Mechanism of action

Indications

Severe psoriasis that cannot be managed by topical treatments or photo(chemo)therapy
Monotherapy is indicated for erythrodermic or pustular psoriasis.
Combination therapy is indicated for chronic plaque psoriasis .
Lichen planus : 30 mg/day for 8 weeks.
Morphea.
Macular or lichen amyloidosis : 0.5 mg/kg/day.
Lipoid proteinosis : 0.5 mg/kg/day for 6 months.
Collodion baby.
Harlequin ichthyosis : 1 mg/kg/day.
Erythrokeratoderma.
Keratoderma.
Ichthyoses : 1 mg/kg /day.
Lupus erythematosus : 50 mg daily + hydroxychloroquine 400 mg daily for 8 weeks.
Darier disease : 10-25 mg /day.
Nail psoriasis: 0.2–0.3 mg/kg/day.
Perforating diseases.
Chronic hand eczema.
Chemoprevention of skin cancer : 0.2–0.4 mg/kg/day.

History to exclude contraindications.
Pregnancy test (when indicated).
Complete blood count.
Liver function tests (AST, ALT, GGT, alkaline phosphatase, bilirubin).
Fasting Serum triglycerides, cholesterol.
Fasting glucose.
Serum creatinine.
Consider spinal X-ray (often initially performed during the first 3 months of therapy if long-term treatment is anticipated).

Monitor mucocutaneous side effects.
liver function tests and fasting cholesterol & triglycerides every 4 weeks for the first 2 months of then every 3 -6 months.
Serum creatinine (elderly patients or patients with mild to moderate renal dysfunction).
Monitor for development of hyperostosis by history (twice yearly) and by X-ray of spine (e.g. once yearly or every other year in patients receiving long-term treatment).

Teratogenic.
Cheilitis, dryness of the oral and nasal mucosa, xerosis, pruritus and skin fragility.
Delayed wound healing.
Formation of excessive granulation tissue
Hypertriglyceridemia
Hyperostosis ( Long-term treatment ).
Myalgias, Arthralgia.
Back pain.
Vulvovaginitis.
Paronychia.
Increased insulin sensitivity.
Elevation of serum creatine kinase levels.
Eyes : Blepharitis, conjunctivitis, xerophthalmia, night blindness.
Liver: occasionally elevated transaminases.

Tetracycline, doxycycline, minocycline : may increase intracranial pressure (Pseudotumor cerebri).
Alcohol : increased conversion of acitretin to etretinate and hepatotoxicity.
Methotrexate : synergistic liver toxicity with retinoids; however, combination may be used with caution in patients with PRP or severe psoriasis.
vitamin A supplements : risk of hypervitaminosis A.
Retinoid drug levels and resultant potential for toxicity may increase with CYP3A4 inhibitors such as azoles and macrolides.
Antituberculosis drugs (rifampin) and anticonvulsants (phenytoin and carbamazepine) may decrease the drug levels of retinoids via CYP3A4 induction.
Retinoids may also increase the drug levels of cyclosporine.
Progesterone pills (minipill) preparations : Acitretin decreases the antiovulatory effect of the progestin only pill (mini-pill) but has no effect on the combined preparations.
Antidiabetic agents : Alterations in blood glucose may occur
Corticosteroids : Hyperlipidemia, pseudotumor cerebri.

When acitretin is added to UV, light dose should be reduced by 30-50%.
In children on long-term therapy growth charting and annual screening radiography is advisable.
Patients should not donate blood during treatment or for at least 6 months after stoppage.
pregnancy should be avoided for the duration of therapy and for 3 years after.

Its bioavailability is increased by intake with fatty food.
Alcohol indirectly increases the conversion of acitretin to etretinate by acting as a catalyst for hepatic enzymes.
It can be used for psoriasis associated with human immunodeficiency virus (HIV) infection.

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