Potent Topical Corticosteroids Research Articles

The Art in Dermatitis

A 32-year-old healthy Somali-American woman presented with one week of a pruritic papular rash over the dorsum of both hands. The rash appeared 7 days after her first henna application. There were no other new skin products identified. She was diagnosed with henna-induced allergic contact dermatitis and treated with a high potency topical corticosteroid and antihistamines with resolution of the lesions. Henna is a plant native to Africa and southern Asia and is commonly used to dye skin and hair. Pure henna as a dyeing agent rarely causes skin sensitization. However, paraphenylenediamine (PPD) is often added to henna to speed drying and darken the dye. The addition of PPD to henna tattoo mixtures is increasingly being recognized as a cause of allergic contact dermatitis. Treatment consists of topical corticosteroids with or without antihistamines. In severe cases, systemic corticosteroids may be warranted. Post-inflammatory hyperpigmentation may occur following the resolution of the dermatitis.

Irritant bullous contact dermatitis caused by a rove beetle: An illustrated clinical course

A 26-year-old Australian female traveller in Sierra Leone presented with an irritant bullous contact dermatitis consistent with paederus dermatitis. The lesions were treated with a potent topical corticosteroid with good effect. The affected area resolved in 6 weeks and hyperpigmention persisted for months until complete resolution. This dermatitis occurs when beetles of the genus Paederus (rove beetles) are crushed on the skin, releasing pederin. The same dermatitis ensues with Australian Paederus species. Serial clinical photographs are presented which will aid Australian dermatologists in the diagnosis of this dermatitis, which presents in regional Australian patients and returned overseas travellers.

A PAMPA Assay as Fast Predictive Model of Passive Human Skin Permeability of New Synthesized Corticosteroid C-21 Esters

The permeation properties of twenty newly synthesized α-alkoxyalkanoyl and α-aryloxyalkanoyl C-21 esters of standard corticosteroids: Fluocinolone acetonide, dexamethasone, triamcinolone acetonide and hydrocortisone were established using a PAMPA assay (70% silicone oil and 30% isopropyl myristate). The data were compared with parent corticosteroids with addition of mometasone furoate and hydrocortisone acetate. All newly synthesized corticosteroid C-21 esters have effective permeability coefficients higher then -6, mostly followed with high values of retention factors and low permeation. The examined compounds were grouped through relationship between obtained retention factors and permeation parameters (groups I–III). The classification confirmed group I (membrane retentions as well as permeation lower then 30%) for all corticosteroid standards except mometasone furoate, a potent topical corticosteroid which, with high membrane retention (81%) and low permeation (7.7%) fits into group III. The largest number of new synthesized corticosteroids C-21 esters, among them all fluocinolone acetonide C-21 esters, have high membrane retentions (32.4%–86.5%) and low permeations (1.3%–27.1%), fitting in group III. The classification was related to previously obtained anti-inflammatory activity data for the fluocinolone acetonide C-21 esters series. According to the PAMPA results the new synthesized esters could be considered as potential new prodrugs with useful benefit/risk ratio.

Lichen Sclerosus in a Post-Menopausal Woman: A Case Report

Lichen sclerosus (LS) refers to a benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes. The previous designation was LS et atrophicus. The “et atrophicus” was dropped because areas of thickening and hyperplasia often occur. LS usually occurs in the anogenital region (85 to 98 percent of cases), but can develop on any skin surface. Extragenital lesions are present in 15 to 20 percent of patients. In post-menopausal women, the disorder is most common when endogenous estrogen production is low. Sideri et al. showed no difference in sexual habits, smoking history, education, or dietary habits. Besides age and post-menopause state, no other risk factors for LS have yet been identified. The anogenital lesion can cause severe discomfort and manifest with erosion, porcelain-white plaques, papules and wide degrees of sclerosis. Potent topical corticosteroids associated with skin care are thought to be the most successful therapy.

