What is the recommended treatment for psoriasis in a patient with Human Immunodeficiency Virus (HIV)?

Treatment of Psoriasis in HIV-Positive Patients

HIV-positive patients with psoriasis should first optimize their HIV control with highly active antiretroviral therapy (HAART), as this alone often improves psoriatic disease, followed by topical therapy for mild disease or phototherapy for moderate-to-severe disease, with acitretin as the preferred systemic agent due to its lack of immunosuppressive effects. 1, 2

Initial Management: Optimize HIV Control First

• HAART is the foundation of treatment because severe psoriasis can be a manifestation of poorly controlled HIV infection, and effective viral suppression frequently improves psoriatic disease without additional therapy 1, 2
• Before initiating any immunosuppressive therapy, verify that the patient has normalized CD4+ T-cell counts, undetectable viral load, and no recent history of opportunistic infections 1
• Mandatory consultation with the patient's infectious disease provider is required before starting any systemic psoriasis therapy 1

Treatment Algorithm by Disease Severity

Mild-to-Moderate Psoriasis

• Topical corticosteroids and vitamin D analogues (calcipotriol) are first-line therapy when combined with HAART 2, 3, 4
• Topical calcipotriol has demonstrated efficacy even in HIV-related erythrodermic psoriasis without immunosuppressive effects 4

Moderate-to-Severe Psoriasis: First-Line Options

• Phototherapy (NB-UVB or PUVA) is the preferred first-line treatment for moderate-to-severe disease after topical therapy fails 2, 3
• However, use PUVA with caution due to concerns about accelerated skin cancer development in immunocompromised patients and potential worsening of HIV status, though studies have not demonstrated HIV deterioration with PUVA use 1
• Acitretin is the preferred systemic agent because it lacks significant immunosuppressive effects and is considered the treatment of choice in HIV-positive patients with severe psoriasis 1, 2, 3
• Acitretin dosing: Start with appropriate dosing balancing safety and efficacy, with 3-6 months required for maximal response 1
• Combination therapy with acitretin plus phototherapy may enhance efficacy while minimizing individual treatment exposures 1

Refractory Severe Disease: Biologic Therapy

Biologic agents may be used in carefully selected HIV-positive patients with well-controlled disease on HAART, with TNF-α inhibitors and IL-12/23 inhibitors showing the most evidence for safety and efficacy. 1, 5

TNF-α Inhibitors (Infliximab, Adalimumab, Etanercept, Certolizumab)

• Patients may receive TNF-α inhibitors only if:
  • They are receiving HAART that has effectively normalized CD4+ T-cell counts 1
  • They show undetectable viral load 1
  • They have no recent history of opportunistic infection 1
• Limited case series (48 published cases) suggest TNF-α inhibitors are safe and efficacious, with some evidence of favorable effects on CD4 counts and viral loads when used with concomitant HAART 5
• Infliximab may be particularly useful for life-threatening presentations at 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 6

IL-12/IL-23 Inhibitors (Ustekinumab, Guselkumab)

• Ustekinumab may be used in HIV-positive patients meeting the same criteria as TNF-α inhibitors: normalized CD4+ counts, undetectable viral load, no recent opportunistic infections, and concurrent HAART 1
• Dosing: 45 mg subcutaneously for patients ≤100 kg or 90 mg for patients >100 kg, initially and at week 4, then every 12 weeks 1
• Case reports demonstrate efficacy with guselkumab in HIV-positive patients 5

Critical Monitoring Requirements for Biologics

• Baseline: CBC with differential, complete metabolic profile, TB testing (PPD, Quantiferon Gold, or T-Spot), hepatitis B and C serologies, chest radiograph if TB test positive 1
• Ongoing: Yearly TB testing in high-risk patients, periodic screening for infections and skin cancer, assessment at discretion for low-risk patients 1

Cautious Use of Traditional Immunosuppressants

Methotrexate and cyclosporine may be considered for refractory severe disease but require extremely careful monitoring and should only be used when benefits clearly outweigh risks. 2, 3

• Cyclosporine: May be used cautiously with close monitoring of renal function, blood pressure, and opportunistic infections 2, 3
• Methotrexate: Requires full blood count and liver function monitoring, with awareness of increased infection risk 6, 2, 3
• Both agents carry significant immunosuppressive effects that may worsen HIV-related immunocompromise 2, 3

Newer Non-Immunosuppressive Option

• Apremilast has been used in challenging cases due to its lack of immunosuppressive effect, though data in HIV-positive patients remains limited 3

Critical Pitfalls to Avoid

• Never use systemic corticosteroids as primary therapy in HIV-positive patients with psoriasis, as they can precipitate life-threatening complications and rebound flares upon withdrawal 6
• Avoid combining cyclosporine with PUVA as this significantly accelerates skin cancer development 1
• Do not initiate biologics without infectious disease consultation and verification of adequate HIV control 1
• Recognize that psoriasis severity often correlates inversely with CD4+ count, and worsening psoriasis may indicate inadequate HIV control requiring HAART optimization rather than escalation of immunosuppressive therapy 7, 3

Special Considerations

• HIV-related psoriasis frequently presents with more severe, exudative clinical pictures and may show atypical histological features with reduced T-cell infiltration 7
• Treatment response is often prolonged with more frequent exacerbations compared to HIV-negative patients 7
• The prevalence of psoriasis in HIV-positive patients (approximately 5%) is higher than the general population (1-2%), and disease typically appears during late-stage infection when CD4/CD8 ratio falls below 0.4 7