Bone changes in children on long-term treatment with etretinate

Bloodletting cupping combined with conventional measures therapy for psoriasis: A systematic review and meta-analysis of randomized controlled trials

Background

Psoriasis is an immune-mediated inflammatory disease prone to recurrence. Some studies indicated that bloodletting cupping combined with conventional measures therapy had been proposed as a treatment strategy for psoriasis. Therefore, we performed a systematic review and meta-analysis to assess the effectiveness of this combination therapy in reducing the severity of disease in patients with psoriasis.

Methods

The following electronic databases were searched for articles from January 1, 2000 to March 1, 2022: PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Chinese Biomedical Literature Database (CBM), Chinese Scientific Journal Database (VIP database), Wan-Fang Database, and China National Knowledge Infrastructure (CNKI). The language was not restricted while performing the search. The quality of articles was evaluated using Rev. Man 5.4 software (provided by the Cochrane Collaboration), comparing bloodletting cupping combined with conventional measures therapy to conventional measures treatments. The studies obtained randomized controlled trials (RCTs) of bloodletting cupping combined with conventional standard treatment for treating psoriasis. Two trained researchers (Xiaoyu Ma and Jiaming He) independently reviewed the literature, extracted data based on exclusion and inclusion criteria, and assessed the quality of the included studies. We estimated the aggregate data using a random effects model.

Findings

We identified 164 studies. Ten studies met the inclusion criteria for the meta-analysis. The primary outcome indicator was the total number of effective individuals. Secondary outcomes included the Psoriasis Area and Severity Index (PASI), adverse effects, and the Dermatology Life Quality Index (DLQI). Compared with conventional treatments, bloodletting cupping combined with conventional medicine yielded an improved total effective number of persons (RR = 1.15, 95%CI: 1.07 to 1.22, p < 0.00001), PASI (MD = -1.11, 95%CI: -1.40 to -0.82, p < 0.00001) and DLQI scores (MD = -0.99, 95%CI: -1.40 to -0.59, p < 0.0001). We found no significant difference in adverse reactions (RR = 0.93, 95%CI: 0.46 to 1.90, p = 0.85). The heterogeneity test showed the total effective numbers (p < 0.00001, I ² = 43%) and PASI (p < 0.00001, I ² = 44%) and DLQI scores (p < 0.00001, I ² = 0%).

Interpretation

Bloodletting cupping combined with conventional treatment can achieve the ideal treatment for psoriasis. However, the combined treatment in psoriasis needs to be further evaluated in high-quality RCTs with large sample sizes to enable future studies in clinical use.

Practical recommendations for systemic treatment in psoriasis according to age, pregnancy, metabolic syndrome, mental health, psoriasis subtype and treatment history (BETA-PSO: Belgian Evidence-based Treatment Advice in Psoriasis; part 1)

Background

Impressive progress in new therapeutic options has been made for psoriasis. Treatments include topical steroids, phototherapy, conventional, synthetic disease‐modifying drugs and an expanding list of biologics.

Objective

The primary objective of this work was to collect evidence for the creation of practice guidelines for systemic treatment of psoriasis (BETA‐PSO: Belgian Evidence‐based Treatment Advice in Psoriasis).

Methods

Evidence‐based recommendations were formulated using a quasi‐Delphi methodology after a systematic search of the literature and a consensus procedure involving 8 psoriasis experts.

Results

In this part, the use of systemic treatment in different age groups, during pregnancy, in metabolic syndrome, in patients with mental health problems, in different psoriasis subtypes and in previously systemically treated patients treatment is discussed.

Conclusion

Guidance on therapeutic choice in specific clinical situations in psoriasis is provided in order to facilitate the decision‐making in clinical practice.

Practical recommendations for systemic treatment in psoriasis in case of coexisting inflammatory, neurologic, infectious or malignant disorders (BETA-PSO: Belgian Evidence-based Treatment Advice in Psoriasis; part 2)

Background

Psoriasis patients carry an increased risk for associated comorbidities. Dermatologists have to be aware of the effects of systemic treatments not only on psoriasis but also on co‐occurring diseases. In case of other coexisting inflammatory diseases, the right psoriasis treatment may improve both disorders. For infectious and malignant disorders, some treatments have to be avoided as they may be harmful.

