Acitretin

1. Introduction

Acitretin is an oral retinoid (Vitamin A derivative) used for the treatment of severe psoriasis and other keratinisation disorders. It works by regulating skin cell growth and reducing excessive keratinisation, leading to improved skin conditions.

2. Indications

  • Severe Plaque Psoriasis
  • Pustular Psoriasis
  • Erythrodermic Psoriasis
  • Keratoderma (Severe palmoplantar keratosis, Ichthyosis vulgaris, Darier’s disease, etc.)
  • Lichen Planus (Off-label use)

3. Dosage

Adults (Severe Psoriasis & Keratinisation Disorders):

  • Initial dose: 10–25 mg once daily with food.
  • Maintenance dose: 25–50 mg/day, depending on response and tolerance.
  • Duration: Treatment may last several months, with periodic reassessment.

Elderly:

  • Same as adults, but start at lower doses to assess tolerance.

Paediatric Use (Off-Label, Severe Cases Only):

  • Initial dose: 0.5 mg/kg/day
  • Max dose: 1 mg/kg/day

Renal Impairment:

  • Use with caution—start at lower doses.

Hepatic Impairment:

  • Contraindicated in severe liver disease due to risk of hepatotoxicity.

4. Administration

  • Take with food to enhance absorption.
  • Avoid alcohol as it increases toxicity risk.
  • Do not crush or chew capsules.

5. Forms Available

  • Capsules: 10 mg, 25 mg

6. Side Effects

6.1 Common Side Effects:

  • Dry skin, lips, and eyes (xerosis, cheilitis, dry eyes)
  • Nail changes (brittle, thickened nails)
  • Hair thinning (temporary)
  • Joint and muscle pain
  • Photosensitivity (sunburn risk)

6.2 Less Common Side Effects:

  • Nosebleeds (due to dry nasal mucosa)
  • Gastrointestinal discomfort
  • Fatigue

6.3 Rare but Serious Side Effects:

  • Liver toxicity (hepatotoxicity, elevated ALT/AST)
  • Hyperlipidaemia (high triglycerides and cholesterol)
  • Depression, mood changes, suicidal ideation
  • Severe birth defects (teratogenicity, fetal malformations)

7. Warnings

  • Teratogenicity (Severe Birth Defects):
    • Absolutely contraindicated in pregnancy.
    • Effective contraception required for at least 3 years after stopping treatment.
    • Avoid alcohol for 2 months after stopping to prevent prolonged toxicity.
  • Liver & Lipid Monitoring:
    • Risk of hepatotoxicity & hyperlipidaemia—monitor liver enzymes and lipids.
  • Skeletal Effects (Long-Term Use):
    • May cause premature epiphyseal closure (in children) and osteoporosis/osteopenia (adults).

8. Precautions

  • Avoid vitamin A supplements (risk of toxicity).
  • Monitor mood changes closely (risk of depression).
  • Use with caution in diabetes—may affect blood glucose levels.

9. Interactions

  • Alcohol: Avoid completely—increases acitretin breakdown into etretinate, which prolongs toxicity.
  • Tetracyclines (e.g., doxycycline): Increased risk of pseudotumor cerebri (severe headache, vision issues).
  • Methotrexate: Increased risk of hepatotoxicity—avoid combination.
  • Warfarin: Increased risk of bleeding—monitor INR.

10. Monitoring Parameters

  • Liver function tests (ALT, AST): Every 2–4 weeks initially, then every 3 months.
  • Lipid profile (cholesterol, triglycerides): Baseline, then every 3 months.
  • Pregnancy tests: Monthly during treatment and for 3 years after stopping.
  • Bone density monitoring in long-term use.

11. Use in Children

  • Not recommended unless absolutely necessary due to risk of growth retardation and premature bone closure.

12. Use in Pregnancy

  • Category X: Strictly contraindicated due to severe teratogenic effects.
  • Requires strict contraception for at least 3 years after stopping.

13. Use in Elderly

  • Start at lower doses due to increased lipid and liver sensitivity.

14. Use in Kidney Disease

  • Use with caution—reduce initial dose.

15. Use in Liver Disease

  • Contraindicated in severe hepatic impairment.

16. Patient Counselling Points

  • Avoid alcohol completely during and for 2 months after stopping.
  • Use two forms of contraception (if applicable) during treatment and for 3 years after stopping.
  • Use moisturisers and lip balm—dryness is common.
  • Wear sunscreen—skin becomes highly sun-sensitive.
  • Regular blood tests required to monitor liver function and lipids.
  • Avoid vitamin A supplements—risk of toxicity.

17. Table of Brand Names, Manufacturer, and Prices in USD

Brand NameManufacturerStrength/Dosage FormPrice (USD)
SoriataneStiefel/GSK10 mg, 25 mg Capsules$1,500 (30 caps)
NeotigasonActavis10 mg, 25 mg Capsules$1,300 (30 caps)
Generic AcitretinVarious10 mg, 25 mg Capsules$800 (30 caps)

18. 15 FAQs (Frequently Asked Questions)

1. What is Acitretin used for?
It is used for severe psoriasis and keratinisation disorders.

2. How does Acitretin work?
It regulates skin cell growth, reducing excessive scaling and inflammation.

3. How long does it take to see results?
Improvement starts in 2–4 weeks, with full effects in 2–3 months.

4. Can Acitretin cure psoriasis?
No, but it helps control symptoms in severe cases.

5. Why must I avoid alcohol while taking Acitretin?
Alcohol converts acitretin into etretinate, which stays in the body for years and increases birth defect risk.

6. Can I take Acitretin with food?
Yes, always take it with food for better absorption.

7. Can Acitretin cause hair loss?
Yes, temporary hair thinning is possible.

8. Can I donate blood while on Acitretin?
No, and for at least 3 years after stopping to avoid fetal exposure risks.

9. Does Acitretin cause depression?
It may cause mood changes—monitor mental health closely.

10. Can I use Acitretin with topical steroids?
Yes, combination therapy is often used for better results.

11. Can I take vitamin A supplements with Acitretin?
No, excess vitamin A can cause toxicity.

12. Does Acitretin affect cholesterol?
Yes, it can increase triglycerides and cholesterol levels.

13. Can Acitretin cause liver damage?
Yes, monitor liver function regularly.

14. Can I take Acitretin if I have diabetes?
Use with caution—it may affect blood sugar levels.

15. How should Acitretin be stored?
Store at room temperature, away from moisture.