LAUSR

Immunological dysfunction in patients infected with human immunodeficiency virus (HIV) is associated with numerous cutaneous diseases, including Kaposi sarcoma (KS) and psoriasis vulgaris. KS is an incurable and sometimes fatal malignancy derived from human herpesvirus 8-infected endothelial cells, and is the most common tumour associated with HIV. In the setting of HIV, psoriasis is often severe and refractory to standard treatments. There is a growing literature of case reports and series describing the use of biologic agents for treating HIV-associated psoriasis. Ustekinumab, a monoclonal antibody that inhibits activity of interleukin (IL)-12 and IL-23, has been reported to significantly improve HIV-associated psoriasis in several cases refractory to standard treatments without compromising control of HIV. However, treatment of an HIV-positive patient with both severe psoriasis and KS has not been described for ustekinumab or any other biologic medication, to our knowledge. A 55-year-old man with plaque-type psoriasis since his mid-20s developed severe disease [75% body surface area (BSA)] after diagnosis of HIV infection in 2004. Antiretroviral medications were initiated, but the patient’s physicians felt it was best at the time to avoid immunosuppressive medications for his psoriasis. Starting in 2007, his psoriasis was treated with combinations of topical therapies, narrowband ultraviolet B phototherapy and acitretin 10–30 mg daily, but this resulted in only mild improvement over the course of 96 months. In 2008, the patient was diagnosed with KS and treated with imiquimod 5% cream, resulting in minimal subsequent progression (BSA ~1%). Given the poor control of the patient’s psoriasis (Fig. 1a–d), the fact that his HIV (CD4 counts 82– 306/lL) and KS were stable, and the increasing number of reports of safe and effective use of biologics in HIV-associated psoriasis, a decision was made to start ustekinumab treatment. In July 2016, the patient received his first dose of ustekinumab 45 mg, which led to almost complete clearance of psoriasis and no change in KS by his second ustekinumab dose 4 weeks later (Table 1). On a standard schedule of every 12 weeks, the patient had received four additional doses by the time of his final follow-up in October 2017, maintaining near-clearance of his psoriasis and stability of his KS lesions (Fig. 1e–h). Furthermore, since initiation of ustekinumab treatment, his CD4 counts have been stable (241–326/lL), viral loads have been < 20 copies/mL and he has not developed any opportunistic infections or adverse effects. To our knowledge, this is the first reported case of ustekinumab treatment for HIV-associated psoriasis in a patient with KS. Achieving adequate control of moderate to severe psoriasis in patients with HIV can be challenging, but is important not only for addressing skin and/or joint symptoms, but also for controlling systemic inflammation that can precipitate comorbid diseases, including cardiovascular disease. Although HIV-associated psoriasis may respond to antiretroviral therapy or traditional psoriatic treatments, severe refractory disease is not uncommon. Biologics have recently shown significant efficacy in patients with HIV with refractory psoriasis, but their risks and immunosuppressive effects must be carefully weighed against their potential benefits. Correspondence: Dr Anthony P. Fernandez, Departments of Dermatology and Pathology, Cleveland Clinic, 9500 Euclid Avenue, A61, Cleveland, OH, 44195, USA E-mail: [email protected]