Objective

The primary objective of this project was to collect evidence for the creation of practice guidelines for systemic treatment of psoriasis (BETA‐PSO: Belgian Evidence‐based Treatment Advice in Psoriasis).

Methods

Evidence‐based recommendations were formulated using a quasi‐Delphi methodology after a systematic search of the literature and a consensus procedure involving eight psoriasis experts.

Results

Recommendations are given on the use of systemic treatment in psoriatic arthritis, inflammatory bowel disease, demyelinating disorders, hepatitis B and C, HIV and cancer.

Conclusion

This expert opinion is a practical guide for dermatologists when handling psoriasis patients with these specific conditions.

Long-term safety and drug survival of acitretin in psoriasis: a retrospective observational study

BACKGROUND

This retrospective observational study aimed to investigate the long-term safety, drug survival, and factors associated with the survival of acitretin in a real-world setting.

METHODS

Data of adult patients with psoriasis who attended Siriraj Hospital between 2012 and 2017 and were treated with acitretin were reviewed. Demographic data and clinical courses were recorded. The Kaplan-Meier curve and Cox regression were used to calculate drug survival and the factors associated with drug survival, respectively.

RESULTS

Of 104 patients, 56 and 48 were male and female, respectively, with a mean treatment duration of 3.2 years. The mean cumulative dose per patient was 19.28 ± 7.84 mg/day. Acitretin was administered to 73, 39, 24, and six patients for more than 1, 3, 5, and 10 years, respectively. Most side effects were mild and tolerable; only nine patients withdrew acitretin due to side effects. No patients developed clinical features of cirrhosis or uncontrolled hyperlipidemia. The drug survival rates were 79%, 69.5%, 61.2%, 57.6%, and 53.5% at 1, 2, 3, 4, and 5 years, respectively, higher than those of previous studies. Patients without obesity, metabolic syndrome, and dyslipidemia did not have a significantly longer acitretin survival compared to patients with these comorbidities.

CONCLUSIONS

Long-term, low-dose acitretin in patients with psoriasis is unlikely to cause significant liver or lipid problems. In countries with difficulty accessing biological agents for psoriasis, acitretin may have a high drug survival rate due to its long-term safety. This study has several limitations: its retrospective nature, single-center study design, and small sample size.

Management of congenital ichthyoses: European guidelines of care, part one

These guidelines for the management of congenital ichthyoses have been developed by a multidisciplinary group of European experts following a systematic review of the current literature, an expert conference held in Toulouse in 2016 and a consensus on the discussions. They summarize evidence and expert-based recommendations and are intended to help clinicians with the management of these rare and often complex diseases. These guidelines comprise two sections. This is part one, covering topical therapies, systemic therapies, psychosocial management, communicating the diagnosis and genetic counselling.

Clinical and molecular characterization and response to acitretin in three families with Sjögren-Larsson syndrome

INTRODUCTION

Sjögren-Larsson syndrome (SLS) is a rare congenital disorder characterized by the triad of ichthyosis, spasticity, and mental retardation. Patients are usually referred to dermatology clinics during infancy. As paraplegia becomes the most debilitating symptom of the disease within a few years, ichthyosis, although a major burden for the patient, takes a back seat. Optimum treatment of ichthyosis in these children and the effect of treatment on different aspects such as severity of the ichthyosis, pruritus, or quality of life of the patients' and their caregivers is not well established.

MATERIALS AND METHODS

Genetic background of eight patients from three families diagnosed clinically with SLS was determined with whole-exome and Sanger sequencing. Clinical phenotypes, laboratory findings, magnetic resonance imaging (MRI), and treatment of the ichthyosis with acitretin were assessed.

RESULTS

All patients had the classical triad of Sjögren-Larsson syndrome. Genetic analysis revealed that one patient had a novel c.799-1 (+/+) homozygous splicing mutation in the ALDH3A2 gene. Other patients had the c.683G>A p.R228H (NM_000382.2) mutation in the same gene. Other manifestations included skeletal anomalies, enamel hypoplasia, bilateral T2-hyperintensities in white matter, and moderate-severe pruritus. Acitretin treatment in a maintenance dose of 0.25 mg/kg/day decreased the severity of ichthyosis in all children. It increased quality of life significantly in all of the children and their caregivers.

