Efficacy of ultraviolet B phototherapy for psoriasis in patients infected with human immunodeficiency virus

[Psoriasis and HIV infection, what do French dermatologists do?]

BACKGROUND

The prevalence of psoriasis among patients presenting human immunodeficiency virus (HIV)infection is the same as in the general population, but the disease is more severe and refractory, and management is more complex. The aim of this survey was to assess the practices of French dermatologists concerning both screening for HIV in psoriasis patients and therapeutic management and follow-up of psoriasis patients with HIV.

PATIENTS AND METHODS

An anonymous national survey of practices was conducted by means of a questionnaire emailed to dermatologists in hospital in private practice in France between March and June 2017.

RESULTS

The questionnaire was completed by 262 dermatologists. They indicated that they carried out screening for HIV in psoriasis patients presenting risk factors (79.4%), prior to biotherapy (63.4%) or different systemic treatments other than retinoids (53.1%), if the psoriasis was severe (45.8%), or in the event of worsening (37.8%). 28.7% of practitioners surveyed were in fact treating patients with psoriasis and HIV, with a mean 3.1 patients being followed up. All practitioners prescribe systemic treatment, other than cyclosporine, but they frequently consult an infectious disease specialist before prescribing these therapies. The most widely used biotherapy was etanercept (65.5% of practitioners). More intensive laboratory follow-up was conducted for these patients in 72.1% of cases.

CONCLUSION

French dermatologists do not perform routine screening for HIV in psoriasis patients. However, where infection has been identified, their practices are modified accordingly. Therapeutic choices are consistent with the French recommendations. Nevertheless, recommendations appear necessary concerning HIV screening in this population.

Psoriasis in HIV infection: an update

Psoriasis is a prevalent systemic immune-mediated disease with cutaneous manifestations. In HIV-infected patients, psoriasis may have a higher incidence, present atypical and more exuberant clinical features, and is frequently recalcitrant to treatment. Despite this aggravated severity, treatment options for psoriasis in HIV-infected individuals remain limited due to the risk of fatal immunosuppression associated with both classical immunosuppressants and new biological drugs. Notwithstanding, drug therapy in psoriasis has been undergoing major advances for the last few years, with novel drugs approved, which could significantly add to the management of HIV-infected patients. It is therefore our aim to present a review of the available literature to highlight the updated evidence on psoriasis in HIV-infected individuals, particularly in regards to its epidemiology, proposed pathophysiology, clinical presentation, currently available therapeutic options, and future perspectives.

Psoriasis in patients with HIV infection: from the medical board of the National Psoriasis Foundation

BACKGROUND

Patients with psoriasis and HIV infection often present with more severe and treatment-refractory cutaneous disease. In addition, many of these patients have significant psoriatic arthritis. Many effective drugs for psoriasis and psoriatic arthritis are immunosuppressive. Therefore, therapy for the HIV-infected patient is more challenging, requiring both careful consideration of the potential risks and benefits of treatment and more fastidious monitoring for potential adverse events.

OBJECTIVE

A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options. Our aim was to arrive at a consensus on therapy for psoriasis in patients with HIV.

METHODS

A MEDLINE search of the terms "psoriasis," "psoriatic arthritis," "human immunodeficiency virus (HIV)," and "HIV skin diseases" was performed and literature relevant to HIV-associated psoriasis and the treatment of HIV-associated psoriasis were reviewed.

RESULTS

Based on a review of the literature, 29 reports were included as evidence in this review. Topical therapy is the first-line recommended treatment for mild to moderate disease. For moderate to severe disease, phototherapy and antiretrovirals are the recommended first-line therapeutic agents. Oral retinoids may be used as second-line treatment. For more refractory, severe disease, cautious use of cyclosporine, methotrexate, hydroxyurea, and tumor necrosis factor-alpha inhibitors may also be considered.

LIMITATIONS

There are no randomized, placebo-controlled trials evaluating the therapeutic efficacy or safety of treatments for patients with HIV-associated psoriasis; consequently, the evidence supporting this review consists mainly of case reports or case series.

CONCLUSIONS

HIV-associated psoriasis is often refractory to traditional treatments. Treatment is challenging and requires careful consideration and should be tailored to patients based on disease severity and the input from an infectious disease specialist. Close monitoring for potential adverse events is necessary.

Activation of HIV in human skin by ultraviolet B radiation and its inhibition by NFkappaB blocking agents

To determine whether ultraviolet B (UVB) irradiation leads to activation of HIV in human skin, we conducted prospective and controlled studies in two academic medical centers in Texas from July 1995 to April 1999. HIV-positive patients with UV-treatable skin diseases were enrolled at each center, 18 subjects at one and 16 at the other. In one center, specimens from lesional and nonlesional skin biopsies were taken before and after sham- or UVB-irradiation administered in vivo or in vitro. In the other center, UVB phototherapy was administered three times weekly and specimens from skin biopsies were taken before and after 2 weeks (six treatments). Cutaneous HIV load was assessed using reverse transcriptase-polymerase chain reaction and reverse transcriptase-polymerase chain reaction in situ hybridization. UVB irradiation led to a 6-10-fold increase in the number of HIV in skin. To ascertain a role for nuclear factor kappa B (NFkappaB) in UVB-inducible HIV activation, two types of blockers, NFkappaB oligonucleotide decoy and sodium salicylate, were tested; each inhibited UVB-inducible HIV activation in skin partially. We conclude that UVB irradiation leads to increased numbers of HIV in human skin via processes that include release of cytoplasmic NFkappaB.

