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Advances in dermatology and venereology Acta Dermato-Venereologica
Biologic Therapies in HIV-infected Patients with Psoriasis : An Italian Experience
Federico BARDAZZI 1 , Michela MAGNANO 1 *, Anna CAMPANATI 2 , Francesco LOCONSOLE 3 , Antonio CARPENTIERI 3 , Concetta POTENZA 4 , Nicoletta BERNARDINI 4 , Vito DI LERNIA 5 , Carlo CARRERA 6 , Beatrice RAONE 1 , Annalisa PATRIZI 1 and Camilla LOI 1
1
Department of Specialized , Clinical and Experimental Medicine , Division of Dermatology , University of Bologna , Via Massarenti 1 , IT-40138 Bologna , 2 Dermatology Unit , Department of Clinical and Molecular Sciences , United Hospital of Ancona , Polytechnic Marche University , Ancona , 3 Clinica Dermatologica , Policlinico Di Bari , Bari , 4 Department of Dermatology , University of Rome La Sapienza-Polo Pontino , Rome ,
5
Dermatology Unit , Arcispedale Santa Maria Nuova IRCCS , Reggio Emilia , and 6 U . O . Dermatologia , Fondazione IRCCS Ca ’ Granda – Ospedale Maggiore Policlinico , Milan , Italy . * E-mail : michela . magnano @ gmail . com Accepted May 16 , 2017 ; Epub ahead of print May 17 , 2017
In HIV-infected patients psoriasis is often severe ( 1 ) and biologic therapy may therefore be needed . However , most dermatologists are cautious when using immunosuppressive agents in patients with HIV , as these agents may reactivate or induce infection in already immunocompromised patients ( 1 ). To date , only a few cases of HIV-infected psoriatic patients treated with biologics have been reported ( 2 ). We report here 10 cases of HIV patients treated for plaque psoriasis with biologic therapies in 6 psoriasis centres in Italy .
MATERIALS AND METHODS
Ten HIV-infected patients were included in this study , mean age 49 years , who had had moderate-to-severe plaque psoriasis for at least 2 years ( mean Psoriasis Area Severity Index ( PASI ) 18.1 ) ( Table I ).
All of the subjects had received a diagnosis of HIV at least 2 years before the diagnosis of psoriasis and 4 patients also had concomitant hepatitis C virus ( HCV ) infection . All of the patients had been treated intermittently for at least one year with cyclosporine , which had to be discontinued to avoid side-effects ( 3 ), while 4 also failed to respond to phototherapy or acitretin . We therefore decided to start biologic therapy in these patients .
Patients had had a stable viral load for at least 12 months , a stable CD4 count for at least 12 months and showed no signs of infection . CD4 count was monitored monthly . In patients with concomitant HCV infection , their viral load and liver enzymes were checked every 2 months , and a hepatic ultrasound was performed every 6 months .
RESULTS AND DISCUSSION
In 4 patients ustekinumab was started at a dose of 45 mg then 45 mg after 4 weeks and then every 12 weeks , while in the other 6 patients an anti-tumour necrosis factor ( anti-TNF ) agent was administered at the standard dose . Four patients were treated with etanercept and 2 with adalimumab ( adalimumab was administered at a dose of 80 mg at time zero , then 40 mg after a week followed by 40 mg every 2 weeks , while etanercept was started at a dose of 50 mg twice weekly for the first 12 weeks than 50 mg weekly ). The choice of the biologic was made according to the lifestyle of each patient .
The mean duration of therapy was 34.8 months . None of the patients developed adverse effects , including infectious complications , or had to interrupt the treatment . All patients are still on biologic therapy . All patients reached
75 % of clearance of the lesions ( PASI75 ) after 3 months . However , relapses were observed after 10 and 13 months in 2 patients treated with ustekinumab and these were managed by adding phototherapy .
The totality of patients showed overall stable or slightly decreased levels of CD4 , which subsequently resolved without changing the antiretroviral therapy ( ART ). This is in accordance with other reports ( 2 ) in which significant fluctuations in CD4 count were not observed .
Although the relationship between HCV reactivation and the use of biologic therapies is still debated ( 4 ), 4 of our subjects also had a concomitant HCV infection . Two were treated with etanercept , one with adalimumab , and one with ustekinumab , without experiencing adverse effects . The HCV viral load and liver enzymes remained at low levels throughout the whole duration of the therapy , and the hepatic ultrasound , performed every 6 months , did not show any substantial changes .
Since psoriasis is often difficult to treat in HIV-infected patients , the use of biologic therapies may be unavoidable . Given the paucity of literature , it is not easy to determine when it is appropriate to start a biologic therapy , which particular therapy to choose , and how to follow up the patient . In addition , the best biologic agent for patients with HIV is unclear . Most case reports describe the use of an anti-TNF agent , mainly because dermatologists are likely to have had more experience with the use of such agents , but also because TNF-alpha seems to have a role in viral replication and the pathogenesis of HIV , improving HIV symptoms and sequelae ( 2 ).
Two case reports on the use of ustekinumab in psoriatic HIV-infected patients have been published so far ( 1 , 4 ) with good results . However , interleukins ( IL ) -12 and IL-23 , targets of ustekinumab , seem to have a positive involvement in the control of opportunistic infections , inflammation and tumourigenesis associated with HIV infection ( 5 ), whereas high levels of TNF-alpha , the target of adalimumab and etanercept , are related to viral replication and progression of the disease ( 6 ).
For the reason given above , although there are more cases of infectious complications in HIV-infected patients treated with anti-TNF agents than ustekinumab , probably due to their longer use , it may be reasonable to first choose an anti-TNF agent to avoid possible long-
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2017 Acta Dermato-Venereologica . doi : 10.2340 / 00015555-2698 Acta Derm Venereol 2017 ; 97 : 989 – 990