2 The technology
2.1 Oral alitretinoin (Toctino, Basilea Pharmaceuticals) is indicated for use in adults who have severe chronic hand eczema that is unresponsive to treatment with potent topical corticosteroids. 'Severe' chronic hand eczema (that is, marked signs of eczema, or oedema, fissures or functional impairment) is defined using the physician's global assessment (PGA; see section 3.2).
2.2 The recommended dosage is 30 mg once daily for 12–24 weeks. The dosage can be reduced to 10 mg once daily if there are unacceptable adverse effects. The summary of product characteristics (SPC) specifies that if a person still has severe disease after the first 12 weeks, stopping treatment should be considered. In the event of relapse, further treatment courses may be of benefit.
2.3 Alitretinoin is a derivative of retinoic acid (9-cis-retinoic acid) that binds to and activates intracellular retinoid receptors. These receptors regulate cellular differentiation and proliferation.
2.4 The most frequent adverse effects seen with alitretinoin include headache, dry mouth, anaemia, flushing and erythema. Increases in cholesterol and triglyceride levels (hyperlipidaemia) have also been observed. Adverse effects are generally dose related and reversible. Alitretinoin is teratogenic and therefore contraindicated in women of childbearing potential unless all of the conditions of the Pregnancy Prevention Programme (as outlined in the SPC) are met. Alitretinoin should not be prescribed if the person's eczema can be adequately controlled by standard measures, including skin protection, avoiding allergens and irritants, and treatment with potent topical corticosteroids. For full details of side effects and contraindications, see the SPC.
2.5 Alitretinoin costs £411.43 for a pack of 30 × 30-mg capsules (excluding VAT; 'British national formulary' [BNF] edition 57). Costs may vary in different settings because of negotiated procurement discounts.