Acitretin in combination with UVB or PUVA

doi:10.1016/S0190-9622(99)70362-2

Journal of the American Academy of Dermatology

Volume 41, Issue 3, Supplement, September 1999, Pages S22-S24

https://doi.org/10.1016/S0190-9622(99)70362-2 Get rights and content

Abstract

Combination therapy of psoriasis with acitretin and phototherapy (psoralen–ultraviolet A [PUVA] or ultraviolet B [UVB]) offers multiple advantages over use of either modality alone. As monotherapy, acitretin in doses of 50 mg/day is moderately effective, but is associated with numerous side effects. Single modality treatment with UVB or PUVA involves multiple visits over a period of months and is also associated with dose-limiting side effects. When used in combination, lower doses of both modalities can be used more effectively, helping to reduce side effects. In addition, clearing occurs much more quickly, reducing treatment time and number of phototherapy visits. Moreover, patients whose psoriasis does not clear with monotherapy will often achieve significant clearing with the combination of acitretin and phototherapy. (J Am Acad Dermatol 1999;41:S22-4.)

Section snippets

ACITRETIN AND UVB

In combination with UVB, acitretin may be used in doses of 10 to 25 mg/day. At these relatively low doses, side effects such as hair loss, cheilitis, and minor musculoskeletal complaints occur less frequently. Typically with use of this combination, low-dose acitretin is started as a single agent for 2 weeks. UVB treatments are then added to the regimen, and the combination is continued for at least 4 more weeks. Because acitretin, like other retinoids, can cause thinning of the stratum

ACITRETIN AND PUVA

In combination with PUVA, as with UVB, acitretin may be used in relatively low doses of 10 to 25 mg/day. UVA doses are decreased by 50%, but a standard dose of psoralen is used. Acitretin is started 1 to 2 weeks before initiation of PUVA treatment.

In one randomized, double-blind trial, the acitretin–PUVA combination resulted in remission in 89% of patients after 8 weeks and 94% after 12 weeks compared with a remission rate of 35% at 8 weeks and 80% at 12 weeks in patients treated with

PALMOPLANTAR PUSTULAR PSORIASIS

The combination of PUVA and acitretin has proven effective in cases in which monotherapy with either agent has failed. One particularly challenging form of psoriasis often refractory to monotherapy is pustular psoriasis of the palms and soles. In the case of palmoplantar pustular psoriasis shown in Fig 1, the patient had been treated with PUVA therapy alone for 3 months with little improvement.

. Effect of combination therapy with acitretin and PUVA in patient with palmopustular psoriasis

CONCLUSION

Acitretin used in combination with phototherapy with UVB or PUVA in the treatment of psoriasis allows lower doses of both modalities to be used, resulting in fewer side effects. In these combinations, acitretin is used in doses of 10 to 25 mg/day and is generally started 1 to 2 weeks before initiation of phototherapy. Doses of UVB or UVA should be reduced by 50% and fewer phototherapy visits are typically required. In many cases, the combination is more effective than either phototherapy or

References (10)

AK Gupta et al.
Side-effect profile of acitretin therapy in psoriasis
J Am Acad Dermatol
(1989)
NJ Lowe et al.
Acitretin plus UVB therapy for psoriasis. Comparisons with placebo plus UVB and acitretin alone
J Am Acad Dermatol
(1991)
A Tanew et al.
Photochemotherapy for severe psoriasis without or in combination with acitretin: a randomized, double-blind comparison study
J Am Acad Dermatol
(1991)
HP Gollnick
Oral retinoids: efficacy and toxicity in psoriasis
Br J Dermatol
(1996)
WL Morison et al.
Consensus workshop on the toxic effects of long-term PUVA therapy
Arch Dermatol
(1998)

There are more references available in the full text version of this article.

Cited by (79)

