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Treatment of von Zumbusch pustular psoriasis is a formidable task, especially when confounded by concomitant human immunodeficiency virus (HIV) infection. To our knowledge, this is the first report of successful use of a biologic agent to treat a patient with both von Zumbusch pustular psoriasis and HIV. Given the propensity of HIV to both trigger and exacerbate psoriasis and the potentially severe complications associated with the acute, von Zumbusch variant, we believe this report provides precedence for dermatologists to consider anti–tumor necrosis factor α (anti–TNF-α) agents as a part of the armamentarium in the treatment of these patients.
A 32-year-old man with a history of HIV, psoriasis, and psoriatic arthritis presented with increased joint pain, widespread pruritic pustules, erythema, and intermittent fever with leukocytosis of 2 weeks’ duration (Figure 1 and Figure 2). The patient had an 11-year history of HIV infection (CD4 cell count, 435/μL; nadir, 200/μL; viral load, <75/μL). He was prescribed lamivudine plus zidovudine, tenofovir disoproxil fumarate, and atazanavir sulfate and had taken no new medications within 6 months prior to presentation. The topical regimen of clobetasol propionate ointment, the superpotent corticosteroid he had been using twice daily to control his plaque psoriasis, failed to alleviate the eruption. In addition, his arthritis became so severe that he was unable to accomplish activities of daily living without assistance. Findings from a biopsy sample of lesional skin demonstrated psoriasiform epidermal hyperplasia with intraepidermal pustules, pustules in the cornified layer, parakeratosis, and a superficial and midperivascular lymphocytic infiltrate most consistent with a diagnosis of pustular psoriasis.
Mikhail M, Weinberg JM, Smith BL. Successful Treatment With Etanercept of von Zumbusch Pustular Psoriasis in a Patient With Human Immunodeficiency Virus. Arch Dermatol. 2008;144(4):453–456. doi:10.1001/archderm.144.4.453
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