A Case Report: The Clinical Features and Treatment Challenges of

HIV-associated Psoriasis

Teffy Nuary

, Anissa Anjani

, Anna Ariane

,Lili Legiawati

, Sri Adi Sularsito

Shannaz Nadia Yusharyahya

, Rinadewi Astriningrum

Department of Dermatology and Venereology Faculty of Medicine Universitas Indonesia

Dr. Cipto Mangunkusumo National Central General Hospital, Indonesia

Department of Internal Medicine Faculty of Medicine Universitas Indonesia

Dr. Cipto Mangunkusumo National Central General Hospital, Indonesia

Keywords: Psoriasis, Erythrodermic, Arthritis, HIV, Methotrexate

Abstract: Psoriasis is a chronic inflammatory skin disease, characterized by complex alterations in epidermal growth,

differentiation as well as multiple biochemical, immunologic, and vascular abnormalities. The prevalence of

human immunodeficiency virus (HIV)-associated psoriasis, and HIV-associated psoriatic arthritis may or

may not be the same as in the general population. Misleading, unusual clinical presentations, severe disease,

and frequent exacerbations are characteristicfindings.Many effective drugs for psoriasis and psoriatic

arthritis are immunosuppressive agents. Therefore, the treatment for the HIV-infected patient is more

challenging. A 64-year old female, the HIV-infected patient, was hospitalized because of severe generalized

skin rash (92% of BSA, PASI: 28.2) with scaling. She diagnosed with HIV 7 years ago with a CD4 count of

500 cells/uL. The patient took antiretroviral therapy (lamivudine, nevirapine, and tenofovir) regularly. She

was diagnosed with erythrodermic psoriasis and psoriatic arthritis. After the risk of opportunistic infection

was eliminated, she receivedmethotrexate (MTX) 7.5 mg/week, and the dose was increased into 10

mg/week.Two months following the treatment, there was clinical improvement (4% of BSA and PASI: 2),

without the presence of any opportunistic infections and MTX’s adverse events. Although there are limited

data on the efficacy and safety of systemic immunosuppressive agents for the treatment of psoriatic disease

in HIV-positive patients,adequate concomitant antiretroviral therapy and close monitoring for the signs and

symptoms of infectionmight reduce the likelihood of acute infection.

1 INTRODUCTION

Psoriasis is a chronic inflammatory skin disease with

a strong genetic basis, characterized by complex

alterations in epidermal growth, differentiation as

well as multiple biochemical, immunologic, and

vascular abnormalities. The relationship to a nervous

system function is poorly understood. The root cause

remains unknown.(Gudjonsson et al., 2012)

The prevalence of human immunodeficiency

virus (HIV)-associated psoriasis, and HIV-

associated psoriatic arthritis may or may not be the

same as in the general population.(Zancanaro et al.,

2006; Morar et al., 2010). Misleading, unusual

clinical presentations, severe disease, and frequent

exacerbations are characteristic findings. Psoriasis

might worsen the HIV infection or might be detected

for the first time concomitantly with HIV. It can be

very severe, but it can regress before death. The

development of HIV-associated psoriasis and HIV-

associated psoriatic arthritis might be associated

with poor prognosis in untreated patients, with a

mean life expectancy ranging from 4 to 24 months

following the diagnosis of psoriasis. (Morar et al.,

2010).

Many effective drugs for psoriasis and psoriatic

arthritis are immunosuppressive agents. Therefore,

the management for the HIV-infected patient is more

challenging, requiring both careful considerations on

the potential risks and benefits of treatment and

more fastidious monitoring for potential adverse

events. (Morar et al., 2010). In this study, we report

a case of safe and successful therapy with

methotrexate in a 64-year-old female with HIV-

associated psoriasis who responded poorly to

282

Nuary, T., Anjani, A., Ariane, A., Legiawati, L., Sularsito, S., Yusharyahya, S. and Astriningrum, R.

A Case Report: The Clinical Features and Treatment Challenges of HIV-associated Psoriasis.

