Methotrexate versus Acitretin in the Treatment of Chronic Hand Dermatitis openaccess articles

December 2015 | Volume 14 | Issue 12 | Editorials | 1389 | Copyright © 2015

Patrick M. O’Shea BS and Aída Lugo-Somolinos MD

University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC

Abstract

BACKGROUND: Recent studies have produced treatment algorithms for hand dermatitis, but there are limited current indications of systemic treatments for chronic hand dermatitis.
OBJECTIVE: To compare the efficacy and safety of methotrexate and acitretin in the treatment of chronic hand dermatitis.
METHODS: A chart-retrospective review of all patients with hand dermatitis seen by the primary author at the University of North Carolina Dermatology and Skin Cancer Center from September 2007 to April 2013.
RESULTS: Eighty-three hand dermatitis charts were reviewed. Twenty- nine patients received systemic therapy, of which 17 (26.5%) were treated systemically with acitretin and/or methotrexate. Of these 17 patients, four patients received courses of both acitretin and methotrexate independently after failing the alternative treatment course. At 6 months, acitretin achieved clearance/almost clearance in 44% of patients, compared to 0% of those treated with methotrexate. At 12 months, 100% of patients treated with acitretin achieved clearance/almost clearance compared to 40% of patients treated with methotrexate. Adverse effects were minimal and as expected.
LIMITATIONS: This was a retrospective study, and the small sample size makes it difficult to generalize results.
CONCLUSION: Systemic retinoids are a good alternative for the treatment of chronic hand dermatitis.

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Introduction

Chronic hand dermatitis (CHD) is an inflammatory condition of the skin, often with a multifactorial cause1 of environmental and genetic factors. It is a chronic, relapsing skin disease,2 with a point prevalence around 4%, and a lifetime prevalence >15%.3 There is no consensus about the treatment of CHD and current conventional therapies include avoidance of irritants and potential allergens, thick emollients, topical corticosteroids and topical immunomodulators. Severe cases often require systemic therapies such as oral steroids and systemic immunosuppressants.2 The purpose of this study was to retrospectively review the charts of patients with CHD seen in a tertiary center and describe the efficacy and safety of methotrexate and acitretin.

Methods

This is a chart-retrospective review of all patients with CHD seen from September 2007 to April 2013 by the primary author at the University of North Carolina (UNC) Dermatology Clinic. Patients with fungal, viral, and bacterial infections were excluded. Due to the retrospective nature of the study, clinical variants of CHD were not identified. The institutional review board at UNC-Chapel Hill approved the study.

All patients treated with a systemic agent were identified and demographics, medical history, laboratories, systemic agent used, time to see improvement, time to achieve a clear or almost clear response and side effects were collected. Response to therapy was graded on a 3-point scale: 0 corresponded to no change or worsening from baseline; 1 corresponded to improvement of fissuring, erythema, and/or desquamation; and 2 corresponded to resolution of erythema, fissuring, and desquamation, or presence of only mild desquamation or erythema. The same investigator evaluated all patients. The follow up period varied from 4 to 39 months.

Data was calculated using a Student t test, 2-sided, type 3 (two sample, unequal variance). Test results were interpreted as statistically significant for P values less than or equal to .05.

Results

A total of 83 charts were reviewed, from which twenty-nine (34.9%) required systemic treatment, including oral prednisone, dapsone, acitretin, and methotrexate. Seventeen (26.5%) were treated systemically with acitretin and/or methotrexate. Demographics of these 17 patients include 12 (70.6%) males and five (29.4%) females with a mean age of 53 (32-71) years. Of these 17 patients, four patients were treated with both acitretin and methotrexate at different times. Three patients failed methotrexate and were switched to acitretin, and one patient relapsed on acitretin at 15 months and was switched to methotrexate.

Acitretin was significantly better than methotrexate to cause a clear or almost clear response in patients with CHD by 6 months (P = 0.0353, see Table 1). The four patients receiving both were considered unique subjects for each treatment. Only 6 patients on acitretin and 5 patients on methotrexate maintained follow-up through 12 months. One hundred percent of patients on acitretin and 40% of patients on methotrexate were clear or almost clear (P = 0.0705) at 12 months follow-up. Mean time to show improvement was not significantly different for both treatments, (2.28 months for acitretin versus 2.75 for methotrexate) but it was significant for mean time to achieve clearance (6.78 months for acitretin versus 12.8 for methotrexate). Adverse effects were minimal and as expected and are summarized in Table II.

Discussion

Chronic hand dermatitis (CHD) is not a uniform disease because of differences in etiology, morphology, and severity.4,5 The chronicity and variable presentation makes treatment difficult.

Some studies have reviewed the therapeutic options available for CHD and proposed treatment algorithms but there are very few clinical trials providing evidence of efficacy of systemic drugs. In a previous large phase III trial, 47.7% of patients with severe CHD who received alitretinoin 30 mg achieved full clinical response, defined as ‘clear’ or ‘almost clear’ hands, within 200 days.6 This study paved the way for the approval of oral

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