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 Table of Contents  
VIVA VOCE
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 54-58

Viva voce on acitretin


1 Department of Pediatric Dermatology, Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, Maharashtra, India
2 Department of Dermatology, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
3 Consultant Dermatologist, Anand Polyclinic, Matunga, Mumbai, Maharashtra, India

Date of Web Publication15-Jun-2016

Correspondence Address:
Resham Vasani
C-1 , 22, Karmakshetra, Near Shanmukhanada Hall, Sion - 400 037, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-3972.184087

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How to cite this article:
Parikh D, Khopkar U, Vasani R. Viva voce on acitretin. Indian J Drugs Dermatol 2016;2:54-8

How to cite this URL:
Parikh D, Khopkar U, Vasani R. Viva voce on acitretin. Indian J Drugs Dermatol [serial online] 2016 [cited 2024 Mar 2];2:54-8. Available from: https://www.ijdd.in/text.asp?2016/2/1/54/184087




  What are the Indications for Which You Have Used Acitretin? Top


Dr. Deepak Parikh – In adults, I have used it with good results in guttate psoriasis in combination with narrowband ultraviolet B (NBUVB), in psoriatic palmoplantar keratoderma with NBUVB, and topical corticosteroids. I have used it as a monotherapy in extensive warts with fair results. I have also used it as a part of rotational therapy with methotrexate (MTX) or cyclosporine in psoriasis.

Dr. Uday Khopkar – In adults, I have extensively used it in psoriasis, particularly pustular psoriasis, palmoplantar psoriasis, ostraceous variant of chronic plaque psoriasis, verrucous psoriasis, and scalp psoriasis as monotherapy as well as combination with UVA or UVB and topicals. Other than psoriasis, I have used in Darier's disease, multiple verrucae, arsenical keratoses, radiation keratoses, etc., Although I have used it in oral lichen planus and leukoplakia, the results are not very promising. In mycosis fungoides, I have combined acitretin with phototherapy.

Dr. Deepak Parikh – In the pediatric age group, I have used it as a therapy of choice in cases of ichthyosiform dermatoses and palmoplantar keratoderma.

Dr. Uday Khopkar – In pediatric age group, I have used it in cases of lamellar or other forms of moderate to severe ichthyoses, fissured hyperkeratotic cases of palmoplantar keratoderma, and those with ainhum formation.

In literature, the indications of acitretin are as mentioned in [Box 1].




  In Cases of Psoriasis What Are the Clinical Scenarios Where You Would Prefer Acitretin as The first Drug? or in Other Words Where Would You Prefer Acitretin over Methotrexate? Top


Dr. Deepak Parikh – Severe palmoplantar psoriasis, guttate psoriasis. In cases of generalized pustular psoriasis, would prefer cyclosporine over acitretin.

Dr. Uday Khopkar – Pustular psoriasis, palmoplantar psoriasis.


  What are the Investigations to Be Performed Before Administering Acitretin in the Adult and Pediatric Age Group? Top


Dr. Deepak Parikh – The investigations in the pediatric age group essentially remain the same as in an adult. A baseline liver function test and a lipid profile are all that is required.

In severe genodermatoses when we intend to administer acitretin for many years, we can get a baseline X-ray of spine, hip and femur done and repeat it yearly to look out for any bony changes.

Dr. Uday Khopkar – Lipid profile and liver function tests are the tests that are required. I do not perform baseline evaluation of bones and would do so if the patient develops any symptoms. Would take a decision whether to continue acitretin or not in such a situation in conjunction with an orthopedic surgeon, after weighing the risk-benefit ratio.


  How Does One Administer Acitretin Capsule to a Child? Top


Dr. Deepak Parikh – The capsule can be frozen and cut to achieve the required dose. It can mixed in honey and administered to the child.

Dr. Uday Khopkar – The capsule can be punctured, and the contents can be squeezed into the mouth of the patient.


  How to Monitor a Patient on Acitretin? Top


Dr. Deepak Parikh – The monitoring would depend on the baseline reports, comorbidities, and lifestyle of the patient. If the patient has baseline abnormal levels, is obese, or is an alcoholic, the monitoring will be more frequent.

Dr. Uday Khopkar – Under normal circumstances, would advise investigations after 2 weeks and then every 2–3 months.

Literature mentions the monitoring of acitretin as mentioned in [Box 2].




  Have You Seen Diffuse Idiopathic Skeletal Hyperostosis/premature Epiphyseal Closure/osteoporosis in Clinical Practice? Top


Dr. Deepak Parikh – No.

Dr. Uday Khopkar – No.

Diffuse idiopathic skeletal hyperostosis is to be kept in mind when the duration of acitretin therapy extends beyond 2 years. Hence, in an attempt to minimize cumulative side effects, I would prefer intermittent therapy with administration of acitretin during seasonal exacerbations.

In cases of psoriasis, would prefer rotational therapy with MTX or cyclosporine in an attempt to minimize the toxicity of both drugs.

[Box 3] lists the recent literature on skeletal side effects of acitretin.




