Herpes zoster in psoriasis patients undergoing treatment with biological agents: prevalence, impact, and management challenges

Abstract

As TNF-α is a major factor in the immune defense against herpes zoster (HZ); an increased incidence and severity of HZ cases were suspected in patients undergoing treatment with TNF antagonists. Several studies and clinical experience provided evidence that the incidence of HZ increases by twofold to threefold in this patient category. The number of severe cases of HZ, with multisegmental, disseminated cutaneous, and/or systemic involvement, is also increased. Concerning psoriasis patients under biologicals, the clinician should be more alert for an eventual HZ event, in particular during the first year of biological treatment, and be aware of the possibility of more severe HZ cases. HZ may also undergo an age-shift toward younger patients. Rapid identification of risk factors for severe HZ, such as severe prodromal pains and/or the presence of satellite lesions, is recommended. The treatment recommendations of HZ in this patient group are identical to the recently published guidelines for the management of HZ. The live attenuated viral vaccine OKA/Merck strain anti-HZ vaccination is recommended before initiating biological treatment in psoriasis patients. The new adjuvanted anti-HZ vaccine will probably also benefit patients while on biological treatment.

Risk of herpes zoster associated with biological therapies for psoriasis and psoriatic arthritis

“…[ 29 ] As TNF-α is a major factor in the immune defence against HZ, we observe an increased risk in patients undergoing treatment with TNF-α inhibitors. [ 26 , 30 ] Among the TNF-α inhibitors, infliximab and etanercept were associated with high risks of HZ, [ 31 ] while ustekinumab was associated with a comparable risk of HZ in patients undergoing non-biological therapies, possibly due to its relatively short application and different targeted cytokine pathways. [ 26 ] The other second-generation biologics did not yet have sufficient data that would allow for further analysis.…”

“…Overall, the mean age of patients treated with biological therapies was younger than 50 years, which may explain the increased risk of HZ linked to younger patients. As El Hayderi et al [ 26 ] reported, HZ might undergo an age-shift toward younger patients. In addition, female sex may be another risk factor for HZ incidents when patients are treated with biological therapies.…”

“…The live attenuated viral vaccine is recommended for administration before starting some biological drugs in these patients, [ 26 ] while the intravenous administration of acyclovir (10 mg/kg/8 h for at least 7 days) is additionally advised for patients who are at a higher risk of developing HZ. [ 26 , 32 ]…”

“…Furthermore, our results are consistent with findings reported in previous studies. For example, El Hayderi et al [26] reported that the administration of biologics in psoriasis patients increased the risk of HZ by 2- to 3-fold; infliximab conferred an increased risk for HZ, whereas adalimumab, etanercept, and ustekinumab did not. Moreover, younger age groups were expected to contain more cases of HZ [26,27] .…”

Incidence, Clinical Features, Management, and Prevention of Herpes Zoster in Patients Receiving Antitumor Necrosis Factor Therapy: A Clinical Review

“…Management of herpes zoster in patients treated with TNF inhibitors may not differ from that of immunocompetent patients, even in severe cases. 48 The prognosis is usually favorable when the patient is actively treated according to the general guidelines. 21 In general, the use of TNF inhibitors should be interrupted at the onset of herpes zoster, and can be safely restarted as soon as vesicles have resolved and antiviral therapy is completed.…”