Common Approach to Metabolic-Associated Fatty Liver Disease in Patients With Psoriasis: Consensus-Based Recommendations From a Multidisciplinary Group of Experts

Recent years have seen concerted efforts to understand the relation between psoriasis and metabolic-associated fatty liver disease (MAFLD). Not only is MALFD diagnosed more often in patients with psoriasis, but its clinical course is also more aggressive. A common approach is therefore needed to enable early detection of liver disease coincident with psoriasis. Especially important is an analysis of risks and benefits of potentially hepatotoxic treatments. This consensus paper presents the recommendations of a group of experts in dermatology and hepatology regarding screening for MALFD as well as criteria for monitoring patients and referring them to hepatologists when liver disease is suspected.

[[Translated article]]Common Approach to Metabolic-Associated Fatty Liver Disease in Patients With Psoriasis: Consensus-Based Recommendations From a Multidisciplinary Group of Experts

Recent years have seen concerted efforts to understand the relation between psoriasis and metabolic-associated fatty liver disease (MAFLD). Not only is MALFD diagnosed more often in patients with psoriasis, but its clinical course is also more aggressive. A common approach is therefore needed to enable early detection of liver disease coincident with psoriasis. Especially important is an analysis of risks and benefits of potentially hepatotoxic treatments. This consensus paper presents the recommendations of a group of experts in dermatology and hepatology regarding screening for MALFD as well as criteria for monitoring patients and referring them to hepatologists when liver disease is suspected.

Characterization and Outcomes in Patients Treated With Apremilast in Routine Clinical Practice in Spain: Results From the APPRECIATE Study

BACKGROUND AND OBJECTIVES

It is necessary to expand the knowledge in the use of apremilast in clinical practice. The APPRECIATE study (NCT02740218) aims to describe the characteristics of patients with psoriasis treated with apremilast, to evaluate their perspectives and those of dermatologists, as well as the outcomes obtained in clinical practice in Spain.

METHODS

Observational, retrospective, cross-sectional, multicenter study of patients with chronic plaque psoriasis who could be contacted 6 (±1) months after apremilast initiation. The data were obtained from medical records and questionnaires from patients and physicians.

RESULTS

A total of 80 patients were evaluated; at apremilast onset, they showed mean (standard deviation, SD) Psoriasis Area and Severity Index (PASI) = 8.3 (5.3), mean (SD) Dermatology Life Quality Index (DLQI) = 8.9 (6.6). At six months, 58.8% (n=47) of patients continued apremilast treatment (discontinuations due to lack of efficacy [16.3%], safety/tolerability [20.0%]). In patients continuing treatment, PASI75 was achieved by 36.7% of patients; mean (95% CI) DLQI score was 2.2 (0.7-3.6) and mean (SD) Patient Benefit Index score was 2.8 (0.8). Compliance with physicians' expectations was correlated with benefits reported by patients (r=0.636). Adverse events were reported by 56.3% of patients (the most common were diarrhoea and nausea).

CONCLUSIONS

Patients receiving apremilast for 6 months in Spanish clinical practice, reported substantial improvements in their quality of life (mean DLQI reduced by more than 6 points) and disease severity (PASI75 achieved by over one-third of patients), despite less skin involvement than patients who enrolled in clinical trials.

Direct-to-Patient Teledermatology During COVID-19 Lockdown in a Health District in Madrid, Spain: The EVIDE-19 Pilot Study

Background

Dermatologic care was halted because of the coronavirus disease 2019 pandemic, prompting us to study the usefulness of direct-to-patient teledermatology via a mobile application. We aimed to evaluate the service as a tool for avoiding face-to-face consultations, describe the main conditions diagnosed, and assess levels of patient and physician satisfaction.

Material and method

Prospective descriptive study of new patients who met the inclusion criteria. Descriptive statistics for all variables were analyzed with SPSS.

Results

Of the 1,497 patients who agreed to participate in the study, 25% (n = 374) sent an image to a consultant dermatologist through the mobile application. Sixty-four patients (17%) were discharged directly and referred to primary care for follow-up. A face-to-face consultation was avoided for at least 3 months in 85% of patients (n = 318); 87.1% (n = 325) received a diagnosis and the dermatologist's level of confidence in this diagnosis was 7 or higher in 77.5% of cases (n = 290). The quality of the images sent was considered sufficient in 52.1% of cases. Patients rated their satisfaction with a score of 4.5 out of 5. Eleven of the 16 dermatologists rated their satisfaction as good overall. The most common conditions were inflammatory and melanocytic lesions. The main diagnoses were nevi, acne, and eczema.

