INTRODUCTION
Psoriasis is a chronic skin condition that affects 1% to 3% of the general population. In patients with human immunodeficiency syndrome (HIV), one study reported the prevalence of psoriasis as 6.4%, while others reported it to be in the same range as the general population.1-3 Additionally, patients with HIV tend to have more severe psoriasis than patients not infected with HIV. Many treatment options for moderate-to-severe psoriasis are immunosuppressive agents; this population is immunocompromised at baseline and these treatments may put the individual at greater risk for opportunistic infections and neoplasms.
Etanercept is a tumor necrosis factor alpha (TNF-α
) inhibitor used for the treatment of moderate to severe psoriasis. It has a very long track record for long-term safety and efficacy for patients with psoriasis who are not infected with HIV. The data for the use of etanercept in patients with HIV are limited, which may cause reluctance amongst physicians to use this medication in this patient population. Our literature search resulted in four case reports of etanercept use in patients with HIV.4-7 Of these case reports, the longest treatment period of etanercept for psoriasis in a patient with HIV was two years. We report a case of an HIV-infected individual with psoriasis who has been treated with etanercept for over six years.
CASE REPORT
The patient is a 46-year-old HIV-infected male with a 27-year history of generalized psoriasis, which is currently well-controlled with etanercept 50 mg weekly. In total, the patient has been on etanercept for over six years. To our knowledge, this is longest documented use of etanercept in a patient with HIV.
Prior to becoming infected with HIV, the patient had mild, chronic plaque psoriasis that was effectively treated with phototherapy and topical corticosteroids. However, after initiating antiretroviral therapy and experiencing a drug reaction to efavirenz in November 2003, he experienced progression of psoriasis, with increased body surface involvement, pain, and pruritis. At that time, the patient had cluster designation 4 (CD4) count of 582. He remained on antiretroviral therapy of zidovudine (ZDV) and lamivudine (3TC) until March 2004, when he experienced severe anemia due to ZDV. He was subsequently switched to the combination antiretrovirals 3TC, tenofovir, and atazanavir. He has been on this combination therapy since that time.
Because the patient failed external psoriasis treatment options, he was prescribed the non-immunosuppressive medication, acitretin. Acitretin was titrated up to a dosage of 50 mg daily, but the patient had poor response. In September 2004, etanercept 25 mg twice a week was added to acitretin therapy. At this time, the patient's HIV infection was being managed well. He had a CD4 count of 1,370. However, this dosage of acitretin and etanercept had limited efficacy, so etanercept was increased to 50 mg twice a week. Acitretin was later discontinued due to side effects including headache, hair loss, and sticky skin.
Upon presentation to our clinic in March 2006, the patient had complete resolution of psoriasis with etanercept 50 mg twice a week. His HIV infection continued to be under good control. He had a CD4 count of 1,450. After six months of continued response, etanercept was decreased to 50 mg once weekly and resistant plaques were treated with topical corticosteroids. For the last five years, the patient has remained at near complete clearance with this treatment regimen, with only a few small psoriatic plaques on his groin and elbows. Throughout this treatment period, the patient had stable CD4 counts (consistently greater than 1,000), undetectable HIV-1 RNA levels, and experienced no opportunistic infections. Additionally, the patient denied any incidences of the common cold, flu, sinusitis, or any other infections while on etanercept.
