What to do with acitretin (Soriatane) in a patient with a history of psoriasis who develops an infection?

Acitretin Management During Infection in Psoriasis Patients

Continue acitretin during infection—unlike immunosuppressive agents, acitretin does not cause significant immunosuppression and does not require discontinuation when infections develop. 1

Key Distinction: Acitretin is NOT Immunosuppressive

Acitretin fundamentally differs from other systemic psoriasis therapies (methotrexate, cyclosporine, biologics) because it lacks immunosuppressive properties. 2, 3, 4 This critical characteristic makes it uniquely safe for continued use during active infections.

Direct Guideline Recommendations

• The American Academy of Dermatology explicitly states that acitretin does not cause significant immunosuppression and there is no contraindication to using acitretin in patients with active infections. 1

• In contrast, biologic therapies must be held when patients develop serious infections requiring antibiotic therapy, and treatment should not resume until the infection has resolved. 2

• Acitretin is specifically recommended as safe for psoriasis patients with chronic infections (HIV, hepatitis B, hepatitis C) or malignancy who have contraindications to immunosuppressive therapy. 4, 5

Practical Management Algorithm

For patients on acitretin who develop an infection:

1. Continue acitretin at the current dose 1
2. Treat the infection appropriately with antimicrobials as indicated
3. Monitor for specific acitretin-related infection considerations:
   • Increased incidence of vulvovaginal candidiasis (Candida albicans) may occur during acitretin treatment 1
   • If prescribing tetracyclines for infection, immediately discontinue acitretin due to risk of pseudotumor cerebri (benign intracranial hypertension) 1

Important Caveats

Drug Interaction Warning

Never combine acitretin with tetracycline-class antibiotics (tetracycline, doxycycline, minocycline) as this combination is absolutely contraindicated due to risk of pseudotumor cerebri. 1 If a tetracycline is required for infection treatment, acitretin must be stopped first.

Surgical Considerations

Acitretin does not significantly affect wound healing and does not need to be stopped for routine surgery, further supporting its safety profile during potential infectious complications. 1

When to Reconsider Acitretin

If the patient requires escalation to immunosuppressive therapy for inadequate psoriasis control, then infection management becomes more complex and would follow the guidelines for immunosuppressive agents (holding therapy during serious infections). 2