Acitretin for the Treatment of Psoriasis: An Assessment of National Trends
August 2011 | Volume 10 | Issue 8 | Original Article | 873 | Copyright © August 2011
Pedram Ghasri BS,a Brad A. Yentzer MD,a Tushar S. Dabade MD,a Steven R. Feldman MD, PhDa,b,c
Center for Dermatology Research, Departments of aDermatology, bPathology and cPublic Health Sciences; Wake Forest University School of Medicine; Winston-Salem, North Carolina
Background: Combination therapy is a common and appropriate treatment strategy for moderate-to-severe psoriasis, as it provides for enhanced efficacy and decreased toxicity compared to the use of a single agent. Acitretin is an effective oral retinoid for psoriasis that seems to find its greatest value when complemented by other topical and systemic treatments.
Objective: The primary aim of this study is to assess the use of acitretin in combination with other treatments for psoriasis.
Methods: We assessed the use of acitretin for the treatment of psoriasis using nationally representative survey data from the
National Ambulatory Medical Care Survey (NAMCS).
Results: Among visits where acitretin was listed in the NAMCS, other psoriasis medications were co-prescribed in 62 percent of visits. The co-prescribed medications included topical corticosteroids (51%), calcipotriene (31%), biologics (6%), cyclosporine (5%), methotrexate (5%) and tazarotene (2%).
Conclusion: The use of acitretin in combination with other psoriasis treatments, particularly topical corticosteroids and calcipotriene, is a common practice. Acitretin is co-prescribed with the biologics, likely because of the relative lack of overlapping effects on immune
function. The immune-sparing method of action of acitretin makes combination treatment with the systemic agents an attractive
treatment option, especially in patients where further immunosuppression is unwarranted.
J Drugs Dermatol. 2011;10(8):876-880.
Psoriasis is caused by the interplay of various cellular processes in the skin, including keratinocyte hyperplasia,
vascular proliferation and lymphocyte infiltration.1 Its multi-factorial etiology calls for many therapeutic agents with which to mitigate the disease burden. Topical corticosteroids, retinoids and vitamin D analogues are generally effective and well-tolerated therapies for mild, localized psoriasis. However, moderate-to-severe forms of disease necessitate treatment with traditional systemic therapies, biologic agents or phototherapy.2 Although all of these agents are effective to some degree when used alone, their long-term use is often limited by such potential systemic toxicities as organ dysfunction, teratogenicity and malignancy. 3 Combination therapy using lower dosages of the individual
agents is a logical and suitable approach, offering the potential for enhanced efficacy and decreased toxicity.
One of the common systemic medications for psoriasis is acitretin.
Since its approval by the U.S. Food and Drug Administration (FDA) in 1996, it remains the only systemic retinoid approved for the treatment of severe psoriasis. The considerable efficacy of acitretin for psoriasis and other keratinization disorders is primarily
due to its modulation of epidermal cell proliferation and differentiation.4 It is one of the treatments of choice for pustular and erythrodermic variants of psoriasis as a monotherapy, and recent guidelines have recommended it as part of a combination treatment with either PUVA, broad-band phototherapy or topical
calcipotriene for plaque psoriasis.5 The primary advantage of using acitretin over other systemic medications (i.e., biologics, methotrexate, and cyclosporine) is that at most it has weak effects on immune function and is not immunosuppressive. Therefore, it is useful when immunosuppression is contra-indicated, such as in patients with chronic infections, or as a complementary medication to immunomodulating systemic treatments.
The often unpredictable course and the variable manifestations of psoriasis make the development of a standardized treatment algorithm quite difficult. The purpose of this study is to assess the use of acitretin with other treatments for psoriasis based on nationally representative data. Such information is elucidative