Acitretin in dermatology

Clinical pharmacokinetics and pharmacodynamics of oral systemic nonbiologic therapies for psoriasis patients

INTRODUCTION

Psoriasis is a chronic inflammatory immune condition. Treatments for psoriasis vary with disease severity, ranging from topicals to systemic biologic agents. The pharmacokinetic (PK) and pharmacodynamic (PD) properties of these therapies establish drug efficacy, toxicity, and optimal dosing to ensure therapeutic drug levels are sustained and adverse effects are minimized.

AREAS COVERED

A literature search was performed on PubMed, Google Scholar, and Ovid MEDLINE for PK and PD, efficacy, and safety data regarding oral systemic nonbiologic therapies utilized for moderate-to-severe plaque psoriasis. The findings were organized into sections for each drug: oral acitretin, methotrexate, cyclosporine, apremilast, tofacitinib, and deucravacitinib.

EXPERT OPINION

Some psoriasis patients may not respond to initial therapy. Ongoing research is evaluating genetic polymorphisms that may predict an improved response to specific medications. However, financial and insurance barriers, as well as limited genetic polymorphisms correlated with treatment response, may restrict the implementation of genetic testing necessary to personalize treatments. How well psoriasis patients adhere to treatment may contribute greatly to variation in response. Therapeutic drug monitoring may help patients adhere to treatment, improve clinical response, and sustain disease control.

Comparative Study Between Tacrolimus 0.1% Ointment Versus Topical White Soft Petrolatum Jelly in the Treatment of Oral Retinoid-Induced Cheilitis

Retinoids are used topically as well as orally, and the most commonly used oral retinoids are isotretinoin and acitretin. Mucocutaneous adverse effects are frequently seen with the use of systemic retinoids, the most common being cheilitis, which is dose-dependent and seen in almost all patients using it. To study the comparative effect of topical tacrolimus 0.1% ointment versus topical white soft petrolatum jelly in the treatment of cheilitis due to retinoids. A total of 26 patients with cheilitis post-treatment with isotretinoin were enrolled in this cross-sectional study conducted over a period of 6 months. They were randomized into two groups of 13 patients each to receive topical tacrolimus 0.1% ointment and soft petrolatum jelly twice daily, respectively. Patients were followed up weekly with clinical photographs. Resolution of cheilitis was assessed on the basis of photograph and ICGS score. About 84.6% of patients of group A and 53.8% of patients of group B showed resolution of symptoms within 1 week of treatment. A significant difference was seen in duration for complete cheilitis resolution and relapse rate in the two groups. Our study concludes that oral retinoid-induced cheilitis shows faster and more significant resolution with twice-daily topical tacrolimus 0.1% ointment application compared to twice-daily topical petrolatum jelly.

ALA-PDT combined with oral acitretin in the treatment of refractory condyloma acuminatum in anal canal

BACKGROUND

Condyloma acuminatum (CA) of the anal canal is difficult to treat and subject to relapse.. We investigated the effects of aminolevulinic acid-based photodynamic therapy (ALA-PDT) combined with oral acitretin during therapy of refractory CA in the anal canal. We also conducted a clinical retrospective study for the treatment of intra-anal CA.

METHODS

A total of 101 patients diagnosed with intra-anal CA were enrolled. All patients underwent liquid nitrogen cryotherapy as a basic treatment until visible wart clearance. Patients were divided into two groups depending on the treatment modality after cryotherapy. ALA-PDT group with 51 patients was given ALA-PDT treatment, and ALA-PDT plus acitretin group with 50 patients was given ALA-PDT treatment combined with oral acitretin. The cure rate, recurrence rate, and adverse reactions of the two groups were analyzed and recorded.

RESULTS

The cure rate in the ALA-PDT plus acitretin group was 94% (47/50), which was significantly higher than 80.4% (41/51) in ALA-PDT group. The recurrence rate in the ALA-PDT plus acitretin group was 6% (3/50), which was lower than 19.6% (10/51) in ALA-PDT group (P<0.05).

