Topical and Systemic Retinoids in the Management of Hidradenitis Suppurativa: A Comprehensive Literature Review

Hidradenitis suppurativa (HS) is a debilitating chronic skin disorder characterized by painful inflammatory nodules, abscesses and sinus tracts involving intertriginous areas and has an adverse impact on patient quality of life. Over the past decade, the therapeutic options of HS have increased significantly to comprise multiple modalities, including topical medication, systemic therapies (mainly antibiotics, retinoids, and biologics), surgical approaches, and lifestyle modifications. Biologics alone or in combination with surgery remain the treatment of choice for moderate to severe disease. However, non-biologic therapies (including retinoids) may be used as monotherapy for mild disease and in combination with biologics and surgical treatment in moderate to severe disease. Retinoids, specifically isotretinoin, acitretin, and alitretinoin, are historically used in the management of HS, supported by anecdotal evidence and with variable treatment response. Although the current American and European guidelines offer different recommendations on the use of retinoids in HS, retinoids remain a valuable ally in HS management. This review provides a comprehensive analysis of the current scientific literature on retinoid therapy (topical and systemic) in HS, highlighting disparities in mechanisms of action, efficacy, and safety to clarify their role in HS treatment.

Alitretinoin as a Treatment Modality for Ichthyosis in Women of Childbearing Age: A Case Series and Review of the Literature

BACKGROUND

Acitretin, a synthetic vitamin A derivative, is the most studied and widely used oral retinoid for ichthyoses. Its major disadvantage is the need for contraceptive measures during 3 years after discontinuation. An alternative is needed for women of childbearing age. With alitretinoin, another retinoid, pregnancy is considered safe 1 month after discontinuation.

OBJECTIVES

The aim of this study was to provide evidence for alitretinoin as an alternative for acitretin for ichthyosis in women of childbearing age. Our experience is shared in a case series combined with an overview of the current literature.

METHODS

Nine women of childbearing age (19-31 years, median 21) with different subtypes of ichthyosis (autosomal recessive congenital ichthyosis, (superficial) epidermolytic ichthyosis, erythrokeratoderma variabilis, and epidermolytic epidermal nevi, a mosaic form of epidermolytic ichthyosis) were included and treated with 30 mg alitretinoin during 2-28 months. Severity was measured by Ichthyosis Area Severity Index (IASI) and Investigator Global Assessment (IGA). A literature search in Pubmed using the Mesh terms "alitretinoin," "skin diseases, genetic" and "ichthyosis" was performed.

RESULTS

Significant reduction in the mean scores of IGA, IASI-erythema, IASI-scaling, and IASI-total was seen. Seven patients are still being treated, 1 patient stopped to become pregnant, 1 patient discontinued due to financial reasons. Observed side effects were reversible headache (n = 6), asteatotic eczema (n = 1), "not feeling well" temporarily (n = 1), and easier blistering of the feet (n = 1). The literature search resulted in six case reports and case series about alitretinoin in ichthyosis and ichthyosis syndromes with in total 29 patients. The vast majority of articles (21/29) reported significant improvement or even complete remission of skin symptoms. However, validated outcome measures to support these results were lacking. Side effects (n = 16) were relatively mild, except for benign intracranial hypertension (n = 1) and autoimmune hypothyroidism (n = 1).

CONCLUSION

Our study shows, with validated outcome measures, that alitretinoin is effective to mitigate the symptoms of ichthyosis in women of childbearing age and a suitable alternative to acitretin.

Alitretinoin for the treatment of severe chronic eczema of the hands

INTRODUCTION

Chronic hand eczema (CHE) is a frequent skin disorder affecting up to 10% of the population and strongly reduces Quality of Life (QoL). The first-line therapeutic strategies for the management of CHE include a change of lifestyle, an education program for the skin and the application of specific emollients. Topical corticosteroids or calcineurin inhibitors are the most used anti-inflammatory drugs. However, up to 65% of patients require systemic options. Alitretinoin, a retinoid structurally related to vitamin A, is the first systemic treatment approved in the European Union (EU) for severe CHE refractory to potent topical corticosteroids.