CONCLUSION

We conclude that ichthyosis can be treated effectively with low-dose acitretin in children with Sjögren-Larsson syndrome, and this treatment is associated with a significant improvement in the quality of life.

Management of pediatric psoriasis with acitretin: A review

Psoriasis is a chronic inflammatory disease of the skin which can occur at any age-group. Psoriasis in childhood is not uncommon and has genetic susceptibility but usually, an environmental trigger such as infection is thought to initiate the disease process. Pediatric psoriasis has profound effects on both physical and psychosocial health of the patient. Treatment of mild psoriasis can be done with topical therapies but those which do not respond to topical therapies can be treated with phototherapy and systemic therapies. The use of systemic therapies in childhood is mainly based on the published data, case series, expert opinion and the experience as there is the lack of controlled trials in the age group. Based on the experience retinoids are probably the second line drugs for the treatment of pediatric psoriasis which do not respond to topical therapies and phototherapy. Using acitretin in a low dose and with proper physical examinations and laboratory investigations will reduce the hazard of potential serious adverse events. This article gives the review of the use of acitretin in pediatric psoriasis.

Italian guidelines on the systemic treatments of moderate-to-severe plaque psoriasis

Psoriasis is a common disease, which has a considerable impact on the healthcare system. Therefore, appropriate use of therapeutic resources is very important. Management of psoriasis in daily clinical practice is highly variable because many issues are still debated and not definitely addressed by the evidence-based medicine. Moreover, the different availability and reimbursability of drugs in each country justifies national guidelines. Expert consensus can provide helpful guidelines for optimizing patient care. A total of 20 dermatologists from different areas of Italy and with large experience in the treatment of psoriasis agreed to participate in the guidelines expert panel who aimed to reach consensus on the factors influencing psoriasis severity, the indications for systemic treatments, the parameters to be considered in the choice of treatment, and the factors to be considered in the choice of biological treatment. The recommendations for the use, screening and monitoring of systemic therapies were based on the 2015 S3 European Dermatology Forum/European Academy of Dermatology and Venereology psoriasis guidelines. Recommendations on the treatment of psoriasis in special patient populations were also agreed. The final document was discussed in a meeting moderated by a facilitator with participation of the entire group and adopting a nominal group technique to reach consensus. A statement was regarded as consented when agreement was achieved by at least 75% of the voting experts according to the Delphi procedure.

Acitretin in psoriasis: an evolving scenario

Acitretin, an active metabolite of etretinate, is the most widely used systemic retinoid in the treatment of psoriasis. There are several unique characteristics of this drug, which set it apart from other options in the therapeutic armamentarium of psoriasis. It is highly efficacious as monotherapy in some specific clinical subtypes of psoriasis. It has dose-sparing effects when used as combination therapy with conventional systemic drugs as well as the biologics. It is a good option for long-term maintenance therapy. Side effects are common but usually mild and can be managed by its proper dosing and monitoring. With appropriate patient selection, gradual dose escalation, and patient counseling, we can deliver good results in psoriasis with this useful drug. This review gives a comprehensive recount of acitretin use in the present era of biologics in psoriasis.