Role of phototherapy in the era of biologics
2021, Journal of the American Academy of Dermatology
Citation Excerpt :
The concomitant administration of acitretin with NB-UVB has been found to hasten clinical response, reduce the required acitretin dose, and decrease the number of phototherapy sessions by approximately 20%, thereby lowering the cumulative UV dose and theoretical risk for photocarcinogenesis.14,38,40 Similar effects have been observed with acitretin plus PUVA, and given the established skin cancer risk with this modality, the coadministration of an oral retinoid is particularly valuable.40-43 Because retinoids have a keratolytic effect, phototherapy dose escalations must be proceeded with cautiously when using this combination.14
Phototherapy is a safe and effective treatment for many dermatologic conditions. With the advent of novel biologics and small molecule inhibitors, it is important to critically evaluate the role of phototherapy in dermatology. Surveys have shown that many dermatology residency programs do not dedicate time to teaching residents how to prescribe or administer phototherapy. Limitations of phototherapy include access to a center, time required for treatments, and insurance approval. Home phototherapy, a viable option, is also underused. However, it should be emphasized that modern phototherapy has been in use for over 40 years, has an excellent safety profile, and does not require laboratory monitoring. It can be safely combined with many other treatment modalities, including biologics and small molecule inhibitors. In addition, phototherapy costs significantly less than these novel agents. Dermatologists are the only group of physicians who have the expertise and proper training to deliver this treatment modality to our patients. Therefore, to continue to deliver high-quality, cost-effective care, it is imperative that phototherapy be maintained as an integral part of the dermatology treatment armamentarium.
Joint American Academy of Dermatology–National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies
2020, Journal of the American Academy of Dermatology
Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 2% of the world's population. In this guideline, we focus the discussion on systemic, nonbiologic medications for the treatment of this disease. We provide detailed discussion of efficacy and safety for the most commonly used medications, including methotrexate, cyclosporine, and acitretin, and provide recommendations to assist prescribers in initiating and managing patients on these treatments. Additionally, we discuss newer therapies, including tofacitinib and apremilast, and briefly touch on a number of other medications, including fumaric acid esters (used outside the United States) and therapies that are no longer widely used for the treatment of psoriasis (ie, hydroxyurea, leflunomide, mycophenolate mofetil, thioguanine, and tacrolimus).
Acitretin
2016, Therapy for Severe Psoriasis
Guidelines for phototherapy of mycosis fungoides and Sézary syndrome: A consensus statement of the United States Cutaneous Lymphoma Consortium
2016, Journal of the American Academy of Dermatology
Citation Excerpt :
Retinoids decrease the thickness of the epidermis,110 enhancing UV penetration and causing a more brisk response to UV exposure. There are data to support the safe use of PUVA with etretinate67 and, by extension, other retinoids, including acitretin,111 isotretinoin,67 and bexarotene112,113 in patients with MF or psoriasis. In psoriasis, both the number of PUVA treatments and the total amount of UVA exposure to achieve CR are decreased with the addition of an oral retinoid to a regimen of PUVA.111
Ultraviolet light (UVL) is a long established treatment for mycosis fungoides (MF) and Sézary syndrome (SS), subtypes of cutaneous T-cell lymphoma (CTCL). Treatments have traditionally included broadband, narrowband ultraviolet B light (UVB) and psoralen plus ultraviolet A light photochemotherapy (PUVA), but more recently, treatment options have expanded to include UVA1 and excimer laser. UVL is used either as monotherapy or as an adjuvant to systemic therapy, demonstrating efficacy in many cases that equal or surpass systemic medications. Despite its utility and duration of use, the current practice of using UVL guidelines for psoriasis to treat patients with MF/SS is problematic because the goals of prolonging survival and preventing disease progression are unique to CTCL compared to psoriasis.
We sought to develop separate guidelines for phototherapy for MF/SS for both clinical practice and for clinical trials.
Literature review and cutaneous lymphoma expert consensus group recommendations.
This paper reviews the published literature for UVB and UVA/PUVA in MF/SS and suggests practical standardized guidelines for their use.
New standardization of phototherapy.
These guidelines should allow the comparison of results with phototherapy in MF/SS across different stages of patients, centers, and in combination with other agents in practice and in clinical trials.
Phototherapy of Mycosis Fungoides
2015, Dermatologic Clinics
Cytotoxic and genotoxic effects of acitretin, alone or in combination with psoralen-ultraviolet A or narrow-band ultraviolet B-therapy in psoriatic patients
2013, Mutation Research - Genetic Toxicology and Environmental Mutagenesis
Acitretin is currently used alone or combined with PUVA (psoralen + UVA) or with narrow-band ultraviolet B (NBUVB), to treat moderate and severe psoriasis. However, little is known about the potential genotoxic/carcinogenic risk and the cytostatic/cytotoxic effects of these treatments. Our aim was to study the cytotoxic and genotoxic effects of acitretin – alone or in combination with PUVA or NBUVB – by performing studies with blood from patients with psoriasis vulgaris who were treated with acitretin, acitretin + PUVA or acitretin + NBUVB for 12 weeks, and in vitro studies with blood from healthy volunteers, which was incubated with acitretin at different concentrations. The cytotoxic and genotoxic effects were evaluated by the cytokinesis-blocked micronucleus test and the comet assay. Our results show that psoriatic patients treated with acitretin alone or with acitretin + NBUVB, did not show genotoxic effects. In addition, these therapies reduced the rate of proliferation and induced apoptosis and necrosis of lymphocytes; the same occurred with lymphocyte cultures incubated with acitretin (1.2–20 μM). The acitretin + PUVA reduced also the proliferation rate, and increased the necrotic lymphocytes. Our studies suggest that therapy with acitretin alone or combined with NBUVB, as used in psoriatic patients, does not show genotoxic effects, reduces the rate of proliferation and induces apoptosis and necrosis of lymphocytes. The combination of acitretin with PUVA also reduces the proliferation rate and increases the number of necrotic lymphocytes. However, as it induced slight genotoxic effects, further studies are needed to clarify its genotoxic potential.

View all citing articles on Scopus

^☆: From the Department of Dermatology, The Mount Sinai School of Medicine, New York.

^☆☆: This manuscript is based on a presentation given at the 5th European Congress on Psoriasis/7th International Psoriasis Symposium in Milan, Italy on September 2, 1998, with support from Roche Laboratories, Inc., Nutley, NJ.

^★: Reprint requests: Mark Lebwohl, MD, One Gustave L. Levy Place, New York, NY 10029.

^★★: 0190-9622/99/$8.00 + 0 16/0/100484

View full text

Acitretin in combination with UVB or PUVA☆,☆☆,★,★★

Abstract

Section snippets

ACITRETIN AND UVB

ACITRETIN AND PUVA

PALMOPLANTAR PUSTULAR PSORIASIS

CONCLUSION

J Am Acad Dermatol

J Am Acad Dermatol

J Am Acad Dermatol

Oral retinoids: efficacy and toxicity in psoriasis

Br J Dermatol

Consensus workshop on the toxic effects of long-term PUVA therapy

Arch Dermatol