CONCLUSION

ALA-PDT combined with oral acitretin is effective and safe in the treatment of refractory CA in anal canal, and with further study may become an option for these patients.

Risk of malignancy in patients with psoriasis according to treatment modalities in Korea: a nationwide cohort study

Intrinsic immunologic disparity of psoriasis itself, along with chronic inflammation and immunomodulatory anti-psoriatic treatments could be associated with increased risk of malignancy. We aimed to estimate the risk of malignancy in patients with psoriasis by treatment modality compared with that in individuals without psoriasis in Korea. We conducted a nationwide cohort study using the claims database of the National Health Insurance Service from January 2005 to December 2018. A total of 255,471 patients with psoriasis, and age- and sex-matched non-psoriasis participants (1:1 ratio) were enrolled. The adjusted hazard ratios (aHRs) [95% confidence intervals (CIs)] for malignancy without nonmelanoma skin cancer (NMSC) were 1.10 [1.08-1.12] in patients with psoriasis, 1.13 [1.00-1.27], 1.05 [0.97-1.13], and 1.24 [0.84-1.83] in phototherapy, non-biologic systemics, and biologics cohort, respectively. Among the non-biologic systemics cohort, patients treated with cyclosporin showed higher risk of malignancy without NMSC (aHR [95% CI], 1.20 [1.04-1.39]). The risk of malignancy without NMSC in patients with psoriasis was higher than that in individuals without psoriasis. Phototherapy and biologics were not associated with significant increase of risk; however, cyclosporin appeared to increase its risk. Dermatologists should be vigilant about this potential risk while managing patients with psoriasis.

Lipid Aberrations in Lichen Planus

Lichen planus (LP) is a dermatosis without a fully understood etiopathogenesis, the frequency of which is estimated to be less than 1% among the population. LP may involve the glabrous skin, mucosal membranes, scalp, nails and genital area. Nowadays, there are reports of its association with lipid homeostasis aberrations. In this review, we present the contemporary view of this matter. Dyslipidemia, especially hypertriglyceridemia, seems to be an actual problem in this group of patients, and along with abnormal arterial vessel parameters, indicates an increased risk of atherosclerosis in these subjects. Dermatologists should be attentive to this relationship and aware that the patients may develop different metabolic complications. More studies are required to establish clear guidelines on the management of lipid aberrations in lichen planus.

Current emerging and investigational drugs for the treatment of chronic hand eczema

INTRODUCTION

: Chronic hand eczema (CHE) is a highly prevalent, burdensome condition associated with functional impairment. Currently, topical therapeutics are the mainstay of CHE management. However, many cases are refractory to existing topical therapeutics, and the few existing systemic options are often limited in efficacy and by their side effect profiles.

AREAS COVERED

: Following a brief overview of CHE pathogenesis and existing treatments, this review will outline the mechanisms and available data on emerging and investigational drugs currently being studied in clinical trials for the treatment of CHE.

EXPERT OPINION

: Immunomodulatory drugs such as topical and systemic JAK inhibitors and Th2-targeting antibodies such as dupilumab are currently under investigation for CHE treatment, with early promise. Management of CHE will likely move toward more targeted treatments through clinical trials and away from broad immunosuppressants such as cyclosporine and methotrexate, which have previously been investigated for CHE and have more side effects. In coming years, CHE patients may benefit from a wider range of both topical and systemic therapeutics that target immune pathways relevant to the various CHE subtypes.

Use of retinoids in dermatology

Background: Retinoid, whose existence was first known in the 20th century, was initially referred to as a naturally occurring substance with vitamin A action. However, now it has become a generic term for all substances exhibiting an active action through the retinoid receptor located in the nucleus of the cells. Retinoids are biologically important substances involved in many functions, including reproduction, embryonic morphogenesis, regulation of epithelial proliferation and differentiation, reduction of sebaceous gland, immune and anti-inflammatory effects, tumor prevention, and effects on extracellular matrix components.Current Concepts: Topical retinoids are used to treat several conditions, including acne, photoaging, and psoriasis. Their side effects are dose-related skin irritations, while teratogenicity risk is rare to non-existent. Systemic retinoids are a treatment of choice for acne and keratinization disorders. They are also useful for the treatment of psoriasis, pityriasis rubra pilaris, cutaneous T-cell lymphoma, and chronic hand eczema. Systemic retinoid therapy requires the careful patient selection and monitoring due to associated teratogenicity. Other important side effects are hypertriglyceridemia, dryness of lips, blepharoconjunctivitis, bone pain, increased muscle tone, myopathy, hypothyroidism, and neutropenia.Discussion and Conclusion: Awareness of the side effects and proper use of retinoids are important for successful treatment outcomes of the above-mentioned dermatological conditions.

