Dermatologists should screen psoriasis patients for tuberculosis (TB) and hepatitis B virus (HBV) before beginning treatment with tumor necrosis factor (TNF) inhibitors or biologics, according to Jashin J. Wu, MD, Director of the Psoriasis Clinic, Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, California, at the 2015 Summer Academy Meeting of the American Academy of Dermatology. Dr. Wu provided 10 psoriasis pearls in 10 minutes. Among them he reviewed important screenings for psoriasis patients.
The National Psoriasis Foundation’s consensus statement on screening for latent TB infection in patients with psoriasis treated with systemic and biologic agents (J Am Acad Dermatol. 2008;59:209-217) indicated that chronic immunosuppression is a known risk factor for allowing latent TB to transform into active TB. Therefore, immunosuppressive and immunomodulatory therapies for psoriasis and psoriatic arthritis may be associated with an increased rate of active TB in some patients receiving these therapies. The consensus statement reported, “It is, therefore, of utmost importance to appropriately screen all patients for latent TB infection prior to initiating any immunologic therapy. Delaying immunologic therapy until latent TB infection prophylaxis is completed is preferable.”
When screening for tuberculosis, Dr. Wu recommends the IFN-γ release assay instead of the purified protein derivative (tuberculin)(PPD) test because it is more sensitive and more specific than the PPD in diagnosing latent TB infection in immunocompetent individuals. Additionally, Dr. Wu reports that the IFN-γ release assay is more specific than the PPD in those who have received the BCG vaccine and is more convenient for patients.
For patients who may receive TNF inhibitors, Dr. Wu recommends screening for HBV using triple serology testing: hepatitis B surface antigen, hepatitis B surface antibody, and hepatitis B core antibody. He also recommends this screening for patients who may be on biologics including ustekinumab and secukinumab. If the patient is at risk for reactivation of HBV, dermatologists should check liver function tests, hepatitis B surface antibody, hepatitis B core e antigen, and HBV DNA counts. Routine follow-up with testing for reactivation should continue for at least 6 months after the TNF inhibitor is discontinued. If patients have chronic HBV and biologics are considered, etanercept is recommended as first-line therapy.