Discussion

Direct-to-patient store-and-forward teledermatology is an effective means of evaluating new patients. Both clinicians and patients expressed high levels of satisfaction with the service. Systems enabling the addition of digital images to patient records are necessary to ensure the efficiency of teledermatology.

Tralokinumab for moderate-to-severe atopic dermatitis: results from two 52-week, randomized, double-blind, multicentre, placebo-controlled phase III trials (ECZTRA 1 and ECZTRA 2)

Background

Tralokinumab, a fully human monoclonal antibody, specifically neutralizes interleukin‐13, a key cytokine driving peripheral inflammation in atopic dermatitis (AD). In phase II studies, tralokinumab combined with topical corticosteroids provided early and sustained improvements in AD signs and symptoms.

Objectives

To evaluate the efficacy and safety of tralokinumab monotherapy in adults with moderate‐to‐severe AD who had an inadequate response to topical treatments.

Methods

In two 52‐week, randomized, double‐blind, placebo‐controlled, phase III trials, ECZTRA 1 and ECZTRA 2, adults with moderate‐to‐severe AD were randomized (3 : 1) to subcutaneous tralokinumab 300 mg every 2 weeks (Q2W) or placebo. Primary endpoints were Investigator’s Global Assessment (IGA) score of 0 or 1 at week 16 and ≥ 75% improvement in Eczema Area and Severity Index (EASI 75) at week 16. Patients achieving an IGA score of 0 or 1 and/or EASI 75 with tralokinumab at week 16 were rerandomized to tralokinumab Q2W or every 4 weeks or placebo, for 36 weeks. The trials were registered with ClinicalTrials.gov: NCT03131648 and NCT03160885.

Results

At week 16, more patients who received tralokinumab vs. placebo achieved an IGA score of 0 or 1: 15·8% vs. 7·1% in ECZTRA 1 [difference 8·6%, 95% confidence interval (CI) 4·1–13·1; P = 0·002] and 22·2% vs. 10·9% in ECZTRA 2 (11·1%, 95% CI 5·8–16·4; P < 0·001) and EASI 75: 25·0% vs. 12·7% (12·1%, 95% CI 6·5–17·7; P < 0·001) and 33·2% vs. 11·4% (21·6%, 95% CI 15·8–27·3; P < 0·001). Early improvements in pruritus, sleep interference, Dermatology Life Quality Index, SCORing Atopic Dermatitis and Patient‐Oriented Eczema Measure were observed from the first postbaseline measurements. The majority of week 16 tralokinumab responders maintained response at week 52 with continued tralokinumab treatment without any rescue medication (including topical corticosteroids). Adverse events were reported in 76·4% and 61·5% of patients receiving tralokinumab in ECZTRA 1 and ECZTRA 2, respectively, and in 77·0% and 66·0% of patients receiving placebo in ECZTRA 1 and ECZTRA 2, respectively, in the 16‐week initial period.

Conclusions

Tralokinumab monotherapy was superior to placebo at 16 weeks of treatment and was well tolerated up to 52 weeks of treatment.

What is already known about this topic?

Atopic dermatitis (AD) is a chronic interleukin (IL)‐13‐mediated disease.

There is a need for safe and effective long‐term treatment options for AD.

Tralokinumab is a fully human monoclonal antibody that binds specifically to IL‐13 with high affinity, thereby preventing receptor interaction and subsequent downstream signalling.

Tralokinumab combined with topical corticosteroids showed early and sustained efficacy and safety in a 12‐week, phase IIb trial in moderate‐to‐severe AD.

What does this study add?

These are the first pivotal phase III trials demonstrating that by specifically targeting IL‐13 alone, patients can achieve significant improvements in AD signs and symptoms and quality of life, and maintain these improvements over time without the requirement for topical corticosteroids.

These trials provide evidence that tralokinumab offers a long‐term, well‐tolerated treatment option for patients with moderate‐to‐severe AD.

Linked Comment: Morra and Drucker. Br J Dermatol 2021; 184:386–387.