Non-medication Acquired Sticky Skin: Case Report of Idiopathic Acquired Cutaneous Adherence and Review of Medication-Induced Sticky Skin

Sticky skin is a dermatologic phenomenon in which the skin may cause objects to adhere to it on contact or adhere to itself or both. The entire skin can be affected in patients with sticky skin. Alternatively, just acral sites, such as the hand, can be involved. The acquisition of sticky skin has been described in patients treated with certain medications. These drugs include retinoids, proton pump inhibitors, and antifungals; they also include combination therapy utilizing an antineoplastic agent and an antifungal drug in patients with hormone-resistant prostate cancer.

The pathogenesis of acquired cutaneous adherence in patients with androgen-independent prostate cancer was postulated to be the result of therapy-induced elevation of endogenous retinoids. Retinoids have multiple biological effects on epidermal differentiation that may contribute to the pathogenesis of acquired cutaneous adherence. These include the induction of fine, granular, mucus-like deposits within and between the keratinocytes in the upper stratum spinosum and stratum corneum, modulation of lipid composition in keratinocytes, prevention of cross-linked, cornified envelope formation in keratinocytes by the inhibition of epidermal transglutaminase, and altered and decreased content of keratin within the epidermis. We describe an older man who developed non-medication acquired sticky skin (NoMasts). His acquired cutaneous adherence was considered to be idiopathic. We postulate that aging may be associated with elevated endogenous retinoid levels in older individuals and may have resulted in his sticky skin. Further investigation into these retinoid-induced effects and to what extent they promote acquired cutaneous adherence is still needed.

Reviewing the Etiologic Agents, Microbe-Host Relationship, Immune Response, Diagnosis, and Treatment in Chromoblastomycosis

Chromoblastomycosis (CBM) is a neglected human disease, caused by different species of pigmented dematiaceous fungi that cause subcutaneous infections. This disease has been considered an occupational disease, occurring among people working in the field of agriculture, particularly in low-income countries. In 1914, the first case of CBM was described in Brazil, and although efforts have been made, few scientific and technological advances have been made in this area. In the field of fungi and host cell relationship, a very reduced number of antigens were characterized, but available data suggest that ectoantigens bind to the cell membrane of host cells and modulate the phagocytic, immunological, and microbicidal responses of immune cells. Furthermore, antigens cleave extracellular proteins in tissues, allowing fungi to spread. On the contrary, if phagocytic cells are able to present antigens in MHC molecules to T lymphocytes in the presence of costimulation and IL-12, a Th1 immune response will develop and a relative control of the disease will be observed. Despite knowledge of the resistance and susceptibility in CBM, up to now, no effective vaccines have been developed. In the field of chemotherapy, most patients are treated with conventional antifungal drugs, such as itraconazole and terbinafine, but these drugs exhibit limitations, considering that not all patients heal cutaneous lesions. Few advances in treatment have been made so far, but one of the most promising ones is based on the use of immunomodulators, such as imiquimod. Data about a standard treatment are missing in the medical literature; part of it is caused by the existence of a diversity of etiologic agents and clinical forms. The present review summarizes the advances made in the field of CBM related to the diversity of pathogenic species, fungi and host cell relationship, antigens, innate and acquired immunity, clinical forms of CBM, chemotherapy, and diagnosis.

