Treatment of Severe Psoriasis and Psoriatic Arthritis With Adalimumab in an HIV-Positive Patient

July 2014 | Volume 13 | Issue 7 | Case Report | 869 | Copyright © 2014

Scott F. Lindsey BS, Jonathan Weiss MD, Eric S. Lee MD, and Paolo Romanelli MD

Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL

Abstract

Psoriasis in HIV-infected patients poses a distinct challenge to the dermatologist due to its increased severity, tendency to be refractory to common treatment modalities, and necessity for cautious use of immunosuppressive agents. Tumor necrosis factor-α inhibitors have been shown to be safe and effective for the treatment of psoriasis in the general population, but their role in the treatment of HIV-positive patients is still unclear. The use of the tumor necrosis factor-α inhibitor adalimumab for the treatment of psoriasis in HIVpositive patients has yet to be reported. We present the case of a 49-year-old HIV-positive man with severe plaque psoriasis who has been successfully treated with adalimumab for the past 30 months with no adverse events related to treatment.

J Drugs Dermatol. 2014;13(7):869-871.

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INTRODUCTION

Psoriasis is a chronic immune-mediated skin disease characterized by abnormal maturation of keratinocytes. It is relatively common, with a prevalence of 1-3% in the United States and Europe.1 The prevalence in HIV-positive patients is similar, if not increased, when compared to the general population.2 HIV-positive patients with psoriasis frequently follow a more chronic course that is often refractory to conventional therapies,3 and exhibit more severe symptoms that often correlate inversely with the CD4 count.2,4,5 Treatment is further complicated since most systemic therapies commonly used for refractory cases involve immunosuppressive agents, and these have the potential to cause serious complications in HIV-positive patients.

Adalimumab is a tumor necrosis factor (TNF)-α inhibitor, which has been shown to be safe and effective for the treatment of moderate to severe psoriasis in the general population.6 Although there is literature describing the safe use of adalimumab in HIV-positive patients for the treatment of rheumatological diseases,7 this has yet to be described for the treatment of cutaneous disease in the dermatology literature. Here we present the case of an HIV-positive man with severe refractory psoriasis successfully treated with adalimumab for 30 months with no significant complications.

CASE REPORT

A 49-year-old HIV-positive Nicaraguan man presented to our dermatology clinic in May of 2010 with marked worsening of plaque psoriasis and psoriatic arthritis over the previous months. He was diagnosed with HIV in 1997, and was non-adherent with antiretroviral therapy (ART) for the majority of his disease due to socioeconomic circumstances. The patient also previously had a localized low-grade renal cell carcinoma that was cleared with a left radical nephrectomy in 2001.

His psoriasis had been fairly limited since first diagnosed in 1993, and had been controlled with topical therapy. The few months preceding his presentation, he experienced generalized cutaneous involvement and worsening pain and morning stiffness involving the distal interphalangeal (DIP) joints in both hands.

On exam, the patient had diffuse pink scaly plaques on the scalp, face, extremities, and trunk. The total body surface area (TBSA) involved was over 90%. The DIP joints were swollen and tender. Fingernails displayed diffuse pitting and distal onycholysis.

A complete blood count and a comprehensive metabolic panel were unremarkable. The absolute CD4 count was 51 cells/mcL, and HIV viral load (VL) was 536,718 copies/mL. The patient was started on acitretin 25 mg daily, narrow-band ultraviolet (UV)-B phototherapy three times per week, and triamcinolone 0.1% ointment twice daily on weekdays and calcipotriene 0.005% cream on weekends. After three months, the patient’s skin improved with a TBSA involvement of 50%. DIP joint pain continued to worsen. Serum triglyceride increased to 354 mg/ dl (baseline 174 mg/dL), with no significant improvement after decreasing acitretin to 10mg daily for one month.

Due to worsening arthropathy and elevation of triglycerides, other systemic therapies were discussed. Cyclosporine and methotrexate were not considered appropriate options due to the patient’s nephrectomy and HIV status. The patient

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