AREAS COVERED

This review summarizes the available data on the pharmacokinetics, pharmacodynamics, efficacy, and safety profile of oral alitretinoin for the treatment of CHE.

EXPERT OPINION

Alitretinoin can be considered as a valid therapeutic option for the treatment of CHE in patients not responding to ordinary treatments. Clinical trials and real-life experiences showed that it acts effectively on both objective and subjective clinical signs, resulting in a significant improvement in QoL of patients. As for other retinoids, caution should be taken in patients with certain chronic diseases (hepatopathies, kidney failure, hyperlipidemia, thyroid dysfunction) or childbearing potential women.

Evaluation of Alitretinoin for the Treatment of Mycosis Fungoides and Sézary Syndrome

BACKGROUND

Mycosis fungoides (MF) and Sézary syndrome (SS) are the most common subtypes of cutaneous T-cell lymphoma (CTCL). There is currently no cure for CTCL, and treatment is aimed at limiting disease progression. This study evaluated the efficacy and tolerability of alitretinoin in CTCL management.

METHODS

A retrospective, multicenter study was conducted on CTCL patients treated with alitretinoin as a primary agent or in combination with standard therapies.

RESULTS

Forty-eight patients with MF (n = 40) and SS (n = 8) with a median age of 59.7 years (±14.3) were eligible for study inclusion. Treatment response data were evaluated in 40 patients and safety in 42 patients. 40.0% of the patients had early-stage, 43.8% had advanced-stage CTCL, and in 16.7% of patients there was insufficient information for staging. 40.0% (16/40) of the patients achieved a complete or partial response, whereas 47.5% (19/40) achieved stable disease, 12.5% (5/40) had progressive disease, and there were no cases of disease relapses in responders. Both early and advanced stages of CTCL were responsive to alitretinoin as a primary or combined modality. Alitretinoin was well tolerated, and 64.3% (27/42) of patients did not report any side effects. The most commonly observed side effect was hypertriglyceridemia.

CONCLUSIONS

This retrospective analysis supports the efficacy and safety of alitretinoin in clearing skin disease and preventing disease progression in CTCL as a monotherapy or in combination with standard therapies.

Alitretinoin Compliance in Patients with Chronic Hand Eczema

Background

Oral alitretinoin is effective in the treatment of chronic hand eczema (CHE), and ≥12 weeks of alitretinoin treatment has been shown to be effective in Korean patients. However, in the real world, a considerable number of patients discontinue alitretinoin, which leads to treatment failure.

Objective

To evaluate the compliance rate of alitretinoin treatment and explore common reasons for poor compliance in patients with CHE in the real world.

Methods

We retrospectively reviewed the electronic medical records of CHE patients treated with alitretinoin. We defined ‘poor-compliance’ as subjects who were treated with alitretinoin for <12 weeks and ‘good-compliance’ as subjects who were treated with alitretinoin for ≥12 weeks. We reviewed the demographics, dose, and duration of alitretinoin usage, efficacy, and reasons for poor compliance.

Results

A total of 137 subjects were enrolled, and 77 (56.2%) did not complete the 12-week treatment with alitretinoin. Among them, the non-improvement rate was significantly higher in the poor-compliance group than in the good-compliance group (p<0.01). The main reasons for the alitretinoin cessation in the poor-compliance group were insufficient response (40.8%), followed by high cost (34.7%), and adverse events (24.5%).

Conclusion

Alitretinoin appears the preferred long-term treatment option for CHE. Although there are complaints about late efficacy, cost, and side effects, following proper explanation, these should not justify discontinuation. Physicians need to recognize the reasons for poor compliance with alitretinoin for each patient and suggest continuing alitretinoin for the successful treatment of CHE.

Efficacy and Safety of Alitretinoin Therapy in Korean Elderly Patients with Chronic Hand Eczema: A Retrospective Single Center Study

Background

Chronic hand eczema (CHE) tends to be refractory to conventional therapy. Previous clinical trials have found that alitretinoin is an effective and well-tolerated treatment for CHE. However, there is a relative lack of data on the effectiveness of alitretinoin in elderly patients.

Objective

The aim of this study was to investigate the efficacy and safety of oral alitretinoin in elderly patients with moderate to severe CHE in Korea.