Etanercept for the treatment of human immunodeficiency virus-associated psoriatic arthritis

Etanercept may play an important role in modulating the inflammatory activity and progression of human immunodeficiency virus (HIV)-associated psoriasis and psoriatic arthritis. We report the case of a 45-year-old homosexual man with a CD4 cell count of less than 0.05 x 10(9)/L and an HIV viral load of 4200 copies/mL (while receiving highly active antiretroviral therapy) who developed extensive psoriatic plaques, 4.5-kg weight loss, onychodystrophy, and psoriatic arthropathy with severe periarticular bone demineralization. The arthritis progressed despite the use of several disease-modifying medications, including corticosteroids, hydroxychloroquine, and minocycline. Because of uncontrolled, progressive, and disabling arthritis and resulting profound disability, he was treated with etanercept. Within 3 weeks, his psoriasis had improved dramatically and his joint inflammation had stabilized. For the next 4 months, immunologic and viral parameters remained stable, but his clinical course was complicated by frequent polymicrobial infections. Etanercept was thus discontinued despite continued improvements in his psoriasis, psoriatic arthritis, and functional status. While both cutaneous and joint manifestations of psoriasis improved dramatically, the experience with this patient dictates that caution and careful follow-up must be exercised when prescribing etanercept in the setting of HIV infection.

HIV, UV and immunosuppression

Cutaneous diseases are common manifestations of infection with human immunodeficiency virus (HIV). Phototherapy with ultraviolet B (UVB) and photochemotherapy with 8-methoxypsoralen plus UVA (PUVA) have been used successfully to treat several of these skin conditions, including psoriasis, folliculitis, pruritus, and eczema. However, in view of the known immunosuppressive effects of UV radiation, concerns have been raised about potential adverse effects of UV on persons infected with HIV. In the following report, we review the effects of UV in HIV-infected cell lines in vitro, in animal models, as well as in human studies. Based on currently available data, UV radiation, as used in phototherapy and photochemotherapy, appears to have no adverse effects in HIV-infected individuals.

HIV-positive patients differ from HIV-negative patients in indications for and type of UV therapy used

BACKGROUND

Treatments using UV, UVB, or oral psoralen and UVA (PUVA) have been advocated for the care of HIV-infected persons with skin diseases. Concerns about the safety of these treatments exist.

OBJECTIVE

We attempted to determine the characteristics of HIV infected persons receiving UV therapy and establish the reasons for and type of treatment administered.

METHODS

During two 2-week periods, we prospectively ascertained basic information on all patients treated at 40 phototherapy clinics and detailed clinical information on patients known to be infected with HIV.

RESULTS

We identified 3716 persons receiving UV therapy, including 311 known to be infected with HIV. When compared with patients not known to be infected with HIV, HIV-positive patients were significantly more likely to be treated with UVB rather than PUVA and were more likely to be treated for pruritic conditions rather than psoriasis.

CONCLUSION

There were great variations in the relative reliance on UVB and PUVA among centers. There appears to be no agreement as to which type of UV therapy is optimal for patients infected with HIV. Most patients known to the treating clinician to be HIV positive are in the advanced stages of HIV disease. The number of persons with less advanced HIV disease receiving treatment remains unquantified but may be even more clinically important.

HIV-associated eosinophilic pustular folliculitis: successful treatment of a Japanese patient with UVB phototherapy

We report the successful treatment with ultraviolet B phototherapy of a patient with HIV-associated eosinophilic pustular folliculitis. We were able to observe the clinical and therapeutic course for about one year and three months. This 35-year-old homosexual Japanese man presented with disseminated, discrete, follicular, erythematous papules with intense pruritus over his face, neck, chest wall, and upper back. Initially, the eruption responded to therapy with topical or oral indomethacin and oral H1 antihistamine. However, the eruption was highly prone to recurrence, and it gradually failed to respond to these therapies. The eruption became chronic and persistent and manifested the excoriated, prurigo-like nodules that are typical of reported pruritic papular eruption, suggesting that this skin disease and HIV-associated eosinophilic pustular folliculitis are two forms of the same disease entity. UVB phototherapy in small doses was very effective for the persistent eruption, and no recurrence of the eruption was noted during or since the six-month maintenance therapy (once a week at a dose equivalent to 0.75 of the minimal erythema dose) (9 months total). No unfavorable side effects have been observed during or after the UVB phototherapy (cumulative UVB doses of 2,320 mJ/cm2).