Vitamin a metabolism, action, and role in skeletal homeostasis

Vitamin A (retinol) is ingested as either retinyl esters or carotenoids and metabolized to active compounds such as 11-cis-retinal, which is important for vision, and all-trans-retinoic acid, which is the primary mediator of biological actions of vitamin A. All-trans-retinoic acid binds to retinoic acid receptors (RARs), which heterodimerize with retinoid X receptors. RAR-retinoid X receptor heterodimers function as transcription factors, binding RAR-responsive elements in promoters of different genes. Numerous cellular functions, including bone cell functions, are mediated by vitamin A; however, it has long been recognized that increased levels of vitamin A can have deleterious effects on bone, resulting in increased skeletal fragility. Bone mass is dependent on the balance between bone resorption and bone formation. A decrease in bone mass may be caused by either an excess of resorption or decreased bone formation. Early studies indicated that the primary skeletal effect of vitamin A was to increase bone resorption, but later studies have shown that vitamin A can not only stimulate the formation of bone-resorbing osteoclasts but also inhibit their formation. Effects of vitamin A on bone formation have not been studied in as great a detail and are not as well characterized as effects on bone resorption. Several epidemiological studies have shown an association between vitamin A, decreased bone mass, and osteoporotic fractures, but the data are not conclusive because other studies have found no associations, and some studies have suggested that vitamin A primarily promotes skeletal health. In this presentation, we have summarized how vitamin A is absorbed and metabolized and how it functions intracellularly. Vitamin A deficiency and excess are introduced, and detailed descriptions of clinical and preclinical studies of the effects of vitamin A on the skeleton are presented.

Oral retinoid therapy for dermatologic conditions in children and adolescents

The efficacy of systemic retinoid therapy in a number of dermatologic diseases is well established; however, concerns about potential side effects limit their use, especially in children. We review the efficacy and toxicity of oral retinoids in the pediatric population. The acute mucocutaneous toxicities commonly observed are typically well tolerated, readily treatable, and reversible. Systemic toxicities include teratogenicity and effects on the musculoskeletal, neurologic, and gastrointestinal systems. Children, like adults, generally tolerate short-term retinoid therapy without major complications. Concerns regarding serious systemic side effects are greater for those on high doses of oral synthetic retinoids for longer periods of time. Close patient monitoring and patient education can minimize the occurrence of complications. (J Am Acad Dermatol 2003;49:171-82.)Learning objective At the conclusion of this learning activity, participants should be familiar with use of oral retinoids for childhood dermatologic conditions such as psoriasis, acne, and ichthyoses as well as safety and risks associated with oral retinoid use in children and adolescents.

Atypical pityriasis rubra pilaris associated with arthropathy and osteoporosis: a case report with 15-year follow-up

Pityriasis rubra pilaris (PRP) is an idiopathic papulosquamous disease that clinically presents with palmoplantar keratoderma and follicular hyperkeratotic papules that coalesce into scaly erythematous plaques. We report a unique case of atypical PRP beginning at 1 year of age with associated severe arthropathy and osteoporosis. We further discuss the clinical and histopathologic aspects of PRP, its possible etiology, and other associated conditions.

Adult skin disease in the pediatric patient

The incidence of many skin diseases peak in adulthood, and these disorders may be difficult to recognize when they do present in childhood. Their clinical features may be distinct in pediatric patients, and they may be managed differently in children as compared to adults. Therefore, it is important that dermatologists are able to identify "adult" skin disease in the pediatric patient, and know how to appropriately manage these problems in young patients. The epidemiology, clinical features, differential diagnosis, and management of the following "adult" skin diseases in children are reviewed: psoriasis, lichen planus, rosacea, Sweet's syndrome, and mucosis fungoides. Distinctive features of lichen sclerosus and immunobullous diseases in childhood will also be briefly discussed.

The use of retinoids in the pediatric patient

Oral retinoids are molecules derived from vitamin A that represent one of the most important steps forward in dermatologic therapeutics in the present century. The treatment of acne, severe psoriasis, and severe disorders of keratinization, prevalent diseases in children and adolescents, have radically changed since the advent of oral retinoids. Like most highly-effective medications, oral retinoids also have important untoward effects. Specialists, and in particular, dermatologists and pediatricians should be prepared to maneuver the delicate balance between therapeutic efficacy and side effects in order to give the pediatric patient the maximum benefit with the lowest possible risk.

Rheumatologic complications of vitamin A and retinoids

Retinoids are synthetic derivatives of vitamin A. They are administered primarily for dermatological conditions, such as psoriasis, acne, and disorders of keratinization. Toxicity has proven a significant problem with long-term administration of the retinoids. Bone abnormalities mimicking seronegative spondyloarthropathy or diffuse idiopathic skeletal hyperostosis have been described in many cases, as well as other rheumatologic manifestations such as arthritis, myopathy, and vasculitis. These retinoid-related adverse effects are reviewed.