Methods

We retrospectively investigated 46 CHE patients who were treated with either 10 mg or 30 mg of alitretinoin between June of 2016 and July of 2018. The physician's global assessment (PGA) was used to evaluate treatment efficacy. All adverse events were retrospectively evaluated with respect to laboratory testing, including complete blood cell count, fasting blood chemistry, lipid profile, and liver and thyroid function tests.

Results

The mean patient age in this study was 71.0±5.1 years. The treatment period was over eight weeks. A total of 38 of 46 patients (82.6%) exhibited clinical improvement with PGA ratings of ‘clear’ or ‘almost clear.’ There were 13 patients (28.3%) who experienced an adverse effect, with the most common being headache (13.0%) and gastrointestinal symptoms (8.7%) followed by xerosis (6.5%). A total of 13 patients developed or exhibited worsening hypertriglyceridemia (28.3%).

Conclusion

Alitretinoin can be considered a safe and effective treatment option in elderly patients with moderate to severe CHE.

Efficacy and Safety of Oral Alitretinoin in Hand Eczema and Palmoplantar Pustulosis in Korean Patients

Background

Previous studies have demonstrated efficacy and safety of oral alitretinoin in hand eczema (HE) whereas in palmoplantar pustulosis (PPP), which can be difficult to distinguish from HE, efficacy of alitretinoin is still controversial.

Objective

This study aimed to investigate the efficacy and safety of oral alitretinoin in HE and PPP and factors that affect the response of these disorders to alitretinoin.

Methods

We retrospectively analyzed Korean adult patients with moderate-to-severe HE and PPP treated with oral alitretinoin, 46 patients for efficacy assessment and 55 patients for safety assessment.

Results

Among 46 patients who were treated with alitretinoin for at least 1 month, 29 patients (61.1% in HE and 40.0% in PPP) showed response to alitretinoin in the median 14 weeks after treatment. Hyperkeratotic HE showed higher response rate than either vesicular HE or PPP (p=0.026 and p=0.026, respectively). However, PPP with hyperkeratotic features showed as much response as hyperkeratotic HE (p=0.554). When responders and non-responders in total patients were compared, morphology, not diagnosis or initial severity, was the only significantly different factor between the two groups. After alitretinoin discontinuation in responders, relapse rate was 63.6% (7/11) and median time to relapse was 150 days (range, 76~730 days). Adverse events occurred in 47.3% (26/55); however, there were no serious adverse events.

Conclusion

In HE or PPP, lesions with hyperkeratotic morphology can be predicted to respond well to alitretinoin regardless of diagnosis.

Alitretinoin reduces erythema in inherited ichthyosis

Background

Acitretin is the main retinoid used to treat severe inherited ichthyosis. Alternatives may be considered if it results ineffective or there are side-effects, or for women of childbearing age.

Our objective is evaluation of the effects and tolerance of alitretinoin.

An observational retrospective multicentric study was designed to analyse patients with inherited ichthyosis treated by alitretinoin.

Results

A total of 13 patients were included, 11 of whom were receiving acitretin at inclusion. The main reason for switching to alitretinoin was a desire for pregnancy, but also because of side-effects or unsatisfactory efficacy. Starting dose was 10 mg/day, increased to 20 or 30 mg/day. Alitretinoin seemed to be more effective than acitretin at reducing erythema, but was less effective at reducing scaling or hyperkeratosis. Global efficacy was considered low for two patients, moderate for nine, and high for two. Treatment was well-tolerated, except for one patient who presented with benign intracranial hypertension leading to discontinuation of treatment.

Conclusions

Alitretinoin may be suitable for hereditary ichthyosis with prominent erythema, especially for women of childbearing age.

