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
