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Chronic Hand Eczema
Alitretinoin in Chronic Hand Eczema – From Clinical Trials to Clinical Practice
Thomas L Diepgen
Professor, Dermatology and Allergology, Ruprecht-Karls University, Heidelberg
Abstract
Chronic hand eczema (CHE) is a highly visible disease that can be debilitating and has a significant physical and emotional burden on
patients. Current treatment strategies for CHE involve elimination of causative factors and the use of moisturising agents. If this is
ineffective, topical corticosteroids can be used, although long-term use is limited by rebound flare-ups, tachyphylaxia and lack of efficacy
in patients with severe CHE. Treatment with systemic corticosteroids, off-label immunosuppressants or light therapy is the next step, but
these can be unsuitable for long-term use. Until recently there was no reliable treatment option for patients with severe CHE refractory to
topical corticosteroids. However, the recent introduction to the marketplace of alitretinoin could address this unmet medical need. In the
largest clinical trial conducted in CHE to date, the BACH study, once-daily oral treatment with 30mg of alitretinoin led to a clearing or almost
clearing of the hands in every second patient and a median 75% reduction of symptoms. Patients not responding to treatment in the BACH
study responded well to a second course of alitretinoin in an open-label extension study. A second course of alitretinoin was also
successful in the re-treatment of patients who had responded to treatment in the BACH study but subsequently relapsed. In all clinical
trials conducted to date, alitretinoin was generally well tolerated. Alitretinoin is currently the only clinical evidence-based treatment option
for CHE and is a suitable intermittent treatment option for the long-term management of this chronic relapsing disease.
Keywords
Alitretinoin, 9-cis-retinoic acid, chronic hand eczema
Disclosure: Thomas L Diepgen has received grants from Basilea Pharmaceutica International Ltd to conduct clinical studies in chronic hand eczema, including the BACH Study.
He has also received consultancy fees from Basilea Pharmaceutica International Ltd.
Received: 15 May 2009 Accepted: 20 May 2009
Correspondence: Thomas L Diepgen, University of Heidelberg, Department of Social Medicine, Occupational and Environmental Dermatology, Thibautstr. 3, 69115 Heidelberg,
thomas.diepgen@med.uni-heidelberg.de
Epidemiology, Burden and Current Treatment Strategies
Impact of Chronic Hand Eczema The current treatment strategy for CHE is a long-term disease
Hand eczema (HE) is among the most commonly diagnosed management process that is delivered through escalating steps.
5
The
dermatological diseases. It affects approximately 10% of the basic therapy comprises non-pharmacological skin protection
population
1,2
and up to 30% of high-risk occupational groups, such as measures, such as allergen identification and avoidance, the use of
hairdressers, bakers and nurses.
1
HE is a multifactorial disease. Factors moisterising agents and skin protection. Patient education is
contributing to its aetiology include genetic predisposition, impaired paramount in this step, which remains essential regardless of other
immune response, atopy and exposure to skin irritants or allergens.
3–5
In treatments used to manage the disease.
a substantial number of patients, HE develops into a chronic condition,
with disease remaining active even after an initial causative agent is The next step is topical treatment. In many CHE patients, topical
avoided.
6,7
Chronic HE (CHE) is defined either as a long-lasting, relapsing corticosteroids are effective in providing disease control, although
course of HE or HE that is unresponsive to standard treatment with their long-term use is limited by rebound flare-ups, tachyphylaxia and
emollients and topical corticosteroids. It is estimated that up to 7% of HE a lack of efficacy in patients with severe disease. Moreover, prolonged
patients are diagnosed as having severe CHE, and up to 4% are corticosteroid administration often causes skin atrophy and can
estimated to be unresponsive to standard treatment.
5
CHE is a contribute to additional weakening of the skin barrier. Phototherapy is
distressing condition that causes significant physical and emotional another topical treatment to be used in conjunction with other
problems and burdens for patients. Common physical symptoms of CHE treatments, but it is not widely available and has a considerable
include itching, painful fissures and blisters (see Figure 1), which can impact on patient lifestyle.
severely limit manual dexterity and function. This can affect the ability of
some patients to work, resulting in a socioeconomic burden on both The third and final step currently includes oral corticosteroids or off-
patient and society. Emotionally, the highly visible nature of the disease label treatment with immunosuppressants (such as methotrexate,
can lead to significant psychosocial problems, such as anxiety, low self- cyclosporine or azathioprine), which can provide patients with
esteem and social phobia.
5
temporary symptomatic relief.
5
However, such treatments are not
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