Bone mineral density of the lumbar spine in psoriatic patients with long term etretinate therapy

Etretinate has been known to produce a variety of skeletal manifestations when administered for prolonged periods. To study whether osteoporotic changes occurred during the treatment bone mineral density (BMD) was measured by dual energy X-ray absorptiometry in 13 psoriatic patients who received long term etretinate therapy (average 3.7 yrs). The values of BMD of the lumbar spine in these patients were decreased from those of age-matched controls (92.3 +/- 9.7%), p < 0.01), while those in psoriatic patients who received topical corticosteroid applications alone showed no significant decrease. Our findings suggest that long term etretinate intake induces an increased risk of osteoporotic changes.

Partial improvement of Olmsted syndrome with etretinate

An 11-year-old Japanese boy with Olmsted syndrome was seen at our clinic. He had a sharply marginated, painful keratoderma with a red border on his palms and soles. Flexion contractures of the fingers were also observed. Hyperkeratotic plaques were present below the lower lip, on the elbows and knees, and in the sacral area. Localized alopecia, leukokeratosis on the tongue, shortness of stature, and laxity of the large joints corresponded to the clinical features of Olmsted syndrome. Treatment with etretinate was effective for the palms and fingers, but resulted in no improvement of the keratoderma of the soles. Because of periosteal thickening of the tibia, presumably caused by etretinate, therapy was terminated one year after it began.

Clinical efficacy and side effects of acitretin on the disorders of keratinization: a one-year study

Acitretin, Ro 10-1670, the principal and free acid metabolite of etretinate, was used to treat twenty patients with disorders of keratinization. An open, prospective study of clinical efficacy, tolerability, and the effects of acitretin on lipid metabolism, hepatic function, and the osteoarticular system was performed over a one year period. Each patient was initially treated with 30 mg/day of acitretin or approximately 0.6 mg/kg/day. Doses were adjusted according to the clinical efficacy and maintained for one year. There were no statistically significant changes in liver function tests or lipid profile. Twelve of eighteen evaluated patients developed asymptomatic skeletal changes; the most common change was disc space narrowing, especially at thoracic-spine level (7 of 18 patients). The earliest bone change was detected 9 months after treatment. Acitretin is effective in improving the disorders of keratinization with mild mucocutaneous side effects and asymptomatic osteoarticular changes.

Side effects of systemic retinoids and their clinical management

The safety profile of oral retinoids appears to be well established, although rare new side effects are occasionally reported. Appropriate patient selection, use of the lowest required dose, and adequate follow-up are significant factors in the prevention of these toxicities. Teratogenicity, which can be avoided by following recommended precautions, is the main adverse effect.

Bone changes and their significance in children with ichthyosis on long-term etretinate therapy

Anxiety about the use of etretinate in children has been provoked by several reports describing skeletal abnormalities during long-term therapy. However, we have observed no evidence of skeletal toxicity in 42 children treated over an 11-year period. Radiological screening before and during treatment has failed to reveal abnormalities that would influence our decision to commence or to continue etretinate administration. We recommend that children who are to be treated with etretinate should have a baseline selective skeletal survey, with follow-up radiology restricted to those with pretreatment radiological abnormalities and those who develop musculo-skeletal symptoms. In addition we advise that dosage should not exceed 1 mg/kg/day. If these guidelines are followed, we believe that long-term therapy with etretinate can be given to children, with an acceptable margin of safety.

Rheumatological symptoms due to retinoids

Isotretinoin and etretinate are synthetic derivatives of vitamin A widely used in the treatment of dermatological diseases, mainly those affecting keratinization. They have numerous side-effects, among which the rheumatic symptoms are not the most common or the most severe. The main skeletal adverse reaction of retinoids is hyperostosis. It mainly occurs with protracted treatments and high dosages, and its incidence may exceed 80% after a few years of administration. Hyperostosis is axial, located in the cervical and thoracic spine, and may be responsible for limitation of movement; in the appendicular bone, enthesopathies occur at the foot, pelvis, hip, and less commonly the shoulder and elbow. They are usually mild and asymptomatic. The radiological appearance is very similar to diffuse idiopathic skeletal hyperostosis. Isotretinoin tends to be responsible for axial involvement, etretinate for peripheral locations. The other skeletal side-effects are uncommon and include periosteal proliferation, calcification of the interosseous membrane of the forearm and diffuse radiological bone hyperlucency. In children, premature epiphyseal closure is very rare. About 20% of patients complain of musculoskeletal pain and arthralgias. A few cases of true arthritis have been reported. Retinoids may be responsible for muscular damage and an abnormality of muscular tone resembling the stiff-man syndrome. Some cases of necrotizing vasculitis and three cases of Wegener's granulomatosis have been observed in patients treated with retinoids. Except for these latter arguable cases, rheumatoid syndromes due to retinoids are rather benign, and should not be an obstacle to the future development of their therapeutic utilization.

