Overview
Acitretin is a second-generation oral retinoid (a vitamin A derivative) used to treat severe skin disorders, primarily psoriasis. It works by regulating keratinocyte differentiation and slowing excessive skin cell growth, making it effective for hyperkeratotic skin conditions.
Acitretin is typically taken once daily with food, as dietary fat enhances its absorption. The drug is available in 10 mg and 25 mg capsules, marketed under Neotigason™ and Novatretin®.
In New Zealand, acitretin requires a Special Authority application from a dermatologist or a vocationally registered general practitioner due to strict prescribing restrictions.
Mechanism of Action
Acitretin modulates epidermal cell proliferation and differentiation by:
- Inhibiting excessive keratinization, reducing skin thickening and scaling
- Suppressing inflammatory pathways associated with psoriasis
- Normalizing epidermal turnover, preventing plaque formation
Unlike biologic therapies, acitretin does not directly target the immune system and is not effective for psoriatic arthritis.
Indications
Acitretin is primarily prescribed for severe, treatment-resistant dermatological conditions, including:
FDA-Approved Uses
- Psoriasis: Particularly pustular, erythrodermic, and palmoplantar psoriasis
Off-Label & Specialist Uses
- Palmoplantar pustulosis
- Severe hand dermatitis (hyperkeratotic cases)
- Darier’s disease
- Lichen planus & lichen sclerosus
- Lupus erythematosus
- Cutaneous T-cell lymphoma
- Extensive granuloma annulare
- Severe ichthyosis
- Widespread actinic keratoses & skin cancers
- Refractory viral warts
Acitretin is not a permanent cure. Most skin conditions improve within two weeks of treatment, with continued improvement over 12 weeks. However, relapse is common after stopping therapy.
Dosage & Administration
How to Take Acitretin
- Take once daily with a fatty meal for optimal absorption
- Do not crush or split capsules
- Avoid alcohol during treatment and for at least two months post-treatment, as it can prolong drug persistence
Standard Dosage
- Psoriasis: 0.5–1 mg/kg/day, maximum 75 mg/day
- Other conditions may require lower doses to minimize side effects
Contraindications & Special Precautions
Who Should Not Take Acitretin?
- Pregnant women or women planning pregnancy (teratogenic risk)
- Individuals consuming alcohol regularly (increases drug conversion to etretinate, prolonging its effects)
- Patients with severe liver or kidney disease
- People with uncontrolled hyperlipidemia
Pregnancy & Teratogenic Risk
- Acitretin is highly teratogenic and can cause severe birth defects. Women must use contraception during treatment and for at least three years post-treatment.
- Blood donation is prohibited during treatment and for three years after stopping to prevent risk to pregnant recipients.
- Men can safely father children while taking acitretin, as sperm is unaffected.
Pre-existing Conditions to Consider
- Diabetes: Acitretin may alter blood glucose levels
- Liver disease: Requires regular liver function tests (LFTs)
- Hyperlipidemia: Can elevate cholesterol & triglyceride levels
Side Effects
Like all retinoids, acitretin has a well-documented side effect profile. While many effects are dose-dependent and reversible, some require medical intervention.
Common Side Effects (Manageable with Skincare)
- Dry skin & lips (cheilitis): Use emollients & lip balms
- Dry eyes & contact lens intolerance: Use lubricating eye drops
- Fragile skin & easy bruising
- Hair thinning (telogen effluvium)
Less Common But Serious Side Effects
- Severe headaches & vision changes: May indicate pseudotumor cerebri (requires immediate discontinuation)
- Liver inflammation & hepatitis: Requires regular liver enzyme monitoring
- Hyperlipidemia (elevated cholesterol & triglycerides): Requires periodic lipid profile testing
- Photosensitivity: Increased sunburn risk; use SPF 50+ sunscreen
Monitoring & Safety Measures
Recommended Lab Tests During Acitretin Therapy
- Liver Function Tests (LFTs): Baseline & periodic monitoring
- Lipid Profile (Cholesterol & Triglycerides): Every 4–8 weeks
- Pregnancy Test (Women of Childbearing Age): Before, during, & after treatment
Frequently Asked Questions
Can Acitretin Be Taken with Other Psoriasis Medications?
- Can be combined with topical treatments (e.g., calcipotriol, corticosteroids)
- Avoid with methotrexate due to increased liver toxicity risk
- Avoid excessive vitamin A intake (risk of toxicity)
Can I Drink Alcohol While Taking Acitretin?
No. Alcohol converts acitretin into etretinate, which has a prolonged half-life (>3 years) and increases teratogenic risks.
What Happens If I Miss a Dose?
Take it as soon as you remember, but if it’s close to the next dose, skip it. Do not double dose.
Conclusion
Acitretin is an effective retinoid therapy for severe psoriasis and keratinization disorders, but it requires careful monitoring due to teratogenicity, hepatotoxicity, and hyperlipidemia risks. Patients must follow strict pregnancy prevention guidelines, monitor liver and lipid levels, and avoid alcohol.
Although not a cure, acitretin can provide significant symptom relief, especially when combined with topical therapies and lifestyle modifications.
References
British Association of Dermatologists (BAD). (n.d.). Acitretin: Patient information leaflet. Retrieved from https://www.bad.org.uk
Mayo Clinic. (n.d.). Acitretin (oral route): Description and brand names. Retrieved from https://www.mayoclinic.org
Cleveland Clinic. (n.d.). Acitretin capsules: Uses and side effects. Retrieved from https://www.clevelandclinic.org
DermNet NZ. (n.d.). Acitretin: Drug information. Retrieved from https://dermnetnz.org