DOI: 10.5220/0009986802820285

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 282-285

ISBN: 978-989-758-469-5

previous treatments, which were steroids and

ultraviolet B phototherapy.

2 CASE

A 64-year old female,the HIV-infected patient, was

hospitalized because of severe generalized skin rash

with scaling and joint pain in lower extremities. A

month prior to hospitalization, she began visiting an

outpatient clinic due to rashes and scaling on her

arms, trunk, and legs. She was treated with topical

steroid ointment, 5% liquor carbonic detergents

(LCD), and two courses of the narrow band-

ultraviolet B (NB-UVB) radiation. However, there

was no improvement. She diagnosed with HIV

7years ago with a CD4 count of 500 cells/uL. She

took antiretroviral therapy (lamivudine, nevirapine,

and tenofovir) regularly. She had a history of

smoking since childhood but no history of alcohol

consumption, lithium or β-blocker treatment nor

family history of psoriasis.

Erythematous skin lesions accompanied by silver

whitish scales were observed on her scalp and over

her entire body (92% of body surface area (BSA),

psoriatic area severity index (PASI): 28.2). The

patient was diagnosed with erythrodermic psoriasis.

We consulted to a rheumatologist for her complaint

of arthralgia in lower extremities, and she was

diagnosed with psoriatic arthritis.

Figure 1. Clinical lesions oferythematous skin lesions accompanied by silver-white scales were observed over the patient’s

entire body (92% of BSA, PASI: 28,2).

The laboratory test results were as follows: white

blood cells 8160/uL (63.9% neutrophils,25%

lymphocytes, 6.6% monocytes, 4% eosinophils),

hemoglobin 12.1 g/dL, platelets 273,000/uL;

aspartate aminotransferase 19 U/L, alanine

aminotransferase 18 U/L; total protein 5 g/dL,

albumin 2.94 g/dL, creatinine 1 mg/dL, and CD4 T-

cell count 750 cells/uL. Serology was negative for

anti-hepatitis B virus and anti-hepatitis C virus

antibodies. Venereal disease research laboratory

(VDRL) test and Treponema

pallidum hemagglutination (TPHA) test were non-

reactive.

The patient received sulfasalazine 500 mgbid for

ten days, but there was no clinical improvement.

After the risk of opportunistic infection was

eliminated, the patient received methotrexate(MTX)

7.5 mg/week and folic acid 5 mg/week for one week.

The MTX’s dosewas increased into 10

mg/weekfollowing no sign of hepatotoxicity.Two

months after receiving MTX therapy, there was a

clinical improvement (4% of BSA and PASI: 2). The

MTX was continued, andthe patient was still being

monitored at the outpatient clinic. After five months

of treatment, the patient showed complete

resolutionwithoutexperiencing relapsenor any MTX

adverse events.

A Case Report: The Clinical Features and Treatment Challenges of HIV-associated Psoriasis

283

Figure 2. After five months of treatment, the erythematous cutaneous lesions and scaly plaque disappeared.

3 DISCUSSION

The characteristic traits of HIV-associated psoriasis,

which distinguish it from classic seronegative

psoriasis, are sudden onset as well as more severe,

extensive, and recalcitrant nature.(Gaspari AA et al.,

2011) The disease exhibits various morphological

types in the same patients, appearing in one-third of

their disease’s course along with the high frequency

of arthritis. Notably, the exacerbation due to

staphylococcal and streptococcal infection is more

common among HIV-infected individuals. (Morar et

al., 2010). In this case,psoriasis began suddenly, and

it became severe immediately (involving 92% of

BSA), without other risk factors,e.g., excessive

alcohol intake and the use of particular drugs

(lithium and β-blockers).

Psoriasis in HIV-infected patients often responds

poorly to the treatment and has a high morbidity

rate, thus posing a challenge to the clinicians.(Je ong

YS et al., 2014).The treatment of HIV-associated

psoriasis depends on the severity of the disease.

