526
SHORT COMMUNICATION
ActaDV ActaDV
Advances in dermatology and venereology Acta Dermato-Venereologica
Psoriasis as a Manifestation of an Immune Reconstitution in Two Patients with Hepatitis C Treated with Ledipasvir / Sofosbuvir
Franz HEPPT and Michael STICHERLING Department of Dermatology, University Hospital of Erlangen, Ulmenweg 18, DE-91054 Erlangen, Germany. E mail: franz. heppt @ uk-erlangen. de Accepted Nov 17, 2016; Epub ahead of print Nov 21, 2016
Psoriasis is a common inflammatory disease of the skin, affecting approximately 2 % of the world’ s population( 1). Induction and exacerbation of skin lesions can be triggered by various exogenous factors, including drugs. Agents that are frequently reported, yet controversial, are beta-blockers, anti-malarials, lithium, imiquimod, angiotensin-converting enzyme, non-steroidal anti-inflammatory drugs( NSAIDs) and interferon( IFN)-α( 2).
We describe here the first 2 cases of occurrence of plaque-type psoriasis in 2 patients with hepatitis C treated with ledipasvir / sofosbuvir( Harvoni ®).
CASE REPORTS
Case 1. A 65-year-old man with classic chronic plaque-type psoriasis for more than 30 years was infected by the hepatitis C virus( HCV), genotype 1a, in January 2001 by an unknown route of transmission. First-line combined treatment with pegylated interferon( IFN)-α and ribavirin( from June to August 2001) was stopped due to exacerbation of his psoriatic skin lesions. After a period of 14 years with no antiviral treatment and the presence of few persistent psoriatic plaques on his elbows, hepatitis C virus RNA serum levels increased up to 6.900.000 IU / ml. Therefore, the patient had been treated with ledipasvir 90 mg / sofosbuvir 400 mg( Harvoni ®) orally once daily since late January 2015. While HCV RNA serum level decreased rapidly and continuously to 20 IU / ml, approximately 2 months after the beginning of the antiviral treatment a massive exacerbation of psoriasis, with a Psoriasis Area and Severity Index( PASI( 3)) score of 37.5, occurred( Fig. 1). None of the exogenous triggers listed above was relevant, especially no other chronic infections, such as acquired immunodeficiency syndrome or hepatitis B. By using topical emollients, corticosteroid ointments and dithranol combined with narrow-band ultraviolet B( UVB 311nm) phototherapy the psoriatic skin lesions improved rapidly within 7 weeks without withdrawal of the antiviral treatment( PASI score after treatment 9.5).
Case 2. A 43-year-old man had had chronic hepatitis C, virus genotype 1b, since 2008 by unknown route of transmission. First-line combined treatment with pegylated IFN-α and ribavirin was given in 2009, with only a partial response, but with no
skin reactions. Since hepatitis C virus RNA serum levels remained distinctly elevated( 1.860.000 IU / ml) he received ledipasvir 90 mg / sofosbuvir 400 mg( Harvoni ®; Gilead Sciences International Ltd., Cambridge, UK) orally once daily from July until October 2015. Three months after initiating therapy hepatitis C viral load was below the limit of detection, which was considered as complete response. However, at the same time patient developed classic plaque-type psoriasis in the absence of any other exogenous triggers. Furthermore, there was no previous medical or family history of psoriasis. On consultation in our department in March 2016, lesions at typical locations, such as the elbows and knees, could be seen( PASI score 7.4), which were treated successfully with corticosteroid and calcipotriol ointments.
DISCUSSION
Whereas an epidemiological association between psoriasis vulgaris and hepatitis C virus infection has been reported in the past( 4, 5), data about the pathogenetic interaction of both conditions are very limited. It is suggested that hepatitis C virus infection itself especially may trigger late-onset psoriasis vulgaris via tumour necrosis factor( TNF)-α, which acts as a common mediator in both diseases( 4).
Regarding all antiviral treatment options including protease- and non-structural protein 5A / B( NS5A / B)-
Fig. 1. Clinical findings for Case 1 showing a massive exacerbation of the pre-existing plaque psoriasis. Extensively confluent erythematous plaques are remarkable. doi: 10.2340 / 00015555-2582 Acta Derm Venereol 2017; 97: 526 – 527
This is an open access article under the CC BY-NC license. www. medicaljournals. se / acta Journal Compilation © 2017 Acta Dermato-Venereologica.