Overcoming Obstacles in Managing Psoriasis and HIV
Patients with psoriasis and HIV comprise a unique subgroup that requires special consideration for treatment due to complications and comorbidities associated with both diseases. Some treatments for psoriasis can suppress the immune system, leaving patients at risk for opportunistic infections, which can be life threatening to those with HIV.
According to the National Psoriasis Foundations (NPF) Medical Board on managing HIV infection in patients with psoriasis, first line treatment still consists of topical therapy for mild to moderate disease.1 Phototherapy and antiretrovirals are recommended as first line agents for those with moderate to severe disease. Second line agents include oral retinoids. For patients with more refractory, severe disease, tumor necrosis factor inhibitors (TNF) inhibitors, cyclosporine, methotrexate, and hydroxyurea may be used cautiously with close monitoring for adverse events.1
Conversely, a review by Kaushik and Lebwohl suggest that cyclosporine and methotrexate are contraindicated in patients with psoriasis and HIV due to the high risk for opportunistic infections associated with these therapies.1,2 They suggest TNF inhibitors, ustekinumab, and apremilast for the management of psoriasis and concomitant HIV and emphasize collaborating with the patient’s infectious disease specialist to manage viral load.2 Acitretin can be used for managing psoriasis in patients with HIV, and hydroxyurea has been recommended because of its “antiretroviral properties” and use for psoriasis in the past. While there is no data on IL-17 and IL-23 inhibitors, these therapies are less commonly associated with opportunistic infections, according to the authors.2
Wilson Liao, MD, associate professor of dermatology at the University of California San Francisco, discussed the prevalence of HIV in this patient population, treatment considerations, and challenges dermatologists should consider when managing patients with comorbid HIV and psoriasis.
Consultant360: How common is HIV among patients with psoriasis?
Wilson Liao: We know that among patients with HIV, the prevalence of psoriasis is around 1% to 3%, which is similar to the prevalence of psoriasis in the general population.1 In the United States, we see very few patients born with HIV. Among adults who acquire HIV, psoriasis may present in a more severe or refractory pattern compared with those without HIV.
C360: What are some of the challenges of treating patients with psoriasis and co-HIV infection? Does HIV affect comorbidities and/or treatment outcomes among patients with psoriasis?
WL: The main challenge in treating psoriasis in patients who are HIV positive is that some psoriasis treatments are immunosuppressive or immunomodulating. We want to avoid further suppressing the immune system in patients with HIV, so we need to be careful with treatment selection. Also, HIV can make psoriasis less responsive to some therapies.
HIV infection is associated with an increased risk of co-morbidities such as cardiovascular disease, kidney dysfunction, and mental health disorders, which is also true for psoriasis. Thus, treating both the HIV and psoriasis is important in reducing the risk of these comorbidities.
C360: What do you recommend dermatologists consider when treating patients with severe psoriasis and comorbid HIV? For example, serological testing be performed when patients receive a biologic?
WL: I recommend dermatologists discuss the treatment plan with the patient’s HIV physician. When starting a new systemic agent for psoriasis in a patient who is HIV positive, it is prudent to monitor the CD4 count and viral load at periodic intervals in the first 1 to 2 years of new treatment.
C360: In your opinion, do the psoriasis guidelines provide enough guidance for physicians treating comorbid HIV and psoriasis? What other resources are available for physicians to ensure patients with psoriasis and HIV are receiving appropriate treatment?
WL: The National Psoriasis Foundation guidelines on treatment of psoriasis in HIV provide a nice foundation. In addition, a recent review published in the Journal of American Academy of Dermatology addresses the same topic.1,2
Also, I would like to emphasize that a collaborative approach between the dermatologist and HIV provider is the best approach.
—Melissa Weiss
References
- Menon K, Van Voorhees AS, Bebo BF Jr, et al. Psoriasis in patients with HIV infection: from the medical board of the National Psoriasis Foundation. J Am Acad Dermatol. 2010;62(2):291-299. doi:10.1016/j.jaad.2009.03.047
- Kaushik SB, Lebwohl MG. Psoriasis: Which therapy for which patient: Focus on special populations and chronic infections. J Am Acad Dermatol. 2019;80(1):43-53. doi:10.1016/j.jaad.2018.06.056