Mild cases (<2% of BSA) can be treated topically

with emollients, corticosteroids, tar, vitamin D

analogs, and retinoids. Meanwhile, moderate and

severe cases (2–10% and <10% of BSA, respec-

tively) can be treated with systemic therapies,

including phototherapy, acitretin, cyclosporin,

hydroxyurea, and tumor necrosis factor-α inhibitors

(e.g., etanercept and infliximab) along with effective

antiretroviral therapy.(De Socio GVL et al., 2006).

This patient was treated with topical steroid

ointment, 5% liquor carbonic detergents (LCD), and

narrow band-ultraviolet B (NB-UVB) radiation, but

there was no clinical improvement.

The treatment of moderate and severe HIV-

associated psoriasis is challenging, and the risk-to-

benefit ratio specific to these patients needs to be

taken into account when selecting therapies.

(Nakamura M et al., 2018)

In this case, after the risk of opportunistic

infection was eliminated, the patient received

MTX.There was a clinical improvement, and she

had not experienced relapse nor any MTX’s adverse

events.In the cases of refractory HIV-associated

psoriasis, more traditional systemic

immunosuppressants, such as cyclosporin A (CsA),

MTX, and hydroxyurea,can be considered under

certain circumstances. The evidence supporting the

use of these agents is limited to a few reported cases,

case series, and anecdotal experiences.(Van

Voorhees et al., 2009) The decision to use a low

dose of MTX should be made on a case-by-case

basis following close consultation with the

appropriate physicians who are caring for the

patient, and cautious use is recommended in the

cases of severe refractory disease.(Nakamura M et

al., 2018)

4 CONCLUSION

Treatment of HIV-associated psoriasis can be

challenging and needs to be tailored to suit the risk-

to-benefit ratio in each patient. Although there are

limited data on the efficacy and safety of systemic

immunosuppressive therapies for the treatment of

psoriatic disease in HIV-positive patients,adequate

concomitant antiretroviral therapy and close

monitoring for the signs and symptoms of infection

might reduce the likelihood of acute infection.

REFERENCES

De Socio GVL, Simonetti S, Stagni G. 2006. Clinical

improvement of psoriasis in an AIDS patient

effectively treated with combination antiretroviral

therapy. Scand J Infect Dis.;38(1):74–5.

Gaspari AA, Gómez-Flores M, Ancer-Rodríguez J, Bryant

JL, Mendez N, Cedeno-Laurent F, et al. 2011.New

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

284

insights into HIV-1-primary skin disorders. J Int AIDS

Soc.;14(1):5.

Gudjonsson J, James E. Psoriasis. In: Lowell AG, Katzi S,

Gilchrest BA, Paller AS, Leffell D, Klaus W.2012.

editor. Fitzpatrick’s Dermatology in General

Medicine. 8 ed. New York: McGraw-Hill;. p. 197–

231.

Jeong YS, Kim MS, Shin JH, Cho JK, Lee HI, Kim HJ, et

al.2014.A case of severe HIV-associated psoriasis

successfully treated with acitretin therapy. Infect

Chemother;46(2):115–9.

Morar N, Willis-Owen SA, Maurer T, Bunker

CB.2010.HIV-associated psoriasis: pathogenesis,

clinical features, and management. Lancet Infect

Dis.;10(7):470–8.

Nakamura M, Abrouk M, Farahnik B, Zhu TH, Bhutani

T.2018. Psoriasis treatment in HIV-positive patients: a

systematic review of systemic immunosuppressive

therapies. Cutis;101(1):38;42;56.

Van Voorhees AS, Gladman DD, Lebwohl MG, Strober

BE, Kalb RE, Bebo BF, et al. 2009. Psoriasis in

patients with HIV infection: From the Medical Board

of the National Psoriasis Foundation. J Am Acad

Dermatol;62(2):291–9.

Zancanaro PCQ, McGirt LY, Mamelak AJ, Nguyen RHN,

Martins CR.2006. Cutaneous manifestations of HIV in

the era of highly active antiretroviral therapy: An

institutional urban clinic experience. J Am Acad

Dermatol;54(4):581–8.

A Case Report: The Clinical Features and Treatment Challenges of HIV-associated Psoriasis

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