Answer:
There are now five FDA-approved biologic therapies and three nonbiologic systemic agents available to treat patients with severe plaque psoriasis. However, seven of these agents are known to be immunosuppressive, and their use in a patient with a history of either hepatitis C or throat cancer is problematic. Obviously, in the patient presented—who has both hepatitis C and a history of throat cancer—treatment options are even more limited. My best choices in this patient would be ultraviolet light, which the patient has not responded to, and acitretin, which the patient is also not responding to. It is important to know more details regarding the definition of failure for both of these therapies. The type of ultraviolet light therapy used (broad versus narrowband UVB versus PUVA) and the length of treatment, along with the dosage and duration of acitretin therapy, are very important factors. Although ultraviolet light alone and soriatane alone have been labeled failures for this patient, it is possible that he may have a good response to a combination of acitretin and ultraviolet light. The combination of retinoids and ultraviolet light is often synergistic; this would be my next choice for this patient.

Although there have been case reports and a few small studies of safe and successful treatment of patients with psoriasis who have concomitant hepatitis C using etanercept, none of these studies included patients with a history of solid cancer. I would be reluctant to use etanercept or any other immunosuppressive agents in this patient given his history of throat cancer.

Neil J. Korman, MD, PhD

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