Scabies: A Review of Diagnosis and Management Based on Mite Biology

Scabies is a contagious parasitic dermatitis that is a significant cause of morbidity, especially outside of the United States. Scabies is diagnosed most often by correlating clinical suspicion with the identification of a burrow. Although scabies should be on the differential for any patient who presents with a pruritic dermatosis, clinicians must consider a wide range of diagnostic possibilities. This approach will help make scabies simultaneously less over- and underdiagnosed by clinicians in the community. Atypical or otherwise complex presentations may necessitate the use of more definitive diagnostic modalities, such as microscopic examination of KOH prepared skin scrapings, high-resolution digital photography, dermoscopy, or biopsy. Scabies therapy involves making the correct diagnosis, recognizing the correct clinical context to guide treatment of contacts and fomites, choosing the most effective medication, understanding how to use the agent properly, and following a rational basis for when to use and reuse that agent. Although the development of new therapeutic agents is always welcome, tried and true treatments are still effective today. Permethrin is the gold standard therapy, with malathion being an excellent topical alternative. Ivermectin is an effective oral alternative that is especially useful in crusted scabies, patients who are bed ridden, and in institutional outbreaks. Despite the availability of effective therapeutics, treatment failures still occur, mostly secondary to application error (ie, failure to treat the face and scalp or close contacts, failure to reapply medication) or failure to decontaminate fomites. Because increasing resistance to scabies treatments may be on the horizon, we propose that standard of care for scabies treatment should involve routine treatment of the scalp and face and re-treating patients at day 4 on the basis of the scabies life cycle to ensure more efficient mite eradication. Practitioners should attempt to treat all close contacts simultaneously with the source patient. To eradicate mites, all fomites should be placed in a dryer for 10 minutes on a high setting, furniture and carpets vacuumed, and nonlaunderables isolated for a minimum of 2 days, or, for those who wish to be rigorous, 3 weeks.

Alitretinoin – molecular and cellular mechanisms of action

Background Chronic hand eczema (CHE) represents an inflammatory skin disease with a high prevalence ranging from 7-12% in Western industrialized countries. It was only starting from 2008 that the first, and until now the only, systemic treatment option, i.e. oral alitretinoin was approved in several countries for severe CHE unresponsive to potent topical corticosteroids. However, as the precise mechanism of actions (MOA) of alitretinoin in CHE are so far unknown, we undertook following investigations in order to shed some light on potential underlying immunomodulatory mechanisms.

Evidence-based (S3) guideline on topical corticosteroids in pregnancy

Women with skin conditions may need topical corticosteroids during pregnancy. However, little is known about the effects of topical corticosteroids on the fetus. A guideline subcommittee of the European Dermatology Forum was organized to develop an evidence-based guideline on the use of topical corticosteroids in pregnancy (http://www.euroderm.org/edf/images/stories/guidelines/EDF-Guideline-on-Steroids-in-Pregnancy.pdf). The evidence from a Cochrane Review suggested that the major possible adverse effects on the fetus of topical corticosteroids were orofacial clefts when used preconceptionally and in the first trimester of pregnancy, and fetal growth restriction when very potent topical corticosteroids were used during pregnancy. To obtain robust evidence, a large population-based cohort study (on 84,133 pregnant women from the U.K. General Practice Research Database) was performed, which found a significant association of fetal growth restriction with maternal exposure to potent/very potent topical corticosteroids, but not with mild/moderate topical corticosteroids. No associations of maternal exposure to topical corticosteroids of any potency with orofacial cleft, preterm delivery and fetal death were found. Moreover, another recent Danish cohort study did not support a causal association between topical corticosteroid and orofacial cleft. The current best evidence suggests that mild/moderate topical corticosteroids are preferred to potent/very potent ones in pregnancy, because of the associated risk of fetal growth restriction with the latter.

Response to Treatment With Oral Alitretinoin in Patients With Chronic Hand Eczema That Is Refractory to Treatment With Potent Topical Corticosteroids: Experience in 15 Patients

Background Alitretinoin (9- cis-retinoic acid) is an endogenous derivative of vitamin A and functions as an agonist of both families of nuclear receptors (retinoic acid receptor-α, -β, -γ; retinoid X receptor-α, -β, -γ). It has been investigated in the treatment of chronic hand eczema in many studies in recent years and the results have been promising. Objectives To evaluate the efficacy and safety of oral alitretinoin in the treatment of chronic hand eczema that is refractory to treatment with potent topical corticosteroids and to analyze the long-term response to treatment. Materials and methods A prospective, observational, descriptive study was undertaken in 15 patients with chronic hand eczema that was refractory to treatment with potent topical corticosteroids. Patients were administered oral alitretinoin 30 mg/d for 3 months followed by 6 months of follow-up. Results A complete response, with “clear” hands was obtained in 7 patients (47%), 5 patients (33%) achieved a partial response (almost clear hands), 1 patient (7%) showed substantial improvement, 1 (7%) showed moderate improvement, and 1 patient (7%) did not respond to treatment. Relapse occurred within 6 months of treatment suspension in 54% of cases. The treatment was well tolerated. Side effects, observed in 50% of cases, were mild (headache, elevated lipid levels, slightly elevated transaminase levels, and epigastric pain), except in 1 patient, who had a substantial reduction in thyroid stimulating hormone levels. Conclusions The results of our study support the proposal of alitretinoin as an effective and safe short-term and medium-term treatment for chronic hand eczema in patients whose disease is refractory to treatment with potent topical corticosteroids.