Systemic Management of Psoriasis Patients in Indian Scenario: An Expert Consensus

Background:

Psoriasis is a common inflammatory disease with significant comorbidities, and regardless of its extent, it affects the patients' quality of life. The various modalities of treating psoriasis comprise topical or systemic medications, phototherapy, and an array of biologic agents. There is a lack of Indian recommendations on the management of psoriasis with these different modalities and challenges faced by the clinicians in day-to-day practice.

Aim:

To develop India-specific consensus for systemic management of patients with moderate-to-severe psoriasis.

Method and Results:

A panel of dermatology experts, based on the evidence and international recommendations, coupled with their own clinical experience, developed recommendations for systemic management of patients with moderate-to-severe psoriasis.

Conclusion:

These recommendations are meant to provide guidance in terms of choice of systemic therapies, dosing, effectiveness, and safety. It also addresses clinical challenges that may be experienced during psoriasis management.

Recurrent N209* ABHD5 mutation in two unreported families with Chanarin Dorfman Syndrome

ABHD5 protein is widely involved in lipid and energy homeostasis. Mutations in the ABHD5 gene are associated with the onset of Neutral Lipid Storage Disease with Ichthyosis (NLSDI), historically known as Chanarin Dorfman Syndrome (CDS). CDS is a rare autosomal recessive lipid storage disease, characterized by non-bullous congenital ichthyosiform eritrhoderma (NCIE), hepatomegaly and liver steatosis. Myopathy, neurosensory hearing loss, cataracts, nystagmus, strabismus, and mental impairment are considered additional findings. To date, 151 CDS patients have been reported all over the world. Here we described two additional families with patients affected by CDS from Turkey. Our patients were a 42 and 22-years old men, admitted to the Hospital for congenital ichthyosis. Hepatic steatosis and myopathy were also detected in both patients. ABHD5 molecular analysis revealed the presence of N209* mutation. Our data enlarge the cohort of CDS patients and provide a revision of muscle clinical findings for this rare inborn error of neutral lipid metabolism.

Drug survival and safety profile of acitretin monotherapy in patients with psoriasis: A multicenter retrospective study

Acitretin is a nonimmunosuppresive systemic agent used in the treatment of psoriasis. Despite its frequent use, research on drug survival and adverse effects is limited. This study aims to evaluate drug survival, factors associated with survival, and adverse effects. Database of the six tertiary referral center for psoriasis patients treated with acitretin between November 2014 and April 2020 were retrospectively analyzed. Demographics of patients, adverse effects, and also drug survival were analyzed. Of 412 patients, 61.2% were male, and 38.8% were female. Common clinical adverse effects were cheilitis (71.4%), dry skin (62.5%), and palmoplantar skin peeling (37.2%). High triglyceride and high total cholesterol levels were observed in 50.0% and 49.5% of patients, respectively. Median survival time (95% confidence interval [CI]) was 18 (13.6-22.4) months. Statistically significant risk factors affecting drug discontinuation were having psoriatic arthritis, age under 65, and receiving previous systemic treatment. Drug survival rates were 56.6%, 25.9%, and 19.8% at 1, 5, and 8 years, respectively. Although mucocutaneous adverse effects of the acitretin were quite frequent, severe, life-treatining ones were infrequent. This old, relatively inexpensive and safe treatment remains a good alternative for the treatment of psoriasis.

Elephantiasis nostras verrucosa gigantea nach nekrotisierender Fasziitis – Erfolgreiche Therapie mit Acitretin