Plain language summary available online

Direct-to-Patient Teledermatology During COVID-19 Lockdown in a Health District in Madrid, Spain: The EVIDE-19 Pilot Study

Antecedentes

Como consecuencia de la pandemia por la COVID-19 cesó la actividad dermatológica asistencial, por lo que iniciamos un estudio para evaluar la utilidad de la teledermatología (TD) directa entre paciente y dermatólogo a través de una App. El objetivo fue evaluar el impacto de esta herramienta para evitar consultas presenciales, así como describir los principales diagnósticos y la satisfacción de pacientes y médicos.

Material y método

Estudio descriptivo prospectivo. Se incluyen pacientes nuevos que cumplen criterios de inclusión. Se realizó un análisis descriptivo de todas las variables mediante el programa estadístico SPSS.

Resultados

De los 1.497 pacientes que aceptaron participar el 25% (n = 374) enviaron una consulta virtual con imagen. De entre ellos el 17% (n = 64) fueron dados de alta de forma directa para control por atención primaria. En un 85% (n = 318) de los pacientes se logra evitar la consulta presencial durante al menos 3 meses. Se emitió un diagnóstico en el 87,1% (n = 325) de los pacientes, siendo la confianza en el diagnóstico ≥ 7/10 en el 77,5% (n = 290). La calidad de la imagen fue suficiente en el 52,1%. La satisfacción del paciente fue de 4,5/5. Once de 16 dermatólogos consideraron la TD útil globalmente. La afección más frecuente fue la inflamatoria y melanocítica, siendo los diagnósticos más habituales nevus, acné y eccema.

Discusión

La TD directa asíncrona es una herramienta eficaz para valorar pacientes nuevos, con un alto grado de satisfacción para médicos y pacientes. El desarrollo de un sistema de TD eficiente implica la integración de la imagen digital en los sistemas de información médicos.

Real-world effectiveness and safety of apremilast in psoriasis at 52 weeks: a retrospective, observational, multicentre study by the Spanish Psoriasis Group

BACKGROUND

Little has been published on the real-world effectiveness and safety of apremilast in psoriasis.

OBJECTIVES

To evaluate the effectiveness, safety and drug survival of apremilast at 52 weeks in patients with moderate to severe plaque psoriasis or palmoplantar psoriasis in routine clinical practice.

METHODS

Retrospective, multicentre study of adult patients with moderate to severe plaque psoriasis or palmoplantar psoriasis treated with apremilast from March 2016 to March 2018.

RESULTS

We studied 292 patients with plaque psoriasis and 85 patients with palmoplantar psoriasis. The mean (SD) Psoriasis Area and Severity Index (PASI) score was 10.7 (7.0) at baseline and 3.0 (4.2) at 52 weeks. After 12 months of treatment, 73.6% of patients had a PASI score of 3 or less. In terms of relative improvement by week 52, 49.7% of patients achieved PASI-75 (≥75% reduction in PASI score) and 26.5% achieved PASI-90. The mean physician global assessment score for palmoplantar psoriasis fell from 4.2 (5.2) at baseline to 1.3 (1.3) at week 52. Overall drug survival after 1 year of treatment with apremilast was 54.9 %. The main reasons for treatment discontinuation were loss of efficacy (23.9%) and adverse events (15.9%). Almost half of the patients in our series (47%) experienced at least one adverse event. The most common events were gastrointestinal problems.

CONCLUSIONS

Apremilast may be a suitable alternative for the treatment of moderate to severe psoriasis and palmoplantar psoriasis. Although the drug has a good safety profile, adverse gastrointestinal effects are common.

The Use of Apremilast in Psoriasis: A Delphi Study

BACKGROUND

Experience in the use of apremilast in clinical practice complements the information available from pivotal clinical trials.

MATERIAL AND METHOD

Following a review of the literature, a panel of dermatologists with expertise in the management of psoriasis considered 5 scenarios in which the evidence supporting the use of apremilast to treat moderate psoriasis is insufficient or controversial. These scenarios were then assessed using a Delphi questionnaire.

RESULTS

Consensus was reached on 96 (67%) of the 143 items (positive in 85 and negative in 11). The therapeutic goal for apremilast should be based on 4 outcomes: clinical response, symptoms, quality of life, and patient satisfaction. The scenario in which the use of apremilast was considered to have the greatest possibility of success was in patients with stable moderate psoriasis. Most of the clinicians considered apremilast to be an appropriate treatment when conventional therapies fail or are contraindicated, preferably before the prescription of biologic therapy. Consensus was reached that apremilast is an appropriate treatment for psoriasis in difficult locations, such as the scalp or the palms and soles. It was also agreed that apremilast requires less prescreening and monitoring than other conventional and biologic systemic therapies.

