A 54-year-old male was referred to the dermatology clinic for management of his psoriasis. He had a long-standing history of HIV that was well controlled on abacavir/lamivudine and efavirenz. His CD4 count exceeded 1000 cells/mm3 and his viral load had been undetectable for years. He was also known for obesity, type 2 diabetes, and hypertriglyceridemia (394 mg/dL despite rosuvastatin and fenofibrate). He reported that his psoriasis was worse in the summertime, and his daytime occupation as a cook precluded regular attendance to a phototherapy unit. Dermatological examination revealed well-demarcated scaly plaques typical of psoriasis affecting 12% total body surface area (TBSA) with a Psoriasis Area Severity Index (PASI) of 10.2. There was involvement of dorsal hands and genitals. His Dermatology Quality of Life Index (DLQI) was 20.
A trial of betamethasone dipropionate 0.05%/calcipotriol foam was only minimally helpful. As previously mentioned, phototherapy was impractical for this patient, and his hypertriglyceridemia made use of acitretin potentially unsafe. After discussion of potential benefits and risks, he was trialed on apremilast with the traditional increasing dose starter pack over 1 week, then at 30 mg po bid.
There was diarrhea during the initial few weeks of treatment. After 3 months on treatment, his PASI decreased to 4.1. After 7 months on treatment, his PASI decreased to 2.7 and his DLQI to 1. Two years later, his PASI score was maintained at 2.4, with a stable CD4 count of 1200 cells/mm3 and an undetectable viral load. There were no serious opportunistic infections or laboratory abnormalities, but the patient did report more self-resolving upper respiratory tract infections.