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Entecavir and intermittent etanercept therapy in a patient with concurrent hepatitis B virus infection and psoriasis.

Traditional systemic therapies are generally contraindicated in psoriatic patients affected by hepatitis B virus (HBV) infection due to the risk of immunosuppression related to the use of cyclosporine and methotrexate and/ or the risk of liver toxicity resulting from the use of methotrexate and acitretin (1). Moreover, many authors suggest that anti-tumour necrosis factor (TNF)-a agents are associated with an increased risk of viral reactivation in patients with chronic inactive HBV infection (2). Although increased levels of TNF-a and TNF-a receptor are found in both the serum and hepatocytes of patients with chronic HBV infection (3), it appears that TNF-a, secreted by HBV specific cytotoxic lymphocytes, plays a pivotal role in the downregulation of HBV replication, by promoting "clearance" of the virus from the hepatocytic cells (3, 4). This would explain the reappearance of the HBV surface antigen (HBsAg) and the subsequent development of hepatitis in patients on longterm therapies with immunosuppressants and/or cancer chemotherapeutic agents (2, 5). We present here a case of a psoriatic patient affected by active HBV infection, who was treated with entecavir as first-line antiviral therapy during intermittent etanercept treatment.