CONCLUSIONS

Apremilast could be a treatment option for patients with a different profile to that of clinical trial participants. The limitations of this proposal are the absence of consensus on the definition of moderate psoriasis, the lack of real-world evidence on the use of apremilast, and certain aspects related to tolerability.

Perception of psoriasis treatment in the outpatient setting: survey of patients and their prescribing physicians

BACKGROUND

Patients' perception of disease management can influence compliance to treatment and thus affect outcome.

OBJECTIVE

To survey patients and physicians on their perceptions of biologic therapy for treating psoriasis in an outpatient setting.

METHODS

The subjective impact of intravenous treatment of severe psoriasis on patients and physicians in the outpatient setting was determined via two surveys.

RESULTS

Between September and November 2014, 24 dermatologists and 90 patients were surveyed. Treatment with biologic agents in the outpatient setting was associated with a high level of patient satisfaction: 93.3% of patients considered their psoriasis well controlled and 46.1% reported complete control. Patients highly valued the feeling of greater disease control (72.2%), regular follow-up (66.7%) and rapid improvement of psoriasis (58.9%) when attending an outpatient setting. Other positive aspects of outpatient treatment were control of other health issues and perceived improvements in quality of life (QoL). Outpatient attendance was high; with 90% of patients keeping scheduled appointments and 79.2% of physicians acknowledged that they were able to monitor their patients' condition more closely.

CONCLUSION

Administration of treatment in an outpatient setting may provide a feeling of improved QoL and disease control.

Safety and effectiveness of ustekinumab and antitumour necrosis factor therapy in patients with psoriasis and chronic viral hepatitis B or C: a retrospective, multicentre study in a clinical setting

BACKGROUND

Both the safety and efficacy of biologic therapy may be affected in the presence of highly prevalent chronic viral hepatitis.

OBJECTIVE

To evaluate the safety and effectiveness of ustekinumab and antitumour necrosis factor therapy in patients with psoriasis and concomitant chronic viral hepatitis.

METHODS

This was a retrospective, multicentre study. Twenty-five patients with psoriasis and concurrent hepatitis C virus (HCV) (20 patients) or hepatitis B virus (HBV) (five patients) infection who had received at least one biologic agent (etanercept, 21 treatments; adalimumab, four; ustekinumab, four; infliximab, two) were included. Clinical, imaging and laboratory data were recorded.

RESULTS

In the case of HCV infection, the majority of the patients did not exhibit increases in their viral load or serum liver tests. Aspartate aminotransferase, alanine aminotransferase and gamma glutamyl transpeptidase were doubled from the baseline measurement in only one patient treated with etanercept. Two other cases exhibited viral load increases during the follow-up period. In total, 18 of the 26 treatments achieved a 75% improvement in their Psoriasis Area and Severity Index (PASI 75) score during the follow-up period. Two patients treated with etanercept were diagnosed with hepatocellular carcinoma. In the case of HBV infection, all of the patients were being treated with antiviral therapy, and none presented significant variations in viral load or serum liver enzymes. All patients achieved a PASI 75 during follow-up.

CONCLUSIONS

Biologic therapy was effective and safe for the majority of our patients with HCV and HBV infection, although there may be a risk of reactivation or aggravation. We describe the first cases to receive ustekinumab. The use of biologics should be limited to those cases in which the risk-benefit ratio is justified.

Mid-follicular LH supplementation in women aged 35-39 years undergoing ICSI cycles: a randomized controlled study

This single-centre, randomized, parallel group, comparative study aimed to identify potential benefits of mid-follicular recombinant human LH (r-HLH) supplementation in women aged 35-39 years undergoing ovarian stimulation for intracytoplasmic sperm injection (ICSI). The main endpoint was the number of metaphase II oocytes retrieved. After pituitary suppression with a gonadotrophin-releasing hormone agonist, ovarian stimulation was initiated with recombinant human FSH (r-HFSH; 300-450 IU/day). On stimulation day 6, patients were randomized to receive r-HFSH alone or r-HFSH + r-HLH (r-HLH 150 IU/day) for the remainder of the stimulation period. Final follicular maturation was triggered with 250 μg of recombinant human chorionic gonadotrophin. After assessing oocyte nuclear maturity, oocyte were fertilized by ICSI and afterwards embryo quality was analyzed. Of the 131 women enrolled, 68 were allocated to r-HFSH alone and 63 to r-HFSH + r-HLH. No significant differences were observed in markers of either oocyte or embryo quality or quantity. However, higher rates of implantation and live birth per started cycle were observed with r-HLH supplementation than with r-HFSH alone. Although additional large studies are required to further investigate these findings, r-HLH supplementation for women aged 35-39 years undergoing ICSI is recommended as it may have a beneficial action on implantation.

