Using Acitretin to Treat Psoriasis

People with psoriasis now have several different treatment options to address their symptoms. Retinoid products, derived from vitamin A, are one potential choice. Acitretin is one such treatment that is available as an oral medication. Though it is used less frequently than some other treatments for psoriasis, it may be worth considering for some people.

Keratinocytes are the main type of cells found in your skin. In normal skin, these cells divide and mature over time. In psoriasis, these same skin cells divide and mature in an abnormal way. These cells are also exposed to an inflammatory skin environment that causes them to behave in diseased ways. This is part of what causes the symptoms of psoriasis.

Acitretin is a retinoid. That means that it is in the same chemical family as vitamin A (an important nutrient found in certain foods). Oral retinoid products like acitretin have been available to treat psoriasis since the early 80s. The first oral retinoid, etretinate, has since been replaced by a newer product, acitretin. In the US, the brand name of acitretin is Soriatane^TM.

Retinoids like acitretin enter the cell membranes of keratinocytes. There they alter the transcription of certain genes found in your DNA. (That means that some genes might be used to make proteins more often, and some genes might be used less often.) This causes secondary effects, like:

• Decreasing skin inflammation
• Decreasing abnormal cell growth and division of skin cells
• Decrease abnormal maturation of skin cells

Other topical retinoid products (like tazarotene) can also be used to treat psoriasis, and they share some similar properties with oral retinoids. However, acitretin has a greater potential for side effects than topical retinoids, because it is taken internally.

Acitretin is a treatment option for patients with moderate to severe psoriasis. That is usually defined as people who have one of the following:

• Psoriasis covering over 10 percent of their skin surface
• Psoriasis over a smaller percentage of their skin, but who have debilitating symptoms, like severe psoriasis on their hands or scalp

Such people generally either need a traditional oral drug (like acitretin) or one of the newer biologic treatments for psoriasis. People who have only mild psoriasis usually only need treatment with topical creams to keep their condition controlled.

Acitretin may also be particularly effective for people with certain types of psoriasis. This includes:

• Psoriasis affecting the palms and soles
• Psoriasis affecting the nails
• Pustular type psoriasis
• Erythrodermic psoriasis

Acitretin is one of an older class of drugs for moderate to severe psoriasis. The three most commonly used traditional oral drugs are acitretin, methotrexate, and cyclosporine. These drugs used to be prescribed more frequently in patients with moderate to severe psoriasis.

However, in recent years, newer drugs, called biologics, have become available. These include drugs like etanercept and adalimumab. On the whole, these newer drugs have fewer significant side effects than older drugs. Biologic drugs are also usually quite effective in treating psoriasis.

Still, for some people, older drugs like acitretin may still be the best choice. One main advantage of traditional drugs like acitretin is that they are taken by mouth. Some people may prefer this to biologic treatments, which are generally given by injection. Also, older drugs like acitretin are usually much less expensive than biologic drugs.

When used by itself, acitretin is usually somewhat less effective than either methotrexate or cyclosporine (the two other most commonly prescribed traditional oral medications). However, it is probably safer than either of these drugs for long-term use.

Another group of psoriasis patients who may particularly benefit from acitretin are people who have suppressed immune systems. Biologic drugs and traditional oral drugs like methotrexate partly work by suppressing a person’s immune response. However, unlike these other drugs, acitretin does not significantly suppress your immune system. That can make it a desirable treatment for people who already have problems with immunosuppression, like people with HIV.

Acitretin is sometimes taken as single therapy, but it often works best combined with other treatments.

• In particular, acitretin is often combined with phototherapy, either some type of UVB therapy or UVA therapy with psoralen (PUVA).
• Acitretin can also be used along with topical treatments for psoriasis.
• Unlike other traditional oral drugs, acitretin can also be taken along with biologic drugs.

You should NOT use acitretin with another vitamin A-based product, because this might lead to vitamin A toxicity.

Acitretin is typically available in capsules of 10mg, 17.5 mg, or 25 mg. Most clinicians give doses between 10mg and 25 mg per day, but some people occasionally need a higher dose.

Acitretin is usually more effective at higher dosages. However, side effects may be more likely to occur at these levels. You may start with a lower dose and move up to a higher dose if you symptoms don’t resolve, and if you aren’t having side effects from therapy. 

It may take three to six months before you achieve a maximum response to your treatment.

• Take acitretin with food.
• Take exactly the dose prescribed by your health care provider.
• If you miss a dose, do NOT double the next dose. Instead, skip the dose and take a regular dose at your next scheduled time.

Your healthcare provider will let you know what dose is the right one for you.

Acitretin is definitely NOT a safe medication for pregnant women to take. Acitretin can cause a variety of birth defects, including ones affecting the cardiovascular system, the nervous system, hearing and vision, and skeletal structures. The greatest risk is for women taking acitretin between the third and sixth weeks of their pregnancy. This is before many women even know that they are pregnant.

Acitretin is not completely broken down by the body until up to three years after stopping the medication. Because of this, acitretin should not be used by any of the following:

• Women who are pregnant
• Women planning on becoming pregnant during therapy or within three years after stopping therapy
• Women of childbearing age who cannot use reliable birth control during therapy and for three years following therapy

It also should not be used by women who are breastfeeding.

• Acitretin is probably not the best treatment for you unless you have severe psoriasis that is unresponsive to other therapies, or you are unable to take other therapies for some reason.
• If acitretin is the best option, you will need two negative pregnancy tests before starting acitretin, one of which should be done during your menstrual period.
• You will need a monthly pregnancy test while on the drug.
• You will need to use two forms of birth control while using the drug, and for three years after stopping the drug.

Acitretin can also potentially cause side effects. These include:

• Dryness of the eyes, nose, mouth, and skin
• Brittle nails
• Hair loss
• Burning skin sensation
• Muscle aches
• Nausea
• Bony growths on the spine
• Increased triglycerides

Other potential side effects can occur as well. Rarely, acitretin can cause more serious problems like liver damage or inflammation of the pancreas. Almost all of these problems are reversible on stopping treatment. Speak promptly to your healthcare provider if you have any concerns.

Before beginning acitretin therapy, you will need a medical history and physical exam. You may also need blood tests to make sure you are a good candidate for treatment. These might include the following:

• Tests of blood fats (triglycerides and cholesterol)
• Liver function tests

Because of the danger of side effects from acitretin, your healthcare provider will need to monitor you. After you initially start the treatment, you may need to have some regular blood tests to check your liver and your blood fats. After several weeks on the drug, you should be able to switch to less frequent tests.

In addition to pregnant women and women who may become pregnant, other specific groups of people also need to avoid acitretin. These include:

• People with hyperlipidemia
• People with sensitivity or allergy to any vitamin A product
• People who have had pancreatitis

Additionally, acitretin might not be the best medication for you if you have other medical problems, like:

• Type 1 or type 2 diabetes
• Liver disease
• Kidney disease
• Problems with alcohol abuse

Managing your psoriasis can be a challenge. Fortunately, these days, there are a number of treatment options for people with moderate to severe psoriasis. Acitretin is usually not the best choice for women of childbearing age. But for some people, older medications like acitretin may make sense, especially when used with other treatments.