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Efficacy of treatment with oralalitretinoin in patient suffering fromlichen simplex chronicus and severe

atopic dermatitis of handsAngelo Massimiliano DErme*, Nicola Milanesi*,Arianna Fay Agnoletti, Vincenza Maio, Daniela Massi &Massimo Gola**Allergological and Occupational Dermatology Unit, Department of Surgeryand Translational Medicine, University of Florence, Florence, DISSALSection of Dermatology San Martino-IRCCS, Genoa, and Division ofPathological Anatomy, Department of Critical Care Medicine and Surgery,University of Florence, Florence, Italy

ABSTRACT: Lichen simplex chronicus (LSC) is a skin disorder characterized by chronic itching andscratching, which can lead to thick, leathery, brownish skin, sometimes with papules and can beassociated with atopic eczema. We report the case of a 52-year-old man with a 45-year atopic conditionand presenting LSC in his dorsum. After a 3-month treatment with alitretinoin at the daily dosage of30 mg, we have observed a moderate improvement of the hand eczema together with a substantialclinical improvement of LSC and an almost complete resolution of pruritus. We want to report thispeculiar case to suggest the use of oral alitretinoin for LSC.

KEYWORDS: alitretinoin, atopic dermatitis, lichen simplex chronicus

Introduction

Lichen simplex chronicus (LSC) is a skin disordercharacterized by chronic itching and scratch-ing, which can lead to thick, leathery, brownishskin, sometimes with papules and can be asso-ciated with atopic eczema. Standard thera-peutic options include topical corticosteroids,calcineurin inhibitors, phototherapy, retinoids,psychopharmacological agents, systemic corti-costeroids, and other immunomodulatory agents

Address correspondence and reprint requests to: AngeloMassimiliano DErme, MD, Allergological and OccupationalDermatology Unit, Department of Surgery and TranslationalMedicine, University of Florence, Piazza dellIndipendenza 11,50129 Florence, Italy, or email: a.m.derme@gmail.com.Learning Points: Alitretinoin can represent an effective drugfor the treatment of lichen simplex chronicus and atopicdermatitis of hands.The authors declare no affiliation or significant financialinvolvement in any organization or entity with a directfinancial interest in the subject matter or materials discussedin the following manuscript.

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Dermatologic Therapy, Vol. 27, 2014, 2123Printed in the United States All rights reserved

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DERMATOLOGIC THERAPYISSN 1396-0296

such as cyclosporin A and combinations thereof(1).

Alitretinoin (9-cis-retinoic acid) is a novelendogenously occurring vitamin A derivative,which binds both retinoic acid receptors and retin-oid X receptors. It has recently been licensed inItaly for oral treatment of severe chronic handeczema (CHE) unresponsive to potent topical cor-ticosteroids (2,3).

In the literature, only one case has beendescribed reporting the efficacy of alitretinoin inextrapalmar atopic eczema (4). The authorsreported the successful oral alitretinoin treatmentof six patients suffering from diffuse atopic eczemaassociated with atopic CHE lesions, whereas noreports are available regarding its potential use inatopic eczema.

Report

We report the case of a 52-year-old man with a45-year history of atopy and atopic eczema.

At the first medical examination, he presentedwith chronic and severe hand eczema and ery-thematous and scratched nonconfluent papu-les involving the dorsum (between shouldersand the neck area) (FIG. 1A). He referred severepruritus.

These lesions had been present for more than ayear and had become permanent. The previousyear, the patient had carried out a cycle of 12 nar-rowband UVB sessions, which he had to stopbecause he did not tolerate the treatment.Moreover, he resulted unresponsive to potenttopical corticosteroids both on hands and on thedorsum.

During the first visit, the patient underwentallergological examination and cutaneous biopsyof a lesion on the dorsum.

The skin prick test with common allergensrevealed positive atopy markers to pollen and der-matophagoides pteronyssinus. Patch tests werecarried out according to International Contact Der-matitis Research Group (ICDRG) recommenda-tions with standard and additional allergens. AtDay 4, the patient showed no reaction to theallergens of standard SIDAPA (Italian Society ofAllergological, Occupational and EnvironmentalDermatology) series.

Histopathological examination showed aspongiotic dermatitis associated to a sparsesuperficial dermal inflammatory infiltrate withlymphocytes, rare eosinophils, and melanophages(FIG. 1B).

These findings led to the diagnosis of LSC of thedorsum in patient suffering from atopic dermatitisof the hands.

FIG. 1. (A) Chronic and severe hand eczemawith erythematous and scratched nonconfluent papules on the dorsum. (B) Hyper-orthokeratosis, parakeratosis, acanthosis, spongiosis, and a dermal lymphohistiocytic infiltrate with some eosinophils andmel-anophages (EE 20). (C) Substantial clinical improvement of lichen simplex chronicus after 3 months of therapy with oralalitretinoin. Resolution of papules and erythema of the dorsum.

DErme et al.

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The patient was treated for CHE with oral alitre-tinoin at the daily dosage of 30 mg for 12 weeks andwith emollients as a basic topical therapy.

After 3 months of treatment, a moderateimprovement of the hand eczema was observedtogether with a substantial clinical improvementof LSC (FIG. 1C). After 4 months from the endof treatment, no recurrence of lesions has beenobserved.

The clinical improvement was followed by analmost complete resolution of pruritus. In fact,the patients visual analogue scales (VAS) itchdecreased from 80 at the baseline to 10 at the end ofthe treatment. The therapy was generally well tol-erated; no cutaneous or systemic side effects wereobserved.

Discussion

No studies or cases have been published so farregarding the potential benefits of this drug in LSC.

Alitretinoin is the only retinoid that activatesboth intracellular retinoid acid receptors, retinoicacid receptors and retinoid X receptors. It isknown to have immunomodulating and anti-inflammatory effects and a regulating action on thekeratinocyte cytokine production and leukocyteactivity. In our patient, the clinical improvement

was paralleled by a marked reduction of pruritus,rubbing, and scratching, which had a positiveimpact on quality of life and contributed to skinlesion improvement.

Our case suggests that oral alitretinoin may con-stitute a novel, effective, and well-tolerated treat-ment option for exacerbated LSC refractory tostandard topical treatments.

In conclusion, our case, together with the sixcases described by Grahovac et al. (4), suggests apotential benefit of oral alitretinoin treatment ofLSC as a manifestation of extrapalmar atopiceczema.

However, further analysis with longer follow-upsand randomized controlled trials are needed toconfirm our clinical observation.

References

1. Lotti T, Buggiani G, Prignano F. Prurigo nodularis and lichensimplex chronicus. Dermatol Ther 2008: 21 (1): 4246.

2. Ruzicka T, Lynde CW, Jemec GB, et al. Efficacy and safety oforal alitretinoin (9-cis retinoic acid) in patients with severechronic hand eczema refractory to topical corticosteroids:results of a randomized, double-blind, placebo-controlled,multicentre trial. Br J Dermatol 2008: 158 (4): 808817.

3. Bissonnette R, Worm M, Gerlach B, et al. Successful retreat-ment with alitretinoin in patients with relapsed chronic handeczema. Br J Dermatol 2010: 162 (2): 420426.

4. Grahovac M, Molin S, Prinz JC, Ruzicka T, Wollenberg A.Treatment of atopic eczema with oral alitretinoin. Br J Der-matol 2010: 162 (1): 217218.

Alitretinoin in lichen simplex chronicus

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