  Do You Routinely Recommend Vitamin D and Calcium Administration When a Patient Is on Acitretin? Top


Dr. Deepak Parikh – No. Only if they are found to be deficient. It is important to screen the patients for rickets as the patients with ichthyosis are more prone to it. So also, the musculoskeletal side effects of acitretin are accentuated in cases of Vitamin D deficiency.

Dr. Uday Khopkar – No. Acitretin has no direct relation with Vitamin D or calcium levels. However, patients with moderate to severe ichthyosis routinely require such supplementation as their skin does not allow penetration of UV rays needed for making Vitamin D.


  What is the Longest Duration That You Have Administered Acitretin Without Any Side Effects in Adults and Children? Top


Dr. Deepak Parikh – Twelve years in a pediatric patient of keratitis-ichthyosis-deafness syndrome. Four years in an adult.

Dr. Uday Khopkar – In cases of adults have frequently administered acitretin for 3 years and for occasionally for 5 years.

In children have had follow-up of patients for about 3–4 years.


  Would You Administer Acitretin to a Married Male Who Is Planning Pregnancy? Top


Dr. Deepak Parikh – Yes.

Dr. Uday Khopkar – I do not advise regularly. Literature denies any evidence of teratogenicity if a male impregnates a female when on acitretin, but I would try to avoid. I am reminded of a patient 5 years back, who was a case of lamellar ichthyosis and who was advised to stop acitretin when he was planning a child, but went ahead consuming it and now has a normal child. Hence, we need not fear about teratogenicity when it is the male on acitretin.


  What are the Adverse Effects of Acitretin That You Have Seen in Practice? Top


Dr. Deepak Parikh – Dryness is the most common side effect. Lipid elevations and transient elevation of transaminases (two times the normal value) have been seen.

Dr. Uday Khopkar – Dermatological side effects I have observed are - dryness, peeling, and erythema on the face. Dryness of mucosae may cause epistaxis and bleeding per rectum.

Non-dermatological side effects observed are – hyperlipidemia, increased blood sugar levels, mild and transient transaminase increases, headache, and menstrual disturbances.

One unusual side effect that I have observed is – pleural effusion. The patient on acitretin presented with pleural effusion and was investigated without any conclusive results. He was given trial of anti-Koch therapy to which the patient did not respond. The effusion resolved after discontinuation of acitretin.


  What are the Combination Therapies That You Have Administered With Acitretin in Cases of Psoriasis? Top


Dr. Deepak Parikh – Acitretin can be added to MTX when a few persistent plaques of psoriasis remain after administration of MTX.

Acitretin with NBUVB is a combination that I have used with good results.

Dr. Uday Khopkar – The best combination is administration of acitretin with UVA or UVB.

I have combined acitretin in resistant plaques of psoriasis on treatment with MTX. In such cases, we need to monitor liver function more frequently.

I have combined acitretin with cyclosporine in unstable psoriasis. Here, we need to monitor lipid profile more frequently.

Acitretin has been combined with biologics, taking advantage of the fact that acitretin does not have immunosuppressive properties.


  How to Manage Lipid Derangements Due to Administration of Acitretin? How Frequently Should it Be Done in a Child/adult? Top


Dr. Deepak Parikh – I would manage lipid derangements in consultation with the physician. Elevated triglycerides in a patient with metabolic syndrome predispose a person to nonalcoholic steatohepatitis (NASH). A baseline FibroScan will be needed in such cases before starting acitretin.

Dr. Uday Khopkar – Statins can be used in conjunction with physician's advice. The lipid levels are done after 2 weeks and then after a month. If administered for long-term, we need to repeat the investigations every 3–6 months.


  How Long We Ask a Female to Avoid Pregnancy When on Acitretin? Are Contraceptive Pills Safe When Used With Acitretin? Top


Dr. Deepak Parikh – In theory, we need to avoid pregnancy for 2 years but in clinical practice, I advise avoidance of pregnancy for at least after 3–4 menstrual cycles. Oral contraceptive pills are safe with acitretin and should be administered after checking the drug interactions.

Dr. Uday Khopkar – Patient should be asked to avoid pregnancy for at least 2 years and if we want to be very sure, for the next 3 years. She should be instructed to avoid alcohol and alcohol-containing products such as cough syrups. Oral contraceptive pills are safe when taken with acitretin, except microdose progestin pills (mini-pills) should be avoided since they interact with acitretin.

[Box 4] mentions the teratogenic side effects of acitretin.




  Can Acitretin be Administered in an Obese Patient With Metabolic Syndrome? Top


Dr. Uday Khopkar – It is a relative contraindication. It would warrant more frequent investigations in consultation with the treating physician. So also, appropriate lifestyle modifications are to be advised to the patient.

Dr. Deepak Parikh – Would start acitretin only after physician consent. Would also like to keep in mind the increased incidence of NASH and hence would like to rule it out with a FibroScan before administering acitretin.

Also I would like to add here, if the patient has increased triglycerides and further develops elevated transaminases on acitretin, I would think of decrease in dosing or stopping the drug earlier than in normal circumstances, since these individuals have a higher risk of NASH.


  Can Acitretin be Administered in an Alcoholic? Top


Dr. Uday Khopkar – Yes. With more frequent monitoring.

