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Systemic retinoid (Vitamin A derivative) Pregnancy: ABSOLUTELY CONTRAINDICATED. Major teratogen. 3-year contraception requirement after stopping.

Acitretin

Brand names: Neotigason

Adult dose

Dose: 25–50 mg once daily; severe psoriasis up to 75 mg/day
Route: Oral (take with food to optimise absorption)
Frequency: Once daily
Max: 75 mg/day
Severe psoriasis/palmoplantar pustulosis: start 25 mg OD, increase to 25–50 mg after 4 weeks. Severe congenital ichthyosis: higher doses under specialist supervision. Must not be prescribed to women of childbearing potential without Pregnancy Prevention Programme.

Paediatric dose

Dose: 0.5 mg/kg
Route: Oral
Frequency: Once daily
Max: 1 mg/kg/day
Severe ichthyosis (specialist only): 0.5–1 mg/kg/day. Not routinely used in children except for severe inherited disorders of cornification. Annual retinal and ophthalmological review.

Dose adjustments

Renal

Use with caution in renal impairment; increased levels possible.

Hepatic

Avoid in severe hepatic impairment; hepatotoxic.

Paediatric weight-based calculator

Severe ichthyosis (specialist only): 0.5–1 mg/kg/day. Not routinely used in children except for severe inherited disorders of cornification. Annual retinal and ophthalmological review.

Clinical pearls

  • Pregnancy absolutely contraindicated during and for 3 years after stopping (long tissue retention)
  • Women must use 2 forms of highly effective contraception (not progestin-only pill alone)
  • Pregnancy Prevention Programme card must be signed by patient before prescribing
  • Alcohol converts acitretin back to its metabolite etretinate (even longer half-life) — complete abstinence essential
  • Annual LFTs, fasting lipids, and blood glucose monitoring

Contraindications

  • Pregnancy (must avoid for 3 years after stopping)
  • Women of childbearing potential without Pregnancy Prevention Programme
  • Breastfeeding
  • Severe hepatic or renal impairment
  • Hyperlipidaemia refractory to treatment
  • Tetracycline co-prescription (raised ICP)

Side effects

  • Teratogenicity (major — Category X)
  • Dry skin, lips (cheilitis), mouth, and eyes
  • Hyperlipidaemia (triglycerides, LDL)
  • Hepatotoxicity (elevated LFTs)
  • Musculoskeletal effects (joint pain, myalgia)
  • Night blindness
  • Hair thinning
  • Pseudotumor cerebri (especially with tetracyclines)

Interactions

  • Tetracyclines — contraindicated (increased intracranial pressure — pseudotumour cerebri)
  • Vitamin A supplements — avoid (toxicity)
  • Methotrexate — avoid combination (additive hepatotoxicity)
  • Progestin-only contraceptives (mini-pill) — unreliable contraception (acitretin reduces efficacy)

Monitoring

  • Fasting lipids (baseline, 4 weeks, then 3-monthly)
  • LFTs (baseline, monthly initially, then 3-monthly)
  • Pregnancy tests (monthly)
  • Ophthalmology (if visual symptoms)

Reference: BNFc; BNF; BAD Psoriasis Guidelines; MHRA Retinoid Pregnancy Prevention Programme. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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