Systemic treatment of severe psoriasis

Severe psoriasis presents a difficult therapeutic challenge. Some modalities such as synthetic retinoids, phototherapy and methotrexate have been available for many years and need reappraisal, cyclosporin has only recently become available and requires careful administration. In this article we focus on the therapeutic modalities available to the dermatologist in Australia.

Ultraviolet therapy of HIV-infected individuals: a panel discussion

Patients infected with the human immunodeficiency virus (HIV) frequently develop skin diseases that are responsive to ultraviolet (UV) radiation. Studies on the effects of UV on HIV and on the immune system in vitro and in transgenic animals have raised questions regarding the safety of UV exposure in these patients. In this article, invited experts address issues concerning the safety of ultraviolet therapy in HIV-infected patients by discussing their clinical and/or research experience.

UVB phototherapy is an effective treatment for pruritus in patients infected with HIV

BACKGROUND

Pruritus in patients positive for HIV may be debilitating.

OBJECTIVE

Our purpose was to evaluate the efficacy of UVB therapy in the treatment of pruritus in patients positive for HIV.

METHODS

Twenty-one male HIV-positive patients with intractable pruritus (14 with eosinophilic folliculitis and 7 with primary pruritus) were treated three times weekly with UVB phototherapy. Pruritus was quantified with use of a subjective score of 0 (none) to 10 (severe).

RESULTS

Mean CD4 counts at the initiation of therapy were 91.0 +/- 31.9 cells/microliter. Pruritus scores before and after treatment were 8.6 +/- 0.4 and 2.2 +/- 0.5, respectively (p < 0.001). The mean number of treatments to achieve maximal improvement was 20.7 +/- 2.3, with a cumulative UVB dose of 3399.1 +/- 597.4 mJ/cm2. No significant difference was found between the group with eosinophilic folliculitis and the group with primary pruritus.

CONCLUSION

UVB phototherapy can produce significant relief of pruritus and improvement in the quality of life in patients positive for HIV.

Is phototherapy safe for HIV-infected individuals?

Patients infected with human immunodeficiency virus (HIV) have a high prevalence of UV radiation-responsive skin diseases including psoriasis, pruritus, eosinophilic folliculitis and eczemas. On the other hand, UV has been shown to suppress T cell-mediated immune responses and to induce activation and replication of HIV. These developments have prompted clinicians and investigators to question whether phototherapy is safe for HIV-infected individuals. We have reviewed these issues and hereby provide a summary and critique of relevant laboratory and clinical evidence.

Medical UV exposures and HIV activation

This paper presents the first attempt to evaluate the potential of clinical UV exposures to induce the human immunodeficiency (HIV) promoter and, thus, to upregulate HIV growth in those skin cells that are directly affected by the exposure. Using the data for HIV promoter activation in vitro, we computed UVB and psoralen plus UVA (PUVA) doses that produce 50% of the maximal promoter activation (AD50). Then, using (a) literature data for UV transmittance in the human skin, (b) a composite action spectrum for HIV promoter and pyrimidine dimer induction by UVB and (c) an action spectrum for DNA synthesis inhibition by PUVA, we estimated the distribution of medical UVB and PUVA doses in the skin. This allowed us to estimate how deep into the skin the HIV-activating doses might penetrate in an initial and an advanced stage of UVB or PUVA therapy. Such analysis was done for normal type II skin and for single exposures. The results allow us to predict where in the skin the HIV promoter may be induced by selected small and large therapeutic UVB or PUVA doses. To accommodate changes in skin topography due to disease and UV therapy, our considerations would require further refinements. For UVB we found that, when the incident dose on the surface of the skin is 500 J/m2 (290-320 nm) (initial stage of the therapy), the dose producing 50% of the maximal HIV promoter activation (ADUVB50) is limited to the stratum corneum. However, with an incident dose of 5000 J/m2 (an advanced stage of the therapy), ADUVB50) may be delivered as far as the living cells of the epidermis and even to some parts of the upper dermis. For PUVA we found that, when the incident UVA doses are 25 or 100 kJ/m2 (320-400 nm) (an initial and an advanced stage of therapy, respectively), and the 8-methoxypsoralen concentration in the blood is 0.1 microgram/mL (the desired level), the combined doses to the mid epidermis (and some areas of the upper dermis) are well below the 50% HIV promoter-activating PUVA dose (ADPUVA50). Only under the worst scenario conditions, i.e. an exceptionally high drug concentration in the patient's tissues and localization of HIV in the nearest proximity to the skin surface, would the combined PUVA dose expected during photochemotherapy exceed ADPUVA50. These results suggest that the probability of HIV activation in the epidermis by direct mechanisms is higher for UVB than for PUVA treatment. However, complexities of the UV-inducible HIV activation and immunomodulatory phenomena are such that our results by themselves should not be taken as an indication that UVB therapy carries a higher risk than PUVA therapy when administered to HIV-infected patients.