Drug-Induced Photosensitivity

Photo-induced drug eruptions are cutaneous adverse events due to exposure to a drug and either ultraviolet or visible radiation. Based on their pathogenesis, they can be classified as phototoxic or photoallergic drug eruptions, although in many cases it is not possible to determine whether a particular eruption is due to a phototoxic or photoallergic mechanism. In this review, the diagnosis, prevention and management of drug-induced photosensitivity are discussed. Diagnosis is based primarily on the history of drug intake and the clinical appearance of the eruption, primarily affecting sun-exposed areas of the skin. Phototesting and photopatch testing can be useful adjuncts in making a diagnosis. The mainstay of management is prevention, including informing patients of the possibility of increased sun sensitivity and the use of sun protective measures. However, once the eruption has occurred, it may be necessary to discontinue the culprit medication and treat the eruption with a potent topical corticosteroid. Drugs that have been implicated in causing photosensitive eruptions are reviewed. Tetracycline, doxycycline, nalidixic acid, voriconazole, amiodarone, hydrochlorothiazide, naproxen, piroxicam, chlorpromazine and thioridazine are among the most commonly implicated medications. We review the medical literature regarding evidence for the culpability of each drug, including the results of phototesting, photopatch testing and rechallenge testing.

Pharmacokinetics study about topical clobetasol on oral mucosa

Clobetasol is the most potent topical corticosteroid used in oral medicine for muco-cutaneous diseases. Several papers reported about patients with cushingoid appearance, suggesting an adrenal suppression related to clobetasol systemic absorption after local application. Owing to the lack of studies, our goal is to assess whether transmucosal assimilation, after its application on oral mucosa, really occurs and to define clobetasol pharmacokinetics profile. Data were recorded by collecting blood samples both on 10 patients in clobetasol therapy and on 14 healthy volunteers instructed about standardized clobetasol applications. A new technique of analytical chemistry was employed to detect its serum concentrations. Clobetasol absorption was ascertained, showing a certain accumulation rate. Different levels have been found in relation to oral disease and individual features (as smoking habits and presence of oral mucosa erosion). Our study validates clobetasol systemic transmucosal absorption, also recommending a careful monitoring of patients in corticosteroid therapy to avoid local and systemic adverse effects.

Cicatricial pemphigoid of the scalp mimicking discoid lupus erythematosus

To the Editor: An 83-year-old African American woman presented with a 30-year history of intermittent lesions on her scalp and oral mucosa. The scalp lesions were associated with burning and itching. The symptoms were intermittent. The scalp lesions lasted longer and did not coincide with the oral lesions, which would come and go. She denied pain with eating or swallowing, fever, chills, fatigue, or joint pain. Therapy included potent topical corticosteroid creams and a compounded mouthwash containing equal parts dexamethasone at 4 mg/mL, aluminum hydroxide/magnesium hydroxide (Maalox), and diphenhydramine elixir at 12.5 mg/5 mL for several months before presentation.

Upregulation of Inflammatory Cytokines and Oncogenic Signal Pathways Preceding Tumor Formation in a Murine Model of T-Cell Lymphoma in Skin

The tumor microenvironment, including its inflammatory components, regulates tumor progression. Herein, we explore the relationship between inflammation and the progression of T-cell lymphoma in the cutaneous microenvironment. Injection of MBL2 murine T lymphoma cells into ear skin of C57BL/6 and immunodeficient SCID/Beige mice resulted in tumor formation in only the latter group. However, induction of skin inflammation by one topical application of DNFB following MBL2 inoculation in C57BL/6 mice resulted in progressive high-grade lymphoma. The DNFB-regulated tumor formation was blocked by early, but not late, application of a potent topical corticosteroid. At 2 days after implantation, a 10-fold decrease in MBL2 cell apoptosis was detected in DNFB-treated ears compared with vehicle control. After DNFB treatment, Gr-1(high) neutrophils and F4/80(+) macrophages constituted the majority of tumor-infiltrating CD45(+) leukocytes. Depletion of macrophages by clodronate-containing liposomes blocked the tumor-promoting effect of DNFB. Transcriptional profiling of inflammatory cytokines and chemokines after DNFB treatment revealed robust changes in genes that are important in chemotaxis, proliferation, and apoptosis. Activation of oncogenic signal pathways, including NF-κB, was also detected. This work provides insights into the cellular and molecular pathways that mediate lymphoma progression and may have applicability to human cutaneous T-cell lymphomas.