[Treatment of moderate-to-severe psoriasis in clinical practice: a survey of Spanish dermatologists]

BACKGROUND AND OBJECTIVES

Various treatment options are available for use in moderate-to-severe psoriasis and election is dependent upon the clinical criteria applied by the attending physician. We undertook a survey among dermatologists to assess the treatment of moderate-to-severe psoriasis currently used in clinical practice in Spain.

METHODS

A cross-sectional study was performed by sending a questionnaire to dermatologists in Spain who treat patients with moderate-to-severe psoriasis. The questionnaire comprised 33 items distributed in 6 sections: profile of the dermatologist, case load, patient profile, follow-up and management of the disease, treatment regimens, and assessment of pharmacological treatments.

RESULTS

According to the responses of the 164 dermatologists surveyed, 6.8% of patients seen in their clinics have moderate-to-severe psoriasis; of those, 45.8% receive systemic treatment and 22.9% are treated with biologic drugs. In many of those patients (50.2%), the dermatologist felt that a change in treatment was necessary; in 51.1% of cases, this change would be from systemic therapy to a biologic drug. The principal reason for the change (50.8%) would be lack of efficacy or the appearance of adverse effects. Efficacy and safety were considered essential criteria in the choice of an appropriate treatment (82.9% and 28.0% of dermatologists, respectively). Patient quality of life was also considered an essential consideration in choice of treatment by 28.0% of dermatologists.

CONCLUSIONS

Optimal treatment for moderate-to-severe psoriasis should be effective and safe, and improve patient quality of life. This makes it essential to use drugs with an excellent efficacy and safety profile.

[Adverse reactions during biological therapy for psoriasis: results of a survey of the Spanish Psoriasis Group]

BACKGROUND

Biologic therapies have been a major breakthrough in the treatment of psoriasis because they are more selective and have a better short-term and medium-term safety profile. There are reliable data to support both the efficacy and the safety of these drugs. However, it is always useful to report the clinical experience of dermatologists who are experts in the use of biologic agents to treat psoriasis, particularly with regard to their safety.

MATERIAL AND METHODS

We present the results of a survey administered to the members of Spanish Psoriasis Group and based on a series of questions referring to the clinical safety of these agents. A total of 988 patients treated with efalizumab, infliximab, etanercept, and adalimumab were reported by 15 members of the group.

RESULTS

There was a particularly high proportion of reactions (34%) to infliximab infusions. Blood test abnormalities were detected in 13.25% of patients and infections in 12.24%, with one case of pulmonary tuberculosis. Attention is drawn to the adverse effects profile of efalizumab: de novo arthritis in 5.8% and rebound in 20.9% of patients.

CONCLUSION

The safety data provided by our study should be taken into account in view of the large number of patients recruited by dermatologists experienced in the use of this type of therapy.

Mid-follicular LH supplementation in women aged 35-39 years undergoing ICSI cycles: a randomized controlled study

This single-centre, randomized, parallel group, comparative study aimed to identify potential benefits of mid-follicular recombinant human LH (r-HLH) supplementation in women aged 35-39 years undergoing ovarian stimulation for intracytoplasmic sperm injection (ICSI). The main endpoint was the number of metaphase II oocytes retrieved. After pituitary suppression with a gonadotrophin-releasing hormone agonist, ovarian stimulation was initiated with recombinant human FSH (r-HFSH; 300-450 IU/day). On stimulation day 6, patients were randomized to receive r-HFSH alone or r-HFSH + r-HLH (r-HLH 150 IU/day) for the remainder of the stimulation period. Final follicular maturation was triggered with 250 mug of recombinant human chorionic gonadotrophin. After assessing oocyte nuclear maturity, oocyte were fertilized by ICSI and afterwards embryo quality was analyzed. Of the 131 women enrolled, 68 were allocated to r-HFSH alone and 63 to r-HFSH + r-HLH. No significant differences were observed in markers of either oocyte or embryo quality or quantity. However, higher rates of implantation and live birth per started cycle were observed with r-HLH supplementation than with r-HFSH alone. Although additional large studies are required to further investigate these findings, r-HLH supplementation for women aged 35-39 years undergoing ICSI is recommended as it may have a beneficial action on implantation.

