Is etanercept safe for treating plaque psoriasis in a patient with chronic hepatitis C virus infection?

A 58-year-old man was evaluated for a 7-year history of severe plaque psoriasis with 20.0% body surface area. Previously, his psoriasis had showed marked improvement with methotrexate. He had discontinued use of methotrexate 1 month into therapy after serum alanine transaminase levels had increased to 9 times the normal value. He was found to have IgG hepatitis C viral antibody– positive status. Initial hepatitis C virus (HCV)–RNA was considered insignificant at 1350 IU/mL (normal levels generally defined as below 800 000 IU/mL). Liver biopsy demonstrated Metavir grade 2-3 (mild to moderate) inflammation with stage 3 bridging fibrosis. Other psoriasis systemic therapies such as acitretin and cyclosporine were not selected because of the concern that hepatotoxic and immunosuppressant activity from these agents could potentiate liver damage by chronic HCV infection. Our patient completed a 1-year course of combined therapy with narrowband UV-B and different trials of topical corticosteroids such as triamcinalone acetonide ointment, 0.1%, fluocinonide ointment, 0.05%, and betamethasone dipropionate ointment, 0.05%, without any improvement. Efalizumab treatment was initiated prior to the drug’s withdrawal from the market after considering our patient’s financial limitations, available prescription assistance, and literature describing minimal hepatotoxicity. The accumulated data concerning the successful use of efalizumab in patients with psoriasis and concomitant chronic HCV is limited to a case report and 1 case series. Data from these observational studies show reduction in plaque psoriasis body surface area involvement during treatment, without laboratory or clinical evidence of hepatic decompensation. Despite initial improvement with efalizumab, our patient’s psoriasis worsened with an acute generalized guttate-type flareup. This result was most likely associated with efalizumab use; there was no change in hepatic function and HCV-RNA levels during treatment. With continuing worsening, alternative therapy was sought. Tumor necrosis factor is implicated in hepatocyte destruction during chronic HCV infection, although its exact pathogenic mechanism is still unclear. One study showed greater reduction in HCV-RNA levels after etanercept was used in combination with interferon alfa-2b and ribavirin for 24 weeks compared with placebo. AntiTNF therapy may therefore provide benefit for chronic HCV infection and severe plaque psoriasis. The aim of this article is to determine from the available evidence whether etanercept would be an effective and safe treatment option for patients with severe plaque psoriasis in the setting of chronic HCV infection.