Palmoplantar keratodermas

Acitretine ch3o x x Oral 0.25-1.0 mg/kg/d Psoriasis (erythrodermic, pustular, and severe recalcitrant) Palmoplantar keratoderma pustulosis palmoplantaris, icthyosis, Darier s disease, pityriasis rubra pilaris, lichen ruber planus... 

Acitretin is most useful for the treatment of severe psoriasis, particularly the pustular and erythrodermic variants. Psoriatic nail changes and arthritis also may respond. Combining the drug with ultraviolet light therapy (Re-UVB, in the case of ultraviolet B radiation, or Re-PUVA, with psoralen plus ultraviolet A radiation) permits the use of lower doses of both acitretin and ultraviolet radiation. Other conditions for which the drug may be especially useful include congenital and acquired hyperkeratotic disorders, such as the ichthyoses and palmoplantar keratodermas, and severe lichen planus. 

In 1990, etretinate (Tigason) was replaced by acitretin (Neo-Tigason), an aromatic retinoid, a carboxylic acid metabolite of etretinate (15). It is effective in pustular psoriasis and psoriatic palmoplantar keratoderma and in combination with PUVA or topical therapy (calci-potriol or glucocorticoids) in the treatment of other forms of psoriasis. It has also been used to treat disorders of keratinization (ichthyosis, palmoplantar keratoderma, Darier s disease) and severe cutaneous forms of lichen planus. It prevents new skin carcinomas in patients with xeroderma pigmentosum and those who are immunosuppressed. The main advantage of acitretin is its short half-life of 50 hours, compared with over 80 days for etretinate (16). 

A case of palmoplantar keratoderma, scleroderma and chloracne was reported in an agricultural worker who had been a weed sprayer for 5 years. He had used 2,4,5-trichlorophenoxyacetic acid and/or 2,4 dichloro-phenoxyacetic acid, both of which may contain chlorinated dibenzodioxins as impurities. He also had been chronically exposed to multiple other, non-chloracne associated herbicides, some of which have been associated with scleroderma. Safety equipment was not utilized (Poskitt et al. 1994). 

Unusual responses to therapy have been that palmoplantar blistering was enhanced by etretinate during therapy of patients with keratoderma palmaris et plantaris (epidermolytic type), epidermolytic hyperkeratosis, and pachyonychia congenita. Patients with Hailey-Hailey disease and atopic dermatitis have worsened with both retinoids. 

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