Extensive Hyperpigmented Plaques in a Chinese Singaporean Woman: A Case of Cutaneous Plasmacytosis

Cutaneous plasmacytosis is a rare disease entity presenting with multiple extensive red-brown plaques, histopathology showing marked hyperplasia of mature polyclonal plasma cells, and polyclonal hypergammaglobulinemia on serum protein electrophoresis, in the absence of an underlying secondary cause. We report in this article the first case of cutaneous plasmacytosis from Singapore. A 33-year-old Chinese woman presented with mildly pruritic reddish brown papules and plaques over her trunk and arms for 2 years. Physical examination, laboratory investigations, and radiographic examination were negative for systemic involvement and lymphadenopathy. Serum immunoelectrophoresis showed polyclonal hypergammaglobulinemia with immunoglobulin G and immunoglobulin A. Two sets of skin biopsies performed 2 years apart essentially showed similar histopathological findings of a superficial and deep perivascular infiltrate with numerous mature plasma cells and small typical lymphocytes. There were lymphoid follicles with well-formed germinal centers and mantle zones, surrounded by mature lymphocytes. No light chain restriction was present on immunohistochemistry, and polymerase chain reaction for heavy chain gene rearrangement was negative for monoclonality. Despite potent topical corticosteroids and 8 months of phototherapy with narrow band ultraviolet light, there was no improvement. Intralesional triamcinolone injections to a few lesions afforded temporary relief of itch and flattening of lesions.

Tinea Corporis Gladiatorum Presenting as a Majocchi Granuloma

Background. Wrestlers are at increased risk of developing cutaneous infections, including fungal infections caused by dermatophytes. Erythematous lesions due to tinea infections can be mistakenly diagnosed as an inflammatory dermatitis and incorrectly treated with potent topical corticosteroid treatments which cause localized skin immunosuppression. This can eventuate in a Majocchi granuloma which then becomes refractory to topical antifungal therapy. To our knowledge, this is the first case of tinea corporis gladiatorum presenting as a Majocchi granuloma. Observations. A 20-year-old wrestler presented with a 4-year history of a large pruritic, scaly erythematous plaque with follicular papules, and pustules on his right forearm. The lesion had the clinical appearance of a Majocchi granuloma. He had been treated with potent topical corticosteroids and topical antifungal therapy. KOH and fungal culture of the lesion were negative. An erythematous scaly lesion in the scalp was cultured and grew Trichophyton tonsurans. Oral Terbinafine therapy was initiated and complete resolution of both lesions occurred within 6 weeks. Conclusion. The purpose of this report is to inform dermatologists that tinea corporis gladiatorum can present as a Majocchi granuloma and needs to be considered in the differential diagnosis of persistent skin lesions in wrestlers.

Safety of Topical Corticosteroids in Pregnancy: A Population-Based Cohort Study

Topical corticosteroids may be indicated in pregnant women with skin conditions, but their safety in pregnancy is unclear. We used the UK General Practice Research Database to conduct a population-based cohort study to investigate whether maternal exposure to topical corticosteroids results in adverse pregnancy outcomes. We identified 35,503 pregnant women prescribed topical corticosteroids during the period from 85 days before last menstrual period (LMP) to delivery or fetal death and 48,630 unexposed women. We found no associations of maternal exposure to topical corticosteroids with orofacial cleft (and its two subtypes, i.e., cleft lip ± palate (CLP) and cleft palate alone (CP)), preterm delivery, and fetal death (including miscarriage and stillbirth). The findings were similar when excluding exposure before LMP. In contrast, maternal exposure to potent/very potent topical corticosteroids shortly before and during pregnancy was significantly associated with fetal growth restriction (adjusted relative risk 2.08; 95% confidence interval 1.40-3.10; number needed to harm, 168), which was confirmed by a significant dose-response relationship (P=0.025) and the sensitivity analysis excluding exposure before LMP. The increased risk for fetal growth restriction should be considered when prescribing potent/very potent topical corticosteroids to pregnant women, and appropriate obstetric care should be provided.

