Case Presentation: A 35-year-old man with a history HIV/AIDS with a CD4 count 60 and recently treated secondary syphilis presented for acute worsening of chronic rash after restarting Biktarvy. Exam found eruptive, generalized exanthem characterized by oval-shaped, pink, scaly plaques and papules with prominent flexural involvement. The initial differential diagnosis included disseminated bacterial or fungal infection, recurrent secondary syphilis, or a primary dermatologic condition. The patient received systemic antibiotics and antifungals for empiric coverage of disseminated, cutaneous bacterial or fungal infection. Punch biopsy results were consistent with pustular psoriasis and stains were negative for infectious organisms. After discussion with dermatology, we discontinued antimicrobials and started topical steroids and a short course of cyclosporine. At two-month follow-up, the patient continued to be highly symptomatic with over 95% of his body surface area affected. Dermatology converted cyclosporine to acitretin, a systemic retinoid, and continued topical agents. He has not yet had follow-up to gauge response.

Discussion: There are numerous dermatologic conditions affecting patient’s living with HIV (PLWH) and the differential diagnosis for a disseminated rash is broad. Large diagnostic categories to consider include infection, infestation, neoplasm, inflammatory conditions, and other (6). The differential specifically for psoriasis in PLWH must include secondary syphilis, seborrheic dermatitis, and drug eruption (1). In this patient the clinical exam was consistent with pustular psoriasis, which the biopsy confirmed.Psoriasis is a pro-inflammatory dermatologic condition. Therefore, the condition has a paradoxical relationship with the level of immunosuppression in HIV infection (1). It is more likely to occur as patients’ CD4 counts decrease, but often spontaneously remits once end-stage acquired immunodeficiency syndrome (AIDS) is reached (1). It can also be precipitated by the restoration of the immune system with anti-retroviral therapy (ART), as occurs with Immune Reconstitution Inflammatory Syndrome (IRIS) (7,2).When psoriasis occurs in PLWH, the presentation is often diffuse, severe, and recalcitrant to treatment (1). Any subtype can occur but the most common is plaque psoriasis (2). Treatment should involve a step-up approach depending on disease severity. Mild presentations can be treated with ART’s and topical agents such as emollients, corticosteroids, vitamin D analogous, or retinoids. Moderate to severe disease can be treated using phototherapy with ultraviolet radiation and oral retinoids. Severe, refractory disease can be treated with immunomodulators such as cyclosporine, methotrexate, hydroxyurea, or TNF alpha inhibitors (1,2,3,4,5). The risks and benefits of immunomodulating therapies in PLWH should be considered given their immunocompromising side effects (1). Data on the use of these agents is limited to case series and anecdotal evidence so there are no clear guidelines addressing efficacy or length of treatment (4).

Conclusions: Both immunosuppression and immune reconstitution can precipitate psoriasis in PLWH. Presentations are often diffuse, severe, and recalcitrant to treatment. Therapeutic options include topical agents, phototherapy, and immunomodulators.