Psoriasis in patients with HIV infection: From the Medical Board of the National Psoriasis Foundation

Accepted 30 March 2009. published online 03 August 2009.

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-α 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.

Key words: biologicals, HIV, phototherapy, psoriasis, systemic therapy, topical therapy

Abbreviations used: CSA, cyclosporine, MTX, methotrexate, PASI, Psoriasis Area and Severity Index, PUVA, psoralen plus ultraviolet A, TNF, tumor necrosis factor, UV, ultraviolet

a Department of Dermatology, New York University, New York, New York

b Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania

c National Psoriasis Foundation, Portland, Oregon

d University of Toronto School of Medicine, Toronto, Ontario, Canada

e Department of Dermatology, Baylor College of Medicine, Houston, Texas

f Department of Dermatology, State University of New York School of Medicine and Biomedical Sciences, Buffalo, New York

g Department of Dermatology, Mount Sinai School of Medicine, New York University, New York, New York

Reprint requests: Bruce E. Strober, MD, PhD, Ronald O. Perelman Department of Dermatology, New York University, 560 First Ave, TCH-158, New York, NY 10016-6497.

Funding sources: None.

Disclosure: Dr Van Voorhees has been a consultant, investigator, or speaker for Abbott, Amgen, Astellas, Centocor, Genentech, Incyte, Connetics, Warner Chilcott, Photomedix, Roche, and Synta. She has a significant conflict of interest with Merck. Dr Bebo is employed by the National Psoriasis Foundation. The Foundation receives unrestricted financial support from Abbott, Centocor, Amgen, Wyeth, Genentech, Astellas, Stiefel, Galderma, Warner Chilcott, and Photomedix. Dr Gladman has been a consultant, investigator, or advisory board member for Abbott, Amgen, Wyeth, Centocor, and Schering. Dr Hsu has been a consultant for Abbott, Amgen, Biogen Idec, Centocor, and Genentech. She has been a clinical investigator for Amgen and Centocor. Dr Kalb has been an investigator and consultant for Abbott, Amgen, Centocor, Astellas, Warner-Chilcott, Stiefel, and Genentech. Dr Lebwohl has been a consultant for Abbott, Amgen, Astellas, Centocor, Genentech, UCB Pharma, Stiefel, Triax, Pharmaderm, Medicis, Novartis, and Warner Chilcott. He has been a speaker for Abbott, Amgen, Astellas, Centocor, and Genentech. Dr Strober has been a speaker, advisor, consultant, and/or investigator for Abbott, Amgen, Astellas, Genentech, Centocor, and Wyeth. Dr Menon has no conflicts of interest to declare.

PII: S0190-9622(09)00393-4

doi:10.1016/j.jaad.2009.03.047

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