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An Oral Retinoid Could Come in Handy

Alitretinoin was effective for treating stubborn eczema of the hands.

Previous studies have shown that alitretinoin (9-cis-retinoic acid) helped heal hand eczema (see Arch Dermatol 2004; 140:1453 and Dermatology 1999; 199:308). In a new study, investigators assessed whether administration of oral alitretinoin was more likely than placebo to "clear" or "nearly clear" chronic hand eczema. They enrolled 1032 subjects at 111 outpatient clinics; entry criteria were having had severe chronic hand eczema for at least 6 months despite avoiding irritants and allergens and having been refractory to treatment with topical steroids for at least 8 weeks, including 4 weeks with superpotent topical steroids, such as clobetasol proprionate. Patients were excluded if they had psoriasis, atopic dermatitis treated with prescription medications, infections, or allergic contact dermatitis from allergens they could not avoid.

Participants were randomized to treatment with 10 mg alitretinoin, 30 mg alitretinoin, or placebo, given orally once daily for up to 24 weeks. They were allowed to use emollients but not topical steroids or a listed array of other possibly helpful drugs. Scoring was based on physician global assessment and on patient global assessment, and on the modified total lesion severity symptom score.

At assessment, nearly half (48%) the participants treated with the 30-mg dose were clear (22%) or almost clear (26%). Of recipients of the 10-mg dose, more than one quarter (27%) were clear (9%) or almost clear (18%). Only 17% of the placebo group were clear (3%) or almost clear (14%). Differences between treatment and placebo recipients were highly significant in favor of the active agent (30 mg, P<0.001; 10 mg, P=0.004). The most common side effect was headache, and investigators observed such typical retinoid side effects as dry lips, cheilitis, increases in cholesterol and triglycerides, and reduced thyroid-stimulating hormone levels.

Comment: It seems counterintuitive that systemic retinoids (which cause rough, scaling skin and barrier dysfunction) would help chronic hand dermatitis, but alitretinoin does so. I found no studies of other oral retinoids to treat chronic eczematous hand dermatitis. The study is well designed and adequately powered. Having alitretinoin as another oral agent to help patients with chronic hand eczemas would be nice. The annual prevalence of hand eczema is about 7% to 12%, and many eczemas can be stubborn about responding to usual treatments.

— Mark V. Dahl, MD

Published in Journal Watch Dermatology March 21, 2008

Citation(s):

Ruzicka T et al. Efficacy and safety of oral alitretinoin (9-cis retinoic acid) in patients with severe chronic hand eczema refractory to topical corticosteroids: Results of a randomized, double-blind, placebo-controlled, multicentre trial. Br J Dermatol 2008 Feb 21; [epub ahead of print]. (http://dx.doi.org/10.1111/j.1365-2133.2008.08487.x)