HCV therapy also improves patient's psoriasis?

John Murphy, MDLinx | January 16, 2018

Researchers have reported the first case of a patient whose psoriasis improved after receiving direct-acting antiviral (DAA) treatment for a hepatitis C virus (HCV) infection.


Psoriasis improved after DAAs

An 80-year-old man with a history of refractory psoriasis was prescribed direct-acting antivirals for an untreated HCV infection. In a few weeks, both the HCV infection and psoriasis improved.

“Before [DAA] therapy, the patient had a Psoriasis Area and Severity Index score of 8.3; after therapy, the score was 2.0,” wrote hepatology specialists from Osaka City University, Osaka, Japan, in a case report published recently in Annals of Internal Medicine.

In this report, an 80-year-old man with a 9-year history of refractory psoriasis was referred to the authors, who replaced his clobetasol topical corticosteroid with betamethasone and his maxacalcitol vitamin D3 analogue with calcipotriol. But even after changing his therapy, the patient’s symptoms and signs of psoriasis persisted.

Because the patient also had chronic HCV infection that hadn’t been treated, the authors started him on a 12-week course of oral, fixed-dose ledipasvir-sofosbuvir. Within 4 weeks of treatment, the patient’s level of HCV RNA was undetectable by polymerase chain reaction testing, and remained undetectable for 24 weeks after therapy.

Remarkably, the patient’s psoriasis skin lesions also started to resolve gradually shortly after he began DAA therapy.

“We believe [this] to be the first report of a patient whose psoriasis improved when therapy with these agents was initiated,” they wrote.

Uncertainty remains

At least one epidemiological study found that HCV is more prevalent in adults with psoriasis, and that HCV-positive patients with moderate to severe psoriasis have a higher rate of hepatic decompensation. Other researchers have suggested that hepatitis C viruses, as well as interferon-based HCV treatment, may induce or exacerbate psoriasis.

“The situation is different today, because treatment of HCV infection almost exclusively involves direct-acting antiviral drugs that are remarkably effective and have good safety profiles,” wrote the authors of the current case report.

“As a result, current guidelines recommend treatment with these agents for all patients with chronic HCV infection, including those with psoriasis, except in patients with a limited life expectancy due to non-hepatic causes,” they noted.

But, they added, it’s still uncertain how DAA therapy may affect patients who have both psoriasis and HCV infection. In contrast to their own case report, the authors pointed to a recent report of ledipasvir-sofosbuvir treatment that was associated with new-onset psoriasis in one HCV-positive patient and worsening psoriasis in another one.

Psoriasis is an immune-mediated skin disorder associated with increased systemic inflammation and an overproduction of inflammatory cytokines, the authors noted.

“The relationship between HCV infection and psoriasis is uncertain, but this infection could change the expression of inflammatory cytokines and alter how psoriasis is expressed in susceptible patients,” they speculated.

A certain subset of patients?

“The use of direct antiviral agents to treat hepatitis C may be promising for improving its extrahepatic manifestations, including cutaneous lesions,” dermatologists Karina M. Parr, MD, and Umer Ansari, MD, noted.

Dr. Parr and Dr. Ansari recently reported a somewhat similar case of a 55-year-old man with hepatitis C whose cutaneous lichen planus improved with ledipasvir-sofosbuvir therapy.

“More research is needed, as we know that not all patients on ledipasvir-sofosbuvir experience improvement in severity of psoriasis or lichen planus,” they wrote, adding that the immune and genetic makeup of a subset of patients with hepatitis C may make them more prone to developing inflammatory skin diseases such as lichen planus and psoriasis.

“With the ongoing development of precision medicine, we may be able to identify these patients in the future and better predict the clinical course of psoriasis and lichen planus in patients with hepatitis C undergoing ledipasvir-sofosbuvir treatment,” Dr. Parr and Dr. Ansari noted.

One of the authors, Norifumi Kawada, MD, received lecture fees and research grants from Gilead Sciences.