Pharmacokinetics, efficacy and safety of alitretinoin in moderate or severe chronic hand eczema

Recent studies have found that alitretinoin can induce clinically significant responses in subjects with severe chronic hand eczema (CHE) unresponsive to topical corticosteroids. To assess the pharmacokinetics (PK), efficacy and safety of alitretinoin 10 or 30 mg once daily. This was a randomized, double-blind study, which enrolled 32 subjects aged 18-75 years with CHE unresponsive to potent topical corticosteroids. Subjects received alitretinoin 10 mg (n = 16) or 30 mg (n = 16) once daily for 12 or 24 weeks. Standard PK variables [area under the curve (AUC) of plasma concentration vs. time, maximum plasma concentration (C(max)), time to maximum plasma concentration (t(max)), elimination half-life (t(1/2)), total systemic clearance (CL/F) and volume of distribution (Vd/F)] were determined for alitretinoin and metabolites. Efficacy was assessed using the Physician's Global Assessment (PGA) scale. Chronic administration of alitretinoin for up to 24 weeks did not result in accumulation or time-dependent changes in the disposition of alitretinoin. Exposure was found to be proportional to dose. Systemic exposure (AUC) to alitretinoin was proportional to dose for 10 and 30 mg alitretinoin; 62.8% of subjects achieved clear/almost clear hands in the 30 mg group and 12.5% in the 10 mg group. Alitretinoin was well tolerated. Chronic administration of alitretinoin for 12-24 weeks did not lead to accumulation or time-dependent changes in drug exposure. Alitretinoin was effective and well tolerated in the treatment of subjects with moderate or severe CHE unresponsive to potent topical corticosteroids.

Influence of alitretinoin on the pharmacokinetics of the oral contraceptive ethinyl estradiol/norgestimate

Alitretinoin (9-cis retinoic acid) is currently registered in many European countries and in Canada as the only licensed treatment for severe chronic hand eczema unresponsive to potent topical corticosteroids. Alitretinoin, like all retinoids, is teratogenic, and women of child-bearing potential must strictly adhere to pregnancy-prevention measures. To investigate the influence of alitretinoin on the pharmacokinetics (PK) of ethinyl estradiol/norgestimate (Ortho Tri-Cyclen 28(®)), a commonly prescribed combination oral contraceptive. In total, 16 healthy premenopausal women received three consecutive cycles of the triphasic contraceptive ethinyl estradiol/norgestimate together with concomitant oral alitretinoin 40 mg once daily during cycle 2. Steady-state PK (noncompartmental analysis) of ethinyl estradiol, 17-deacetyl norgestimate, alitretinoin and its main metabolite 4-oxo-alitretinoin were assessed alone and in combination. The PK profiles of ethinyl estradiol and 17-deacetyl norgestimate were similar when contraceptives were given alone or with alitretinoin, and the area under the plasma concentration vs. time curve and the maximum concentration met the conventional criteria for PK equivalence. Similarly, the influence of ethinyl estradiol/norgestimate on systemic exposure to alitretinoin and 4-oxo-alitretinoin was not clinically relevant. Alitretinoin was well tolerated when given either alone or with ethinyl estradiol/norgestimate. There was no clinically relevant influence of alitretinoin on the PK of ethinyl estradiol/norgestimate, and no influence of ethinyl estradiol/norgestimate on systemic exposure to alitretinoin and 4-oxo-alitretinoin. Consequently, oral contraception with ethinyl estradiol/norgestimate is an appropriate primary method of birth control during alitretinoin treatment for women of childbearing potential.

Everyday clinical experience of alitretinoin in the treatment of severe chronic hand eczema: seven case studies

Chronic hand eczema (CHE) is a debilitating and distressing disease for patients, the physical symptoms of which are compounded by psychosocial problems. Alitretinoin is an endogenously occurring physiological vitamin A derivative (retinoid) that possesses strong anti-inflammatory and immunomodulatory activity. It is currently the only licensed product for severe CHE unresponsive to treatment with potent topical corticosteroids, and has been proven to be highly effective in clinical trials with two-thirds of patients who responded to treatment remaining in remission at 6 months. For those that did relapse, a second study showed they could be successfully retreated with a further 3-6 month course of alitretinoin. Seven case studies of alitretinoin have been provided by consultant dermatologists showing its use in normal UK clinical practice. The cases chosen demonstrate the efficacy of alitretinoin across several different subtypes of CHE, and the positive effects the treatment brought to patients' quality of life.