Dr. Deepak Parikh – Yes.[21]



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sbidian E, Maza A, Montaudié H, Gallini A, Aractingi S, Aubin F, et al. Efficacy and safety of oral retinoids in different psoriasis subtypes: A systematic literature review. J Eur Acad Dermatol Venereol 2011;25 Suppl 2:28-33.  Back to cited text no. 1
    
2.
Lassus A, Geiger JM. Acitretin and etretinate in the treatment of palmoplantar pustulosis: A double-blind comparative trial. Br J Dermatol 1988;119:755-9.  Back to cited text no. 2
    
3.
van Dooren-Greebe RJ, van de Kerkhof PC, Happle R. Acitretin monotherapy in Darier's disease. Br J Dermatol 1989;121:375-9.  Back to cited text no. 3
    
4.
Kirby B, Watson R. Pityriasis rubra pilaris treated with acitretin and narrow-band ultraviolet B (Re-TL-01). Br J Dermatol 2000;142:376-7.  Back to cited text no. 4
[PUBMED]    
5.
Laurberg G, Geiger JM, Hjorth N, Holm P, Hou-Jensen K, Jacobsen KU, et al. Treatment of lichen planus with acitretin. A double-blind, placebo-controlled study in 65 patients. J Am Acad Dermatol 1991;24:434-7.  Back to cited text no. 5
    
6.
Lacour M, Mehta-Nikhar B, Atherton DJ, Harper JI. An appraisal of acitretin therapy in children with inherited disorders of keratinization. Br J Dermatol 1996;134:1023-9.  Back to cited text no. 6
    
7.
Choi YL, Lee KJ, Kim WS, Lee DY, Lee JH, Lee ES, et al. Treatment of extensive and recalcitrant viral warts with acitretin. Int J Dermatol 2006;45:480-2.  Back to cited text no. 7
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8.
Lee YS, Jung SW, Sim HS, Seo JK, Lee SK. Blastomycosis-like pyoderma with good response to acitretin. Ann Dermatol 2011;23:365-8.  Back to cited text no. 8
    
9.
Ruzicka T, Sommerburg C, Goerz G, Kind P, Mensing H. Treatment of cutaneous lupus erythematosus with acitretin and hydroxychloroquine. Br J Dermatol 1992;127:513-8.  Back to cited text no. 9
    
10.
Newland K, Marshman G. Success treatment of post-irradiation morphoea with acitretin and narrowband UVB. Australas J Dermatol 2012;53:136-8.  Back to cited text no. 10
    
11.
Bousema MT, Romppanen U, Geiger JM, Baudin M, Vähä-Eskeli K, Vartiainen J, et al. Acitretin in the treatment of severe lichen sclerosus et atrophicus of the vulva: A double-blind, placebo-controlled study. J Am Acad Dermatol 1994;30(2 Pt 1):225-31.  Back to cited text no. 11
    
12.
Boer J, Nazary M. Long-term results of acitretin therapy for hidradenitis suppurativa. Is acne inversa also a misnomer? Br J Dermatol 2011;164:170-5.  Back to cited text no. 12
    
13.
Darwich E, Muñoz-Santos C, Mascaró JM Jr. Erosive pustular dermatosis of the scalp responding to acitretin. Arch Dermatol 2011;147:252-3.  Back to cited text no. 13
    
14.
Vasani RJ. Response to oral acitretin in lichen amyloidosis. Indian Dermatol Online J 2014;5 Suppl 2:S92-4.  Back to cited text no. 14
    
15.
Garg T, Chander R, Varghese B, Barara M, Nangia A. Generalized linear porokeratosis: A rare entity with excellent response to acitretin. Dermatol Online J 2011;17:3.  Back to cited text no. 15
    
16.
Katz HI, Waalen J, Leach EE. Acitretin in psoriasis: An overview of adverse effects. J Am Acad Dermatol 1999;41(3 Pt 2):S7-12.  Back to cited text no. 16
    
17.
Roenigk HH Jr., Callen JP, Guzzo CA, Katz HI, Lowe N, Madison K, et al. Effects of acitretin on the liver. J Am Acad Dermatol 1999;41:584-8.  Back to cited text no. 17
    
18.
Vahlquist C, Selinus I, Vessby B. Serum lipid changes during acitretin (etretin) treatment of psoriasis and palmo-plantar pustulosis. Acta Derm Venereol 1988;68:300-5.  Back to cited text no. 18
    
19.
McGuire J, Lawson JP. Skeletal changes associated with chronic isotretinoin and etretinate administration. Dermatologica 1987;175 Suppl 1:169-81.  Back to cited text no. 19
    
20.
Van Dooren-Greebe RJ, Lemmens JA, De Boo T, Hangx NM, Kuijpers AL, Van de Kerkhof PC. Prolonged treatment with oral retinoids in adults: No influence on the frequency and severity of spinal abnormalities. Br J Dermatol 1996;134:71-6.  Back to cited text no. 20
    
21.
Sarkar R, Chugh S, Garg VK. Acitretin in dermatology. Indian J Dermatol Venereol Leprol 2013;79:759-71.  Back to cited text no. 21
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