DENVER — Although there are good reasons to prescribe biologics to treat moderate-to-severe psoriasis in HIV-positive patients, evidence supporting their safe use is thin, according to a dermatologist speaking at American Academy of Dermatology (AAD) 2026 Annual Meeting.

“Even if someone has well-controlled HIV, there’s always a very logical and reasonable concern that they may be at higher risk of infectious complications,” said Philip Doiron, MD, MSc, assistant professor of dermatology at the University of Toronto, Toronto, Ontario, Canada, in a presentation at the meeting.

He offered these pearls about careful treatment of psoriasis in HIV-positive patients:

Try Nonimmunosuppressive Options First

Work through nonimmunosuppressive agents before reaching for biologics, Doiron suggested.

Acitretin has the strongest evidence in the HIV-positive population, with a 1997 case series showing that most of the 11 patients had a good-to-excellent response. However, he noted that certain antiretroviral therapies may boost the risk for hypertriglyceridemia and pancreatitis linked to acitretin.

Apremilast, another option, has only two case reports in patients with HIV but showed efficacy and safety.

Beware of Methotrexate and Cyclosporine

Methotrexate has contributed to poor outcomes in patients with HIV, Doiron said, although the reports are from the pre-antiretroviral era. “[It] is not a medication I jump to use in patients with HIV,” he noted.

He’s also cautious about cyclosporine, he said, because both drugs can interact with antiretroviral medications.

Don’t Rely on Outdated Guidelines

Recommendations from 2010 regarding treatment of psoriasis in patients who are HIV positive are outdated, Doiron said. Updated 2025 guidelines on general psoriasis treatment from the Psoriasis Research Group of the French Society of Dermatology are helpful, although their HIV-specific recommendations are sparse, he said.

The French guidelines recommend that all patients with psoriasis undergo HIV testing before beginning systemic treatment. They also recommend working with relevant specialists when prescribing systemic therapy in HIV-positive patients and making sure HIV is well controlled.

Doiron agrees with these recommendations. “I’ve never had an HIV specialist have a problem with putting someone on therapy, but it’s always good to have them in the loop,” he said, adding that “you don’t want to put someone who’s not on [antiretroviral] therapy or who isn’t well controlled on a biologic.”

The guidelines also caution about deucravacitinib, a selective tyrosine kinase 2 (TYK2) inhibitor, because there are no case reports about its use in this population. 

Biologic Data Are Limited

HIV-positive patients are often left out of research on skin disease. Doiron highlighted a 2025 report showing that of 175 studies on atopic dermatitis, psoriasis, and alopecia areata, only two included patients with HIV.

Only 128 HIV-positive patients appear in all published reports about the use of biologics for psoriasis, Doiron said. There are no reports at all about some drugs.

Check Case Reports for Data

Many of the published case reports are about TNF inhibitors: 31 with etanercept, 11 with adalimumab, and seven with infliximab. These treatments showed efficacy in most patients, no different than the general population, and there were no notable changes in viral loads and CD4 counts.

There were seven adverse events and six opportunistic infections reported for the three drugs. One patient with a severely compromised immune system (CD4 = 20 cells/mm³) had frequent polymicrobial infections and died; another had fatal peritonitis.

Doiron highlighted case reports about patients on interleukin inhibitors: Ustekinumab, secukinumab, ixekizumab, brodalumab, guselkumab, risankizumab, and tildrakizumab showed efficacy in all cases and no serious adverse events.

There’s more good news: A 2023 report found no effect of biologic therapy for psoriasis on HIV viral load and CD4 counts.

Consider How Long Medications Stay in the Body

Doiron noted that some of his colleagues prefer TNF inhibitors like adalimumab to newer targeted therapies that stay in the body longer.

“If there were something to go wrong, they can stop giving that medication, and it’s out of the person’s system,” he said. “As opposed to some of the newer, more targeted biologics: If you’ve given a dose every 8-12 weeks, and something bad happens a week after their dose, you can’t really get rid of that medication. That bothers some people.”

However, “that is balanced by the fact that within the biologics, the TNFs do have a slightly broader mechanism of action and potentially do have more infections than some of our more targeted agents,” Doiron pointed out.

Regardless, he said, “I personally have HIV-positive patients on all of these medications.”

Doiron disclosed relationships with AbbVie, Amgen, Eli Lilly, Janssen, Leo, Novartis, Pfizer, Sanofi, and Sun.