, suggesting their potential role in psoriasis pathogenesis. CCNA2, TFDP1 and MECOM might play role in the hyperproliferation of keratinocytes, whereas FYN may be involved in the disturbed immunity in psoriasis. AR can be an important link between inflammation and insulin resistance, while MEF2A has role in insulin signaling. A controller sub-network was constructed from interlinked positive feedback loops that with the capability to maintain psoriatic lesional phenotype. Analysis of chemical-protein interaction networks detected 34 drugs with previously confirmed disease-modifying effects, 23 drugs with some experimental evidences, and 21 drugs with case reports suggesting their positive or negative effects. In addition, 99 unpublished drug candidates were also found, that might serve future treatments for psoriasis.