Synthetic retinoids in veterinary dermatology

The synthetic retinoids, isotretinoin (Accutane) and etretinate (Tegison) are vitamin A analogs. They affect epithelial differentiation and thus have potential for therapy for disorders of epithelial maturation such as keratinization defects of cutaneous neoplasia. The pharmacology, indications for use, clinical experience, potential toxicities, and recommended monitoring of these drugs are discussed.

Risk: benefit ratio in the treatment of psoriasis with systemic retinoids

This is a review of the efficacy of etretinate/acitretin in the treatment of psoriasis and of the currently reported side-effects. The data indicate that retinoids bring significant improvement (if not total clearing) with frequent low-morbidity but rarely serious side-effects. The most serious side-effect of etretinate/acitretin is teratogenicity.

A retrospective study of bone changes in adults treated with etretinate

Ninety patients aged 17 to 80 years were treated with etretinate for disorders of keratinization and were studied for bone changes. The treatment lasted from 0.1 to 7.9 years, mean 2.4 years. The average dosage of etretinate was 0.57 mg/kg/day (range 0.21 to 1.32 mg/kg/day), and the total dose was 31 gm (range 1 to 197 gm). Standard radiographs of the axial and peripheral skeleton were evaluated. The films of 44 patients showed skeletal abnormalities such as periosteal thickening, hyperostosis of the vertebral column, disk degeneration, osteoporosis, calcification of the spinal ligaments, and slender long bones. The present data indicate that the risk of skeletal disorders in adults treated with etretinate is significant (44 of 90), but that the severity of changes is minor.

Etretinate in severe psoriasis of children

Ten children, five with generalized pustular psoriasis and five with erythrodermic disease, were treated with etretinate and observed for up to seven years. In all those with pustular psoriasis, complete clearing was obtained in three weeks to four months, but in one child maintenance therapy had to be introduced twice, for one year each time. In those with erythrodermic psoriasis, the results were favorable only in two, and in two it was necessary to introduce Re-PUVA. Clinical side effects were slight, and laboratory examinations did not disclose any significant abnormalities. In one child who was treated intermittently for seven years, focal osteoporosis of one tibia was disclosed by radiography. No adverse effects on children's development were noticed.

Dermatologic therapy: December 1986 to December 1987

In this article I review significant therapeutic advances reported in the English literature from December 1986 to December 1987. Readers should review the original articles in toto before attempting any new experimental or controversial therapy summarized.

Long-term radiographic follow-up after isotretinoin therapy

We evaluated the effects of long- and short-term isotretinoin therapy on the skeletons of patients. Eight patients who were treated with isotretinoin for disorders of keratinization received frequent radiographic evaluations for 4 to 9 years. Seven patients developed multiple hyperostoses at the spine and extremities. Hyperostoses increased in size and number over the course of therapy, although relatively few sites were symptomatic. Hyperostoses typically developed first in the spine and later in the extremities, where both bilaterally symmetric and asymmetric involvement was observed. After 5 years of therapy one patient did not develop hyperostosis. In a group of nine patients who received a relatively high dose of isotretinoin in 1982 for the treatment of acne, two patients developed tiny, asymptomatic hyperostoses. One patient had hyperostoses 1 year after isotretinoin therapy, which remained unchanged 3 years later, whereas the other patient had one hyperostosis 4 years after therapy had been stopped. Although we suspect that these hyperostoses were retinoid induced, they should not be of concern for the patient needing routine isotretinoin therapy for the treatment of cystic acne.