Acitretin in psoriasis: an evolving scenario

Abstract

Acitretin, an active metabolite of etretinate, is the most widely used systemic retinoid in the treatment of psoriasis. There are several unique characteristics of this drug, which set it apart from other options in the therapeutic armamentarium of psoriasis. It is highly efficacious as monotherapy in some specific clinical subtypes of psoriasis. It has dose-sparing effects when used as combination therapy with conventional systemic drugs as well as the biologics. It is a good option for long-term maintenance therapy. Side effects are common but usually mild and can be managed by its proper dosing and monitoring. With appropriate patient selection, gradual dose escalation, and patient counseling, we can deliver good results in psoriasis with this useful drug. This review gives a comprehensive recount of acitretin use in the present era of biologics in psoriasis.

Psoriasis and Fat-soluble Vitamins: A Review

“…The original retinoid mechanism was the antiproliferative effects and promotion of epithelial differentiation. Both effectively inhibit the hyperproliferation of keratinocytes and alter the abnormal differentiation seen in psoriasis [6]. However, studies have shown that a paradox exists in psoriatic lesions-there is a higher level of retinoic acid within lesions due to an alteration in vitamin A metabolism, yet retinoid therapy is effective in such lesions.…”

Current and Future Oral Systemic Therapies for Psoriasis

“…Acitretin, the active acid metabolite of etretinate, is hypothesized to treat psoriasis through antiproliferative effects on keratinocytes, immunomodulatory effects, and antiangiogenic effects by binding to nuclear retinoic acid receptors and/or retinoid X receptors. 50 Unlike other systemic treatments for psoriasis, retinoids are not found to be immunosuppressive, a distinct advantage for certain patients. Acitretin generally is started at low doses (10-25 mg/d), and increased as tolerated, except in the case of generalized pustular psoriasis, where it should be started high and titrated down to the lowest effective dose.…”

“…Acitretin generally is started at low doses (10-25 mg/d), and increased as tolerated, except in the case of generalized pustular psoriasis, where it should be started high and titrated down to the lowest effective dose. 50 A study of subjects treated with 50 mg daily of acitretin over 8 weeks reported 23% achieving PASI 75. 51 In another study, after 12 weeks of treatment with acitretin, the mean PASI improvement was 70% to 75%.…”

“…53 A recent review of acitretin serves as an update to the 2009 AAD guidelines. 1,50 In short, acitretin as monotherapy usually reveals poor tolerability at doses required to achieve PASI 75. However, acitretin excels at treating the generalized, palmoplantar pustular, and hyperkeratotic variants of psoriasis.…”

“…Dose-related hyperlipidemia occurs in 25% to 40% of acitretin users and may necessitate addition of a lipid-lowering medication. 50 Liver transaminase elevation also occurs but less frequently than with methotrexate. Acitretin is pregnancy category X, and women of childbearing potential should not conceive for 3 years after ceasing the drug, thus eliminating acitretin as a practical therapy for these patients.…”