Wir berichten über einen 54-jährigen männlichen Patienten mit einer posttraumatischen und postinflammatorischen Elephantiasis nostras verrucosa (ENV) des linken Beines. 5 Jahre zuvor war ein Arbeitsunfall vorausgegangen (Bagatellverletzung der linken Patella) mit nachfolgendem komplikationsreichen Verlauf (u. a. Entwicklung einer nekrotisierenden Fasziitis). Die dadurch entstandenen Hautdefekte wurden mittels Spalthauttransplantation versorgt. Nach initialer Einheilungstendenz kam es bei Verbandswechseln jedoch zu erheblichem Spalthautverlust mit begleitender infizierter Wundheilungsstörung. In den darauffolgenden Jahren bildeten sich eine massive Umfangsvermehrung des linken Beins sowie übel riechende, vegetierende, flächige Hyperkeratosen mit scharfer zirkulärer Demarkationslinie ca. 10 cm proximal des Kniegelenkes. Wir begannen eine Therapie mit Acitretin 40 mg/d p. o., eine intensivierte externe Therapie (stadienadaptiert antiseptisch, aggressiv keratolytisch) sowie mechanische Débridements (Skalpell, Kürette) zur Massenabtragung. Im Verlauf wurde die Acitretindosis auf 10 mg alle 2 Tage reduziert. Hierunter zeigt sich ein langfristig stabiler Befund. Pathogenetisch kann eine ENV bei einer wie im vorgestellten Fall insuffizienten Wiederherstellung des lymphatischen Abflusses nach z. B. Operationen oder Traumen mit Sistieren des Clearings relevanter Zytokine und Wachstumsfaktoren entstehen. Aufgrund der Seltenheit der ENV mit nur wenigen Fallberichten in der Literatur existiert keine standardisierte Therapie. Im hier dargestellten Fall wird über eine erfolgreiche Therapie der ENV mit Acitretin berichtet.

Drug-Induced Neutropenia During Treatment of Non-Neoplastic Dermatologic Diseases: A Review

Idiosyncratic drug-induced neutropenia (DIN) is a rare, potentially fatal adverse reaction. A literature search was performed on Pubmed and Embase, targeting articles indicating neutropenia as a complication during the treatment of non-neoplastic dermatological disorders. In 66 identified articles, the common incriminated drugs included conventional oral immunomodulators, topical cytotoxic agents, antibacterials, antifungals, biologics and targeted synthetic disease-modifying antirheumatic drugs, non-steroidal anti-inflammatory drugs, and retinoids, with dapsone being reported most often. The duration of drug exposure before the diagnosis of neutropenia varied, but mostly ranged from days to weeks. The majority of patients recovered after drug discontinuation and supportive management including antibiotics and granulocyte colony-stimulating factor, but fatal cases were reported. The proposed pathogenesis of DIN consists of direct drug toxicity and immune-mediated reaction. Certain genetic variants, individual variability in enzyme efficiency, and concomitant use of other drugs may increase the risk of DIN. Being familiar with the most commonly implicated agents and risk factors helps early identification and prompt management of this potentially fatal complication.

Successful clearance of extensive/recalcitrant cutaneous warts by acitretin monotherapy: A case series study

Most available options for the treatment of warts are limited by the potential for scarring, pain, lack of response, or recurrences, and the patients are often unable to tolerate and accept those experiences. The aim of this study was to evaluate the clinical efficacy and safety of oral systemic acitretin monotherapy in patients with extensive/recalcitrant cutaneous warts. The patients were given a dose of acitretin of 0.8 mg kg^-1 day^-1 , and the clinical efficacy and safety of acitretin was assessed every 2 weeks for 2 months. A total of 14 patients (12 males and 2 females) were included, with an age of 14-60 years (mean 33 ± 14.7 years) and a course of 4-48 months (mean 21.6 ± 13.4 months). After 2 months of acitretin treatment, 42.9% (6/14) of patients (including warts of the feet, legs, and hands) exhibited complete response, 28.6% (4/14) excellent response, and 28.6% (4/14) good response. All patients demonstrated significant improvement, and the drug was well tolerated, with no patients discontinuing therapy due to side effects. Common mild side effects included dry skin and cheilitis. There were no recurrences during a follow-up period of 6 months. Acitretin monotherapy is an effective, safe, and well-tolerated treatment for patients with extensive/recalcitrant cutaneous warts who are unsuitable for or unwilling to accept traditional treatment methods.

