Continuing medical education
Psoriasis: Which therapy for which patient: Focus on special populations and chronic infections

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Despite the availability of several new systemic agents for psoriasis treatment, choosing the right therapy in certain patient populations can be challenging. There are few up-to-date reviews on systemic drugs for moderate to severe psoriasis in pregnant and pediatric patients and in patients with concomitant chronic infections, such as hepatitis, HIV, and latent tuberculosis. These groups are usually excluded from clinical trials, and much of the available evidence is based on anecdotal case reports and case series. As a chronic disease, psoriasis requires long-term treatment, and there are concerns of adverse maternal–fetal outcomes, long-term side effects in children, and the reactivation of latent infections with the use of systemic agents in these patients. The second article in this continuing medical education series provides insights for choosing appropriate systemic agents for treating moderate to severe psoriasis in pregnant and pediatric patients and in the setting of chronic infections, such as hepatitis, HIV, and latent tuberculosis.

Section snippets

Pregnancy

The treatment of psoriasis in pregnant patients can be challenging. Because of the immunomodulatory changes of pregnancy, psoriasis generally tends to improve, but some patients can experience worsening of psoriasis, warranting the need for systemic treatment.1 Pregnant patients are excluded from clinical trials and much of the available safety data are obtained from case reports.

Pediatric population

Approximately one third of psoriasis cases develop in childhood, and psoriasis accounts for nearly 4% of all dermatoses seen in children <16 years of age.39 Among the multiple systemic treatments available for psoriasis in adults, only a few systemic drugs are approved for use in the pediatric population.

Chronic infections

Most systemic agents for psoriasis are immunosuppressive, which poses a unique treatment challenge in patients with psoriasis with chronic infections because they are already immunosuppressed. In this section, we discuss treatment strategies for patients with psoriasis who have concomitant hepatitis B virus (HBV) and hepatitis C virus (HCV), HIV, and latent tuberculosis.

HIV

The prevalence of psoriasis among HIV-positive patients in the United States is reported to be 1% to 3%, which is similar to rates reported in the general population.110

Latent tuberculosis

Approximately 4.2% of the US population is affected by latent tuberculosis infection (LTBI).130, 131 All patients should be screened for LTBI with either a tuberculin skin test or interferon gamma release assay (IGRA) before starting any immunosuppressive systemic therapy.132 A positive screening test requires further medical evaluation and a chest radiograph. Normal chest radiography suggests LTBI, and these patients should receive isoniazid prophylaxis for 1 to 2 months before biologic

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    Funding sources: None.

    Dr Lebwohl is an employee of Mount Sinai and receives research funds from Abbvie, Boehringer Ingelheim, Eli Lilly, Incyte, Janssen/Johnson & Johnson, Leo Pharmaceuticals, MedImmune/AstraZeneca, Novartis, Pfizer, Sciderm, Valeant, and ViDac. Dr Lebwohl is also a consultant for Allergan, Aqua, Boehringer-Ingelheim, LEO Pharma, Menlo, Mitsubishi, Promius, and Theravance. Dr Kaushik has no conflicts of interest to disclose.

    Reprints not available from the authors.

    Date of release: January 2019

    Expiration date: January 2022

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