Abstract
Psoriasis, a chronic inflammatory skin disease, presents unique challenges when co-occurring with HIV. Tildrakizumab, an IL-23p19 inhibitor, has demonstrated efficacy in treating moderate-to-severe psoriasis. This retrospective case series reports three individuals living with HIV and psoriasis treated with tildrakizumab. Clinical outcomes, including Psoriasis Area and Severity Index (PASI) and HIV viral load, were recorded over a year. All three patients achieved significant clinical improvements with tildrakizumab, with PASI scores improving by over 95%. No adverse effects were reported, and HIV viral loads remained undetectable. Tildrakizumab appears to be a safe and effective treatment option for psoriasis in individuals living with HIV, providing significant benefits without compromising HIV control.
Keywords
Introduction
Psoriasis, a chronic inflammatory skin disease, presents unique challenges when co-occurring with HIV. The interaction between HIV-induced immune dysregulation and the inflammatory mechanisms of psoriasis necessitates a careful therapeutic approach. In the United States, psoriasis prevalence in adults has been estimated at 3%. 1 HIV can exacerbate psoriasis, making it more severe and treatment-resistant. 2 Tildrakizumab, an IL-23p19 inhibitor, has demonstrated efficacy in treating moderate-to-severe psoriasis. However, data on tildrakizumab specifically in people living with HIV (PLWH) are limited. This limitation is likely due to the exclusion of PLWH from many clinical trials due to concerns about immunosuppression and potential HIV-related complications. Including PLWH in future trials, particularly those with undetectable HIV on antiretroviral therapy (ART), would provide more robust data and help establish guidelines for the safe and effective use of biologics in this population. This case series presents the outcomes of three individuals living with HIV treated with tildrakizumab, highlighting the potential for similar success in broader populations of patients with comparable conditions.3,4
Case series
Patient 1
A 46-year-old male with a history of psoriasis for 10 years, characterized by both plaque and guttate forms covering 40% of the body surface area (BSA), with a Psoriasis Area and Severity Index (PASI) score of 40.2. Previous treatments, including topical corticosteroids, UVB therapy, ciclosporin, and methotrexate, were ineffective. During pre-treatment evaluation for biologic therapy, the patient was diagnosed with HIV-1, with an estimated infection occurring approximately 3 months prior. ART with bictegravir/emtricitabine/tenofovir alafenamide was initiated, achieving an undetectable viral load within 1 month (initially 361,000 copies/mL). Three months after achieving viral suppression, tildrakizumab treatment was commenced. At 3 months post-initiation, the patient achieved a PASI96, maintaining an undetectable viral load. At 1 year, the patient attained a PASI99, with continued viral suppression and no reported adverse effects from tildrakizumab.
Patient 2
A 65-year-old male known with HIV for 15 years, on a stable ART regimen with emtricitabine/rilpivirine/tenofovir alafenamide and maintaining an undetectable viral load. The patient had mild psoriasis for 40 years, managed with topical corticosteroids, but experienced a severe exacerbation following an emotional shock 6 months prior. His BSA increased to 25% and PASI to 17.4. Multiple actinic keratoses on his face and scalp precluded UVB therapy, poorly controlled hypertension ruled out ciclosporin, and elevated liver enzymes with significant fibrosis (Fibroscan F3) due to chronic alcohol use made methotrexate unsuitable. Tildrakizumab was initiated, resulting in a PASI95 at 3 months and PASI97 at 1 year. No adverse effects from tildrakizumab were noted, and the patient’s viral load remained undetectable.
Patient 3
A 37-year-old male diagnosed with HIV for 10 years, on injectable ART with rilpivirine and cabotegravir, maintaining an undetectable viral load. The patient had moderate psoriasis for 20 years, predominantly affecting genital areas severely, impairing his sexual relations. Topical corticosteroids had become ineffective, and phototherapy was contraindicated due to carcinogenic risks on genital areas. 5 A trial of ciclosporin was quickly halted due to severe acne induced by the medication. Methotrexate was also discontinued due to gastrointestinal intolerance. After starting tildrakizumab, the patient experienced dramatic improvement, achieving PASI99 at 6 months and maintaining this improvement at 1 year, with almost complete resolution of genital lesions, no side effects, and maintained viral suppression.
Discussion
Recent evidence suggests that biologic treatments like tildrakizumab, risankizumab, and guselkumab are safe and effective for treating psoriasis in individuals living with HIV.4,6,7 These agents are all IL-23p19 inhibitors that target the IL-23/Th17 pathway, which is central to the pathogenesis of psoriasis. The choice between these agents often depends on factors such as drug availability, prior clinical experience, and patient preferences regarding the injection schedule. For instance, guselkumab is administered every 8 weeks after the initial dose, whereas both risankizumab and tildrakizumab are administered every 12 weeks after the initial dose. Although these drugs have similar efficacy and safety profiles, the choice of tildrakizumab in our case series was influenced by clinical experience and familiarity with this treatment.
To increase clinical experience and data availability, collaboration between dermatologists, infectious disease specialists, and researchers is crucial. Registries and real-world studies documenting the outcomes of biologic therapies in PLWH would be valuable. Furthermore, patient advocacy for inclusion in trials could drive policy changes that lead to more inclusive study designs.
Psoriasis management in special populations, including those with chronic infectious diseases, requires careful selection of therapy to avoid exacerbating the underlying condition. 8 This case series underscores the potential of tildrakizumab as a safe and effective treatment option for psoriasis in individuals living with HIV, even in cases with severe and sensitive area involvement like the genital region. The drug’s ability to provide significant clinical benefits without compromising HIV control or causing adverse effects suggests it could fill an important gap in the treatment of psoriasis among individuals living with HIV.
Conclusion
Tildrakizumab offers a promising therapeutic alternative for managing psoriasis in individuals living with well-controlled HIV, demonstrating significant clinical improvements and a favorable safety profile across diverse clinical scenarios.4,6–8 Continued research and more extensive clinical trials are needed to further validate these findings and optimize treatment strategies for this unique patient group.
Footnotes
Author contributions
All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by J.K. The first draft of the manuscript was written by J.K. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical statement
Data Availability Statement
The data that support the findings of this study are available from the corresponding author, JK, upon reasonable request.