Acitretin is a synthetic retinoid medication used to treat severe psoriasis and other skin conditions. What are the key indications, adverse effects, and monitoring required for acitretin therapy? Get a detailed overview.

Acitretin Overview

Acitretin is a synthetic retinoid medication that belongs to a class of drugs known as retinoids. Retinoids are compounds that have similar activity to vitamin A, which plays a crucial role in regulating the immune system, cellular growth, differentiation, and proliferation, as well as embryonic development. Acitretin is the active metabolite of etretinate, another synthetic retinoid drug.

FDA-Approved Indications

Acitretin is primarily FDA-approved for the treatment of severe plaque-type psoriasis, generalized pustular psoriasis, and localized pustular psoriasis. It can be used as monotherapy or in combination with other treatments, such as ultraviolet B (UVB) therapy, psoralen ultraviolet A (PUVA) therapy, cyclosporine, or biologic therapies.

Off-Label Uses

Beyond its approved indications, acitretin has also been used off-label in dermatology for other conditions, including:

• Chemoprevention of non-melanoma skin cancers in solid organ transplant recipients
• Darier disease
• Pityriasis rubra pilaris (PRP)
• Ichthyoses (e.g., lamellar ichthyosis)
• Grover disease (transient acantholytic dermatosis)
• Lichen planus
• Lupus erythematosus

Mechanism of Action

Acitretin exerts its effects by binding to cytosolic retinoic acid-binding protein (CRABP), which acts as an intracellular carrier, transporting the drug to the nucleus. In the nucleus, acitretin binds to two families of nuclear receptors: retinoic acid receptors (RARs) and retinoid X receptors (RXRs). These receptors form heterodimers or homodimers that bind to specific DNA regulatory sequences, known as retinoic acid response elements (RAREs), to modulate gene transcription. Acitretin has anti-inflammatory and anti-proliferative effects, and it helps normalize keratinocyte differentiation in the epithelium.

Adverse Effects and Monitoring

Acitretin is associated with various adverse effects that require close monitoring and management. Some of the key adverse effects include:

• Teratogenicity: Acitretin is a highly teratogenic drug, meaning it can cause severe birth defects. It is contraindicated in pregnancy and strict contraceptive measures are required for both male and female patients.
• Elevated lipid levels: Acitretin can lead to elevated triglyceride and cholesterol levels, which require monitoring and potentially the use of lipid-lowering medications.
• Liver toxicity: Periodic monitoring of liver function tests is necessary during acitretin therapy.
• Mucocutaneous effects: Acitretin can cause dryness of the skin, lips, and eyes, as well as other mucocutaneous side effects.
• Skeletal effects: Long-term use of acitretin may lead to changes in bone density and skeletal abnormalities.

Patients on acitretin require regular monitoring of their lipid profile, liver function, and other relevant parameters to ensure the safe and effective use of this medication.

Interprofessional Team Strategies

Optimal management of patients undergoing acitretin therapy requires an interprofessional team approach, including:

• Dermatologists: Responsible for prescribing and monitoring acitretin therapy, as well as managing any skin-related adverse effects.
• Primary care physicians: Involved in the overall management of the patient’s health, including monitoring for systemic adverse effects and coordinating care with other specialists.
• Pharmacists: Provide medication counseling, ensure appropriate dosing and monitoring, and identify potential drug interactions.
• Nurses: Educate patients on the proper use of acitretin, monitor for adverse effects, and coordinate care between the patient and the healthcare team.

By working together, the interprofessional team can effectively manage patients on acitretin therapy and optimize patient outcomes.

Conclusion

Acitretin is a synthetic retinoid medication primarily used for the treatment of severe psoriasis, both as a monotherapy and in combination with other therapies. While it is effective in managing certain skin conditions, acitretin is associated with a range of adverse effects that require close monitoring and management by an interprofessional healthcare team. Understanding the indications, mechanism of action, and safety profile of acitretin is crucial for providing optimal care to patients undergoing this treatment.