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Retinoid (Systemic)

Alitretinoin

Brand names: Toctino

Adult dose

Dose: 30 mg once daily; reduce to 10 mg once daily if not tolerated
Route: Oral
Frequency: Once daily with main meal

Clinical pearls

  • Indicated for severe chronic hand eczema refractory to potent topical corticosteroids (NICE TA177)
  • Pregnancy Prevention Programme (PPP) is mandatory — negative pregnancy test before starting and monthly
  • Prescribers, pharmacists, and patients must be enrolled in the PPP (Toctino REMS programme)
  • Effect may persist months after stopping — do not re-treat within 4 weeks of completing course
  • Efficacy seen in 50–70% of patients by 12–24 weeks
  • Can be restarted if eczema recurs — reassess PPP compliance

Contraindications

  • Pregnancy — teratogenic (Pregnancy Prevention Programme mandatory)
  • Breastfeeding
  • Hepatic impairment
  • Severe renal impairment
  • Hyperlipidaemia (uncontrolled)
  • Hypervitaminosis A
  • Concomitant tetracyclines (risk of benign intracranial hypertension)

Side effects

  • Headache (common — monitor for signs of intracranial hypertension)
  • Dry skin, lips, eyes (retinoid class effect)
  • Hyperlipidaemia (triglycerides and cholesterol)
  • Elevated liver enzymes
  • Arthralgia/myalgia
  • Depression and mood changes (rare)
  • Anaemia, neutropenia (rare)

Interactions

  • Tetracyclines — increased risk of benign intracranial hypertension; contraindicated
  • Vitamin A supplements — avoid (additive hypervitaminosis A risk)
  • Methotrexate — additive hepatotoxicity; avoid
  • Progestin-only contraceptives — may be less reliable; use additional contraception
  • CYP3A4 inducers (rifampicin, phenytoin) — may reduce alitretinoin levels

Monitoring

  • Pregnancy test before treatment, monthly during, and 1 month after stopping
  • Fasting lipid profile at baseline, 1 month, then every 3 months
  • Liver function tests at baseline and periodically
  • Blood count
  • Mood/mental health assessment

Reference: BNF; NICE TA177 (Alitretinoin for chronic hand eczema, 2009); MHRA Drug Safety Update (Retinoids — Pregnancy Prevention Programme, 2020); BAD Guidelines on hand eczema; https://bnf.nice.org.uk/drugs/alitretinoin/. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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