Tres casos de neurosífilis precoz en pacientes infectados por VIH

In spite of the relative control of the disease in the late 20th century, syphilis, like other sexually transmitted diseases, has undergone a strong resurgence in recent years in the large urban centers of Europe and the US. Many patients with syphilis are also HIV+. The association between the two diseases may modify the clinical evolution of syphilis and increase the incidence of neurological disorders. We discuss the cases of three patients diagnosed with both diseases last year, with neurological presentation of syphilis occurring early and ophthalmic or cochlear vestibular involvement. This recent outbreak of syphilis seems to lead to an increase in the number of atypical cases presenting in our daily practice, where we must be prepared for early diagnosis and treatment.

Postmenopausal frontal fibrosing alopecia

Recently a new entity, postmenopausal frontal fibrosing alopecia, was added to the established subtypes of scarring alopecias affecting postmenopausal women. This condition is characterized by a progressive frontal hairline recession associated with scarring. We studied the clinical and histopathologic features in four women with this disorder. Of note, a history of bilateral oophorectomy in two of them appears to be a new association. All four cases had frontoparietal recession of the hairline and two of them also had loss of their eyebrows. None of our four patients had any mucous membrane or other skin lesions. Histological examination showed perifollicular fibrosis and lymphocytic inflammation around the isthmus and infundibular areas of the follicles. No effective treatments have emerged for this type of postmenopausal alopecia, but progression of the hair loss and scarring appears to be self-limiting. We believe that this condition is a distinct clinicopathological variant of lichen planopilaris.

Successful treatment of aphthous ulcerations in AIDS patients using topical granulocyte-macrophage colony-stimulating factor

Oral recurrent aphthous ulceration (RAU) is a well-recognized complication in patients infected with human immunodeficiency virus. RAU can be progressive and destructive, causing dysphagia and secondary malnutrition. The aetiology of RAU remains unknown, and its response to available treatments is often unsatisfactory. We describe three patients with advanced AIDS who suffered from extensive RAU which failed to respond to several treatments, including topical viscous lidocaine and topical and systemic glucocorticoids. Owing to difficulties in using thalidomide (two patients had neurological conditions which precluded thalidomide use), all three patients were treated with an oral solution containing recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF, 400 microg in 5% glucose 200 mL). From the first application, all three patients showed significant improvement of their lesions and amelioration of pain, and they were completely cured in a few days. No adverse effects were recorded. The patients did not show relapses of RAU over a prolonged follow-up. Controlled trials are warranted in order to establish the role of GM-CSF as a valid, alternative option for aphthous ulcerations of the mouth in AIDS patients in whom corticosteroids or thalidomide are not suitable.

Destructive herpetic whitlow in AIDS: report of three cases

Herpes simplex virus infection in immunocompromised individuals, including AIDS patients, is characterized by its tendency for atypical presentations and unusual locations, often resulting in delayed diagnosis and treatment. Three HIV-infected patients who developed prolonged cutaneous lesions of the fingers are presented. These lesions were unmodified by previous antibiotic treatment, and rapidly progressed to the complete destruction of nail structures in two patients. Viral culture confirmed the diagnosis of herpetic whitlow in all cases, and treatment with oral acyclovir resulted in complete recovery. Surgical treatment was not necessary.

Toenail onychomycosis in patients with acquired immune deficiency syndrome: treatment with terbinafine

Skin infections caused by dermatophytes are one of the most frequent dermatological complications in patients with acquired immunodeficiency syndrome (AIDS) resulting from infection with human immunodeficiency virus (HIV). Tinea unguium associated with AIDS is characterized by being clinically more aggressive and therapeutically more difficult to treat than in the general population. Terbinafine is considered to be a first-choice option for the treatment of dermatophyte onychomycosis in immunocompetent individuals. This drug has been used in a series of 21 HIV-positive patients diagnosed with tinea unguium for 1 year in the University Hospital La Paz, Madrid. All patients underwent a subsequent clinical follow-up for 6 months. The results showed a high percentage of clinical and mycological cures, as well as maintenance of the response after follow-up; no drug interactions or significant adverse effects related to the drug under study were recorded.