Most people who receive etretinate or acitretin develop reversible, dose-dependent mucocutaneous side-effects, including chapped lips, a tendency to nose bleeds, hair loss and dry or peeling skin. Hyperlipidaemia occurs frequently. In a small open study in 25 psoriasis patients with retinoid-induced hyperlipidaemia, fish oil supplementation (providing 3 g omega-3 fatty acids daily) resulted in a 27% reduction in triglyceride levels and an 11% reduction in the ratio of total to high-density lipoprotein cholesterol after 4 weeks.75 As fish oil may also have a mild antipsoriatic effect, it was felt that it could prove a useful adjunct in such patients. In a prospective study of 128 adults with chronic, stable psoriasis treated with oral acitretin for 2 years, there was no evidence from serial liver biopsy of cumulative hepatotoxicity.76 A 5-year prospective study of 956 patients with psoriasis treated with etretinate provided no evidence for an increased risk of cardiovascular disease, cancer, diabetes or inflammatory bowel disease in association with long-term use.77

Oral retinoids are teratogenic. Etretinate may be detected in body fat stores for up to 2 years after discontinuation of therapy; acitretin, although normally excreted much more rapidly, may in certain circumstances be converted in vivo to etretinate. For these reasons both drugs should normally be avoided in women of child-bearing potential.

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