As moderator of the Danger and Defense in the Age of Biologics, Kieron Leslie, MD, FRCP, discussed the ins and outs of using immunosuppressive and biologic agents in patients with chronic infectious diseases. While a portion of his presentation focused on biologics and COVID-19, Dr Leslie also highlighted what dermatologists should know when caring for a patient with HIV whose dermatologic disease requires an advanced therapy.
“The first thing I want to say is patients living with HIV are more susceptible to a whole host of inflammatory skin disease, most commonly conditions such as psoriasis and eczema,” said Dr Leslie. “These patients also often have severe disease, especially when their HIV is not well-controlled.”
When their CD4 count is low, psoriasis is most often severe in the patient with HIV. The first-line treatment in these patients, then, is antiretroviral therapy (ART) to control their chronic infection. Once ART is initiated, skin-directed therapies—topical steroids, phototherapy, and retinoids—may be used.
But what happens when patients fail first-line therapies? Dr Leslie pointed out that there is no clinical trial data to create an evidence-based guideline. However, in 2010, the National Psoriasis Foundation published a paper regarding recommendations in this special patient population. As noted previously, first-line therapy for mild to moderate disease is topical therapies and for moderate to severe disease is phototherapy and ART. Second-line therapy includes oral retinoids. These guidelines recommend cautious use of cyclosporine, methotrexate, hydroxyurea, and TNF inhibitors in more refractory disease. Dr Leslie highlighted several modern case reports using immunosuppressive or advanced therapies in patients with psoriasis and HIV, including oral PDE4, IL-12/IL-23, and IL-17 inhibitors.
“I think it is fair to say biologics are much preferred to conventional disease-modifying antirheumatic drugs,” he explained.
Dr Leslie then shared his approach to immunosuppressive management in patients with HIV:
- Optimize ART
- Consider nonimmunosuppressive alternatives
- Consult with an infectious disease or HIV physician
- Monitor CD4 and viral loads
—Lauren Mateja
Reference
Leslie KS. Management of immunosuppressants and biologics in dermatology patients in the era of COVID-19 & HIV infection. Presented at: American Academy of Dermatology Virtual Meeting Experience 2021; April 23-25, 2021; virtual.