Treatment of Medicare Patients with Moderate-to-Severe Psoriasis who Cannot Afford Biologics or Apremilast

Elderly patients are a group with a high frequency of psoriasis. Their disease burden has negative impacts on their quality of life. While there is a clear need to treat these patients, there are challenges in doing so. This work seeks to define the challenges that exist in treating elderly Medicare patients, as well as to provide treatment suggestions for providers to follow if they encounter one or more of these challenges. Providers face the following challenges when creating treatment plants for elderly patients with psoriasis: difficulty in obtaining drug coverage through Medicare, increased medical comorbidities, and polypharmacy. Providers aim for regimens that are affordable, safe, and efficacious, but it is not always clear how to achieve this combination, especially in elderly Medicare patients. This work is relevant in that it aims to explain the logistical roadblocks posed by Medicare coverage and provide solutions for commonly encountered issues in the treatment of a disabling and common disease in a high-risk population. Specifically, alternative treatment options to biologics and small-molecule inhibitors are discussed and include topical therapies, phototherapy, methotrexate, acitretin, and cyclosporine and for psoriatic arthritis include corticosteroids and leflunomide. The specific risks and benefits of these therapies in the elderly population are provided, allowing providers to make patient-specific decisions about optimal regimens.

RNA sequencing-based longitudinal transcriptomic profiling gives novel insights into the disease mechanism of generalized pustular psoriasis

Background

Generalized pustular psoriasis (GPP) is a rare, episodic, potentially life-threatening inflammatory disease. However, the pathogenesis of GPP, and universally accepted therapies for treating it, remain undefined.

Methods

To better understand the disease mechanism of GPP, we performed a transcriptome analysis to profile the gene expression of peripheral blood mononuclear cells (PBMCs) from patients enrolled at the time of diagnosis and receiving follow-up treatment for up to 6 months.

Results

RNA sequencing data revealed that gene expression in five GPP patients’ PBMCs was profoundly altered following acitretin treatment. Differentially expressed gene (DEG) analysis suggested that genes related to psoriatic inflammation, including CXCL1, CXCL8 (IL-8), S100A8, S100A9, S100A12 and LCN2, were significantly downregulated in patients in remission from GPP. Functional enrichment and annotation analysis unveiled a cluster of DEGs significantly associated with the function of leukocytes, particularly neutrophils. Pathway analysis suggested that a variety of pro-inflammatory pathways were inhibited in patients in remission. This analysis not only reaffirmed known signaling pathways in GPP pathogenesis, but also implicated novel factors and pathways, such as cell cycle regulation pathways. Furthermore, regulator network analysis provided bioinformatics-based support for upstream molecules as potential therapeutic targets such as oncostatin M.

Conclusions

This longitudinal analysis of blood transcriptomes provides the first evidence that dysregulated gene expression in peripheral blood may significantly contribute to psoriatic inflammation in GPP patients. Novel canonical pathways and biomarkers identified in the current research may provide insights to help understand GPP pathobiology and advance novel therapeutics.

Electronic supplementary material

The online version of this article (10.1186/s12920-018-0369-3) contains supplementary material, which is available to authorized users.

Case Report: Successful Treatment of Chromoblastomycosis Caused by Fonsecaea monophora in a Patient with Psoriasis Using Itraconazole and Acitretin

Chromoblastomycosis is a worldwide chronic subcutaneous infection caused by dematiaceous fungi and clinically characterized by verrucous lesions. Herein, we report a rare case of chromoblastomycosis caused by Fonsecaea monophora in a 60-year-old male carpenter with a 40-year history of psoriasis from Shandong in northern China. A fungal infection coexisting with psoriasis presents a management dilemma. Our patient responded well to combined itraconazole and acitretin therapy and the lesions resolved completely after 1 month of treatment.

Retinoic acid syndrome in a elderly male with psoriasis- A case report

The retinoic acid derivatives are used for disorders of keratinization such as psoriasis. Retinoic acid syndrome is a cytokine release syndrome, commonly encountered in patients with acute promyelocytic leukaemia (APL). It is very rarely described in psoriasis seconday to use of retoind derivatives. Here we report a case of elderly male with psoriasis presenting with acitretin induced retinoic acid syndrome.

