What is Acrozutin and how is it treated?

Acitretin (Acrozutin): Overview and Management

Acitretin (commonly referred to as Acrozutin in some regions) is an oral retinoid medication primarily used to treat severe psoriasis and other keratinization disorders that requires careful monitoring and management due to its significant side effect profile and teratogenic potential.

What is Acitretin?

Acitretin is a second-generation retinoid (vitamin A derivative) that modulates epidermal differentiation and proliferation while also providing anti-inflammatory and immunomodulatory effects 1. Unlike many other systemic treatments for psoriasis, acitretin is not immunosuppressive, making it valuable in certain clinical scenarios.

Clinical Applications

Acitretin is particularly effective for:

• Severe plaque psoriasis
• Erythrodermic psoriasis
• Generalized pustular psoriasis
• Palmoplantar psoriasis (both pustular and hyperkeratotic forms)

It shows remarkable efficacy in pustular forms of psoriasis, with studies reporting improvement in 84% of patients with pustular psoriasis 1. The response in pustular psoriasis can be quite rapid and dramatic compared to its effects on plaque psoriasis.

Dosing Protocol

The British Association of Dermatologists guidelines recommend the following dosing approach 1:

1. Initial phase: Start with 25-30 mg daily for 2-4 weeks
2. Maintenance phase: Adjust to 25-50 mg daily for 6-8 weeks based on clinical efficacy and tolerability
3. Maximum dose: Up to 75 mg daily in some cases
4. Treatment duration: Typically 3-6 months to reach peak response

Gradual dose escalation is recommended to allow patients to develop tolerance to side effects 1. The medication should be taken once daily with meals or milk to enhance absorption.

Monitoring Requirements

Regular monitoring is essential due to potential adverse effects:

• Liver function tests: Every 2-4 weeks for first 2 months, then every 3 months
• Lipid profile: Every 2-4 weeks for first 2 months, then every 3 months
• Blood glucose (in diabetic patients): Similar intervals with more frequent capillary glucose monitoring during first few weeks

Critical Laboratory Thresholds:

• Liver function: Discontinue if transaminases reach 3× upper limit of normal
• Bilirubin > 50 μmol/L or ALT > 200 IU/L: Refer to gastroenterology
• Triglycerides > 5 mmol/L: Refer to lipidologist
• Triglycerides > 10 mmol/L: Discontinue acitretin and urgently refer to lipidologist due to risk of acute pancreatitis

Major Adverse Effects

1. Mucocutaneous effects: Dry lips, dry skin, hair thinning, nail fragility
2. Hepatotoxicity: Elevated liver enzymes
3. Hyperlipidemia: Elevated cholesterol and triglycerides
4. Skeletal changes: Hyperostosis (with long-term use)
5. Teratogenicity: Severe birth defects

Contraindications and Precautions

The most significant concern with acitretin is its teratogenic potential. Key precautions include:

• Absolute contraindication in pregnancy
• Contraception required for 3 years after discontinuation in women of childbearing potential
• Avoid in patients with significant hepatic dysfunction
• Caution in patients with hyperlipidemia

Combination Therapy

Acitretin can be effectively combined with phototherapy:

• Combination with NB-UVB or PUVA shows greater efficacy than monotherapy
• Allows lower doses of both acitretin and phototherapy, reducing cumulative toxicity
• More convenient and cost-effective for patients 1

Treatment Algorithm

1. Patient selection: Determine if patient has severe psoriasis (especially pustular or erythrodermic forms) that warrants systemic therapy
2. Contraindication screening: Ensure patient is not pregnant, not planning pregnancy, and has normal baseline liver function and lipid profile
3. Initiation: Start with 25-30 mg daily with food
4. Monitoring: Perform baseline and follow-up laboratory tests as outlined above
5. Dose adjustment: Titrate dose based on clinical response and tolerability
6. Maintenance: Continue until satisfactory improvement, then consider discontinuation
7. Relapse management: Restart using same protocol if disease relapses

Common Pitfalls and Caveats

1. Pregnancy prevention: The 3-year contraception requirement after discontinuation is frequently underemphasized but critically important
2. Alcohol consumption: Should be minimized or avoided due to additive hepatotoxicity
3. Drug interactions: Limited compared to other systemic agents, but should be considered
4. Lipid management: Dietary measures should be tried before considering lipid-lowering medications
5. Patient expectations: Inform patients that response is gradual and may take 3-6 months to reach peak effect

Acitretin therapy should be initiated and supervised by a dermatologist experienced in managing systemic retinoids and their potential adverse effects 1.