Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 28, 2016; 22(28): 6444-6455
Published online Jul 28, 2016. doi: 10.3748/wjg.v22.i28.6444
Management of psoriasis patients with hepatitis B or hepatitis C virus infection
Claudio Bonifati, Viviana Lora, Dario Graceffa, Lorenzo Nosotti
Claudio Bonifati, Viviana Lora, Dario Graceffa, Center for the Study and Treatment of Psoriasis San Gallicano Dermatologic Institute, IRCCS, 00144 Rome, Italy
Lorenzo Nosotti, Gastrointestinal and Liver Department, National Institute for Health, Migration and Poverty, 00153 Rome, Italy
Author contributions: Bonifati C performed research and wrote the paper; Lora V, Graceffa D and Nosotti L contributed critical revision of the manuscript.
Conflict-of-interest statement: No conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Claudio Bonifati, MD, Center for the Study and Treatment of Psoriasis San Gallicano Dermatologic Institute, IRCCS, ViaElioChianesi 53, 00144 Rome, Italy.
Telephone: +39-6-52665140
Received: March 23, 2016
Peer-review started: March 23, 2016
First decision: May 12, 2016
Revised: May 25, 2016
Accepted: June 15, 2016
Article in press: June 15, 2016
Published online: July 28, 2016

The systemic therapies available for the management of Psoriasis (PsO) patients who cannot be treated with more conservative options, such as topical agents and/or phototherapy, with the exception of acitretin, can worsen or reactivate a chronic infection. Therefore, before administering immunosuppressive therapies with either conventional disease-modifying drugs (cDMARDs) or biological ones (bDMARDs) it is mandatory to screen patients for some infections, including hepatitis B virus (HBV) and hepatitis C virus (HCV). In particular, the patients eligible to receive an immunosuppressive drug must be screened for the following markers: antibody to hepatitis B core, antibody to hepatitis B surface antigen (anti-HBsAg), HBsAg, and antibody to HCV (anti-HCV). In case HBV or HCV infection is diagnosed, a close collaboration with a consultant hepatologist is needed before and during an immunosuppressive therapy. Concerning therapy with immunosuppressive drugs in PsO patients with HBV or HCV infection, data exist mainly for cyclosporine a (CyA) or bDMARDs (etanercept, adalimumab, infliximab, ustekinumab). The natural history of HBV and HCV infection differs significantly as well as the effect of immunosuppression on the aforementioned infectious diseases. As a rule, in the case of active HBV infection, systemic immunosuppressive antipsoriatic therapies must be deferred until the infection is controlled with an adequate antiviral treatment. Inactive carriers need to receive antiviral prophylaxis 2-4 wk before starting immunosuppressive therapy, to be continued after 6-12 mo from its suspension. Due to the risk of HBV reactivation, these patients should be monitored monthly for the first 3 mo and then every 3 mo for HBV DNA load together with transaminases levels. Concerning the patients who are occult HBV carriers, the risk of HBV reactivation is very low. Therefore, these patients generally do not need antiviral prophylaxis and the sera HBsAg and transaminases dosing can be monitored every 3 mo. Concerning PsO patients with chronic HCV infection their management with immunosuppressive drugs is less problematic as compared to those infected by HBV. In fact, HCV reactivation is an extremely rare event after administration of drugs such as CyA or tumor necrosis factor-α inhibitors. As a rule, these patients can be monitored measuring HCV RNA load, and ALT, aspartate transaminase, gamma-glutamyl-transferase, bilirubin, alkaline phosphatase, albumin and platelet every 3-6 mo. The present article provides an updated overview based on more recently reported data on monitoring and managing PsO patients who need systemic antipsoriatic treatment and have HBV or HCV infection as comorbidity.

Keywords: Psoriasis, Therapy, Conventional disease-modifying drugs, Biological disease-modifying drugs, Hepatitis B virus infection, Hepatitis C virus infection

Core tip: At present, no guidelines give clear indications regarding the management of psoriasis patients with concomitant hepatitis B or hepatitis C virus infection who need a systemic treatment. On the basis of the available literature data, this paper provides an overview in this field from a practical point of view. A particular emphasis is given, with regard to the use of biological drugs, in the aforementioned patients.