Case study 1 – A 54-year-old male gardener with chronic hand eczema

A 54-year-old man presented to his dermatologist with severe chronic vesicular hand eczema, which had been present for over 3 years. The patient had previously lost an arm in an earlier injury, and the disease on his remaining hand was causing significant distress and complications in his daily life. He worked as an odd-job man and gardener, so his remaining hand was vital to his chosen occupation. He was patch tested, which showed multiple contact allergies including a positive result to Compositae mix, sesquiterpene lactone mix, thiuram mix and potassium dichromate. Since the patch test, he had been using non-rubber gloves at work and tried to avoid coming into sustained contact with compositae plants such as asters, sunflowers and daisies. It was clear however, that despite these measures his occupation was exacerbating the disease and in turn the disease was interfering with his occupation. He was initially treated with ciclosporin (2–3 mg/kg/day) and concomitant potent topical corticosteroids continuously for many months, but despite this aggressive treatment, his eczema remained poorly controlled with frequent flares requiring the patient to take oral corticosteroids and antibiotics on a regular basis. Additionally he suffered from hypertension during treatment, potentially as an adverse reaction to ciclosporin. Later, the patient enrolled in a clinical trial with azathioprine 100 mg daily, but had minimal benefit after 6 months and was unable to tolerate the associated side effects of sickness and diarrhoea. Subsequent treatment with acitretin 25 mg daily for 3 months also proved ineffective, and as the patient had albinism, phototherapy was not an appropriate option. His disease therefore remained significant (Fig. 1) and his dermatologist prescribed oral alitretinoin 30 mg in October 2009. Patient 1: A 54-year-old male gardener. Prior to alitretinoin treatment. After 3 months’ treatment, he showed significant improvement in all symptoms and the Physician’s Global Assessment score improved from ‘very severe’ to ‘almost clear’ (Fig. 2). Patient 1: A 54-year-old male gardener. After 3 months’ alitretinoin treatment. The treatment was well tolerated, with no significant side effects or laboratory anomalies. The improvement in his condition led to the discontinuation of treatment in January 2009, but unfortunately he relapsed 2 months later as he was allergic to Compositae plants, which are ubiquitous in the environment. Retreatment with alitretinoin 30 mg once daily improved his condition again, and he remains on treatment. The patient was very happy with the results he achieved with alitretinoin treatment; he described it as the best treatment he has received for his hand eczema, and one that he considers to have transformed his life. He has been able to continue his chosen occupation, and he feels his overall quality of life has improved substantially.

Respuesta al tratamiento con alitretinoína oral en ECM refractario con eczema crónico de manos refractario al tratamiento con corticoides tópicos potentes: nuestra experiencia en 15 pacientes

Background Alitretinoin (9- cis-retinoic acid) is an endogenous derivative of vitamin A and functions as an agonist of both families of nuclear receptors (retinoic acid receptor-α, -β, -γ; retinoid X receptor-α, -β, -γ). It has been investigated in the treatment of chronic hand eczema in many studies in recent years and the results have been promising. Objectives To evaluate the efficacy and safety of oral alitretinoin in the treatment of chronic hand eczema that is refractory to treatment with potent topical corticosteroids and to analyze the long-term response to treatment. Materials and methods A prospective, observational, descriptive study was undertaken in 15 patients with chronic hand eczema that was refractory to treatment with potent topical corticosteroids. Patients were administered oral alitretinoin 30 mg/d for 3 months followed by 6 months of follow-up. Results A complete response, with “clear” hands was obtained in 7 patients (47%), 5 patients (33%) achieved a partial response (almost clear hands), 1 patient (7%) showed substantial improvement, 1 (7%) showed moderate improvement, and 1 patient (7%) did not respond to treatment. Relapse occurred within 6 months of treatment suspension in 54% of cases. The treatment was well tolerated. Side effects, observed in 50% of cases, were mild (headache, elevated lipid levels, slightly elevated transaminase levels, and epigastric pain), except in 1 patient, who had a substantial reduction in thyroid stimulating hormone levels. Conclusions The results of our study support the proposal of alitretinoin as an effective and safe short-term and medium-term treatment for chronic hand eczema in patients whose disease is refractory to treatment with potent topical corticosteroids.