Severe ectropion in lamellar ichthyosis managed medically with oral acitretin

Congenital ectropion is commonly associated with lamellar ichthyosis. Severe eyelid ectropion may cause corneal exposure, keratopathy, and permanent corneal scarring. We report a neonate with severe, bilateral, congenital ectropion and eclabium managed using oral retinoids. Both corneas were protected with topical antibiotics and lubricating eyedrops and eye ointments. At 12-month follow-up, the child was doing well, with no ectropion or corneal opacity.

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.

Acitretin Use in Dermatology

BACKGROUND

Acitretin has been used for the treatment of severe psoriasis for over 20 years.

OBJECTIVE

The current project was conceived to optimise patient care by recognising the role acitretin can play in the treatment of patients with psoriasis and those with other disorders of keratinisation.

METHODS

A literature review was conducted to explore the role of acitretin and to assess its value for dermatologic disorders other than severe psoriasis. A panel of Canadian dermatologists developed a clinical pathway using a case-based approach, focusing on specific patient features.

RESULTS

The clinical pathway covers plaque psoriasis with hyperkeratotic plantar disease, palmoplantar pustulosis, hyperkeratotic hand dermatitis, lichen planus, lamellar ichthyosis, and hidradenitis suppurativa.

CONCLUSION

The recommendations in our clinical pathway reflect the current use of acitretin in Canada for severe psoriasis and other disorders of keratinisation.

Efficacy of oxymatrine for treatment and relapse suppression of severe plaque psoriasis: results from a single-blinded randomized controlled clinical trial

BACKGROUND

Drugs that are currently used in the treatment of psoriasis are associated with drawbacks such as rapid recrudescence, high costs and unwanted side-effects. Oxymatrine has a long history of clinical use in the treatment of hepatitis and cancer in China.

OBJECTIVES

To explore the efficacy and safety of intravenous oxymatrine in patients with severe plaque psoriasis.

METHODS

A total of 67 patients were randomly allocated to receive oxymatrine injections (0.6 g per day for 8 weeks) or acitretin capsules (0.75 mg kg^-1 per day from week 0 to week 2 and 20-30 mg per day from week 3 to week 8) and followed up for another 24 weeks. The primary end point was the percentage of patients with ≥ 50% reduction of Psoriasis Area and Severity Index (PASI 50) at week 32. The secondary end points included the skin classification grade and the Dermatology Quality of Life Index (DLQI) score. Side-effects were recorded throughout the whole study to assess the safety profile.

RESULTS

Treatment with oxymatrine or acitretin for 8 weeks significantly decreased PASI score, skin classification grade and DLQI score (P < 0.001), with no significant differences between the oxymatrine and acitretin groups in terms of PASI 50. However, at week 32, the relapse rate in the oxymatrine group was significantly lower than that of the acitretin group (P < 0.001). Moreover, while there was an increase in the number of patients with metabolic abnormalities in the acitretin group, a significant reduction was observed in the oxymatrine group. Furthermore, rates of adverse reactions were significantly decreased in the oxymatrine group compared with that of the acitretin group (P < 0.001).

CONCLUSIONS

Treatment with oxymatrine effectively ameliorated severe plaque psoriasis, and was accompanied by only minor adverse effects.

Possible alternative therapies for oral lichen planus cases refractory to steroid therapies

Oral lichen planus (OLP) is a chronic inflammatory disorder with a multifactorial etiopathogenesis. Immune dysregulation plays a critical role in the development and progression of this disease. Patients' lives may be affected by pain caused by atrophic-erosive lesions. Given the obscure etiology, treatment is usually symptomatic. Topical steroids remain the mainstay of management. However, their therapeutic benefits are not always evident. There are substantial data on the possible therapeutic strategies that are effective in OLP cases refractory to steroids. This review provides an overview of the current approaches for the management of steroid-refractory OLP. The miscellaneous treatment regimens include tacrolimus, pimecrolimus, thalidomide, low-level laser therapy, photodynamic therapy, and surgical excision. Some results obtained from these studies were promising. However, further studies, especially randomized controlled trials with strict inclusion and exclusion criteria and larger sample sizes, are required for the evaluation of the long-term safety and efficacy of these therapies.