Human immunodeficiency virus (HIV) leads to immunosuppression by depleting CD4+ T-cells. Psoriasis, a common immune-mediated inflammatory dermatosis, can paradoxically worsen or emerge as an initial presentation of HIV. The introduction of highly active antiretroviral therapy (HAART) in psoriatic patients with HIV may trigger severe psoriasis flare-ups, often linked to immune reconstitution inflammatory syndrome (IRIS).

This case involves a 31-year-old Filipino male with recurrent, resistant psoriatic plaques. Further testing revealed latent syphilis and HIV infection. The patient completed treatment for syphilis and began HAART, but developed erythrodermic psoriasis, likely due to IRIS. After an inadequate response to acitretin, guselkumab, an IL-23 inhibitor, was administered. The patient responded well, showing significant improvement after four months of treatment without adverse effects.

This case suggests that in severely immunocompromised patients with newly diagnosed HIV, adding guselkumab to conventional HAART may be a safe and effective option for controlling erythrodermic psoriasis flares triggered by immune reconstitution. However, further research is needed to assess the long-term safety and efficacy of guselkumab in HIV-associated psoriasis.