The effectiveness of alitretinoin for the treatment of chronic hand eczema: A meta-analysis

Alitretinoin is a new oral retinoid authorized for use in grownups that have severe chronic hand eczema (CHE). A comprehensive search to solicit all studies of alitretinoin for the treatment of CHE. A comprehensive search to solicit all studies of alitretinoin for the treatment of CHE including randomized controlled trials (RCTs) or uncontrolled trials, re-treatment studies, open-label studies, or observational studies, along with case series of 10 or more participants. Physician global assessment (PGA), patient global assessment (PaGA) and modified total lesion symptom score (mTLSS) are the methods and outcomes criteria. Generated effect size and 95% confidence intervals were calculated for the outcomes. Heterogeneity and publication bias were also tested for all selected trials. When a noteworthy Q statistic (P < 0.1) demonstrates the heterogeneity crosswise over studies, an arbitrary impact model is used. On the other hand, a settled effect model is when heterogeneity is not shown. The initial search yielded 408 records of which 15 articles were selected. The 15 clinical trials included 3734 patients with CHE. Among alitretinoin-treated patients, the PGA effect size was directly proportional to the drug dosage, ranging from 40% to 69%, while the PaGA score ranged from 28.8% to 62.4%, and mTLSS ranged from 60.4% to 76.9%, much higher than placebo. A higher drug dose was about twice as effective as lower dose. The odds ratio for a better outcome with drug treatment taking duration into account was about 3-4 times that versus placebo. In conclusions, alitretinoin cleared lesions in about 50% of cases, particularly using a higher dose for a longer duration.

Psychiatric disorders, acne and systemic retinoids: comparison of risks

BACKGROUND

The link between isotretinoin, treatment of a severe form of acne, and psychiatric disorders remains controversial, as acne itself could explain the occurrence of psychiatric disorders. This study aims at assessing the disproportionality of psychiatric adverse events reported with isotretinoin in the French National PharmacoVigilance Database, compared with other systemic acne treatments and systemic retinoids.

MATERIALS AND METHODS

Data were extracted from the French National PharmacoVigilance Database for systemic acne treatments, systemic retinoids and drugs used as comparators. Each report was subjected to double-blind analysis by two psychiatric experts. A disproportionality analysis was performed, calculating the number of psychiatric ADRs divided by the total number of notifications for each drug of interest.

RESULTS

Concerning acne systemic treatments: all 71 reports of severe psychiatric disorders involved isotretinoin, the highest proportion of mild/moderate psychiatric adverse events was reported with isotretinoin (14.1%). Among systemic retinoids, the highest proportion of severe and mild/moderate psychiatric events occurred with isotretinoin and alitretinoin.

CONCLUSION

Our study raises the hypothesis that psychiatric disorders associated with isotretinoin are related to a class effect of retinoids, as a signal emerges for alitretinoin. Complementary studies are necessary to estimate the risk and further determine at-risk populations.

Efficacy and Safety of Alitretinoin for Chronic Hand Eczema in Korean Patients

Background

Chronic hand eczema (CHE) tends to be refractory to conventional therapy. Previous clinical trials have found that a 24-week treatment course of oral alitretinoin is effective and well tolerated for CHE treatment.

Objective

The aim of this study was to investigate the efficacy and safety of oral alitretinoin in Korean CHE patients.

Methods

A total of 27 patients with moderate to severe CHE took 30 mg of alitretinoin daily for 12 weeks. The primary efficacy parameter was the physician's global assessment (PGA). The response was defined as a patient being "clear" or "almost clear" of disease. The secondary efficacy parameters were the modified total lesion symptom score (mTLSS) and the patients' global assessment (PaGA). All adverse events and laboratory abnormalities were recorded during the treatment period.

Results

Alitretinoin led to CHE symptom improvement in 44.4% of patients. The PGA, mTLSS, and PaGA scores correlated well with each other. Reported adverse events were typical retinoid class effects and headache was the most common.

Conclusion

Taking 30 mg of oral alitretinoin daily for 12 weeks was found to be effective in treating Korean patients with CHE, compared with the 24 week-treatment shown in previous studies.

Alitretinoin in Dermatology-An Update

Alitretinoin is a pan retinoic acid agonist. It was initially used as 0.1% gel in the management of localized Kaposi's sarcoma. At present, the use of systemic alitretinoin has proved extremely efficacious in the management of recalcitrant chronic hand eczema. Furthermore, there have been other retinoid responsive dermatosis that have demonstrated remission post usage of systemic alitretinoin. With a better toxicity profile, compared to the other systemic retinoids, alitretinoin could be considered a valuable treatment option in the near future for the treatment of these dermatologic disorders.