Clinical Experience Etretinate and Acitretin for HS

Etretinate and acitretin were of great benefit in all ten patients with HS, as described in five case reports [33-38]. In 1984 Stewart [34] was the first to report on HS treatment with etretinate in a study of six patients; four other case reports followed in the period from 1988 until 2002 [35-38]. The data are summarized in Table 17.3.

Overall, eight patients were treated with 17 etretinate at a dose of 0.35-1.0 mg/kg per day [34, 36, 37] and two patients with acitretin at a dose of 0.5-1.0 mg/kg per day [35, 38]. Six out of ten patients were on isotretinoin (0.8-2 mg/kg per day) before starting etretinate and acitretin, of whom two were in Stewart's series [34] and their dosage is not mentioned. The results were unsatisfactory in all cases. The doses of isotretinoin were usually high, i.e., two full courses for

4 months of isotretinoin at a dose of 1.4 and 2.0 mg/kg per day, respectively [38]; two courses at a dose of 0.8 mg/kg per day for 4 and 3 months, respectively [36]; two full courses for 5 months at a dose of 2 mg/kg per day [35], and in one patient a 4-month course of isotretinoin (1 mg/ kg per day), which cleared the patient's acne conglobata but was singularly unhelpful for his HS lesions [37]. Stewart [34] treated his six patients with ongoing doses of etretinate and they were observed over periods of 6-39 months. After 3 months of treatment, three patients showed good clearing of disease (50%-75%) and after 12 months of treatment all patients eventually had an excellent response. The criteria for clearing in the HS patients were: disappearance of sinuses and cessation of discharge. Two patients were taken off etretinate, and it took 4 months for them to begin to show signs of disease recurrence (increasing discharge and formation of the old sinus tracts). Hogan and Light [35] treated a 24-year-old women with a 6-month course of acitretin at a dosage of 0.5 mg/kg per day. After 2 months of treatment with acitretin a 50% decrease in induration of the axillae was noted. After 4 months of treatment there was no longer any induration or abscess formation in her axillae. Her HS remained in remission until 11 months after discontinuation of acitretin. Therapy was reinstituted with success [35].

Vahlquist and Griffiths [36] treated a 47-year-old man with etretinate (0.7 mg/kg per day). Within a few weeks the lesions had become less painful. After a treatment period of 11 months, the patient was essentially free of active lesions and the etretinate therapy was discontinued. Although scarring was still a problem, the patient had no longer pain. A minor relapse was recorded 1 year after stopping etret-inate and this was successfully controlled by a short course of oral antibiotics [36]. Chow and Mortimer [37] treated a 31-year-old man with etretinate (0.5 mg/kg per day) for 9 months, the first 3 months together with erythromycin 1 g daily. Within 2 months, he was showing signs of improvement, with less pain, less discharge, and a decrease in the number of acute exacerbations. After 3 months there was no sign of disease activity, although linear fibrotic bands of scarring remained. Disease was still in remis-

Table 17.3. Reported results of etretinate/acitretin therapy for hidradenitis suppurativa (HS)

Author (s)

No. of patients, sex, age (in years)

Region

Retinoid dose (mg/kg per day)

Duration of treatment (months)

(years)

Improvement1

At the end of treatment

At the end of follow-up

Stewart [34]

3F: 34, 36, 64 3M: 31, 32, 55

Mixed

Etretinate 0.35-1.1

3-39

3-39

No data

Clearb

Clear with ongoing treatment

Hogan and Light [35] 0.5

At least 11 months

Acitretin 10

clear

Mild flare 11 months; clear with acitretin

Vahlquist and Griffiths [36]

1M: 47

Buttocks

Etretinate 0.7

11

Years

12

clear

Minor flare 12 months; clear with antibiotics

Chow and Mortimer [37]

1M: 31

Mixed

Etretinate 0.5

12

3

5

clear

Clear

Scheman [38] 0.6-0.9

1M: 41 12

Groin 12

Acitretin No data

clear

Clear with ongoing treatment

a Clear defined as no disease activity; fibrotic bands and scarring remain b Two patients discontinued etretinate after 3 months, for reasons not mentioned

sion 3 months after stopping etretinate [37]. Scheman [38] treated a 41-year-old man, who presented with severe nodulocystic facial acne and HS on the inguinal folds, with acitretin (0.6 mg/kg per day). After 2 months, the patient's HS was completely controlled, and his very severe acne improved to only a few inflamed nondraining facial cysts. With a dosage of acitretin of 0.9 mg/kg per day the patient was completely free of inflammatory lesions on his face and groin. After 4 months on this dosage, however, alopecia and unacceptable joint pain developed. After 1 month off acitretin, the patient's side-effects resolved. Treatment was resumed back at a dose of 0.6 mg/kg per day, with results similar to those when the patient was previously on this dosage. After 5 months of therapy, improvement continued to be satisfactory [38].

It is of concern that no controlled studies have been published. Nevertheless, there seem to be some striking points in these case studies. All patients (n=10) treated with etretinate or acitretin at a dose of 0.35-1.1 mg/kg per day responded excellently. All patients were essentially free of active lesions [36], and were completely free of inflammatory cysts [38] and sinus tracts [34]; any induration and abscess formation disappeared [35-37], although linear fibrotic bands of scarring remained [36, 37]. These excellent responses were obviously not obtained by earlier courses with isotretinoin in the same patients. In addition, the decrease of disease activity seemed to start after approximately 2 months of treatment. However, in a panel discussion Cun-liffe stated that their group treated three or four patients with etretinate without too much success (unpublished observations). The treatment with etretinate was stopped after 6 or 8 months [39].

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