Acitretin revisited in the era of biologics

Acitretin is a time-honored treatment for psoriasis. During the last decade biologics have revolutionized the treatment of psoriasis. This raises the question: What is the position of acitretin as a classical systemic treatment for psoriasis in the era of biologics? Based on the mode of action of acitretin, it is evident that at least one antipsoriatic treatment has to be available in the armamentarium of antipsoriatic treatments that is not immunosuppressive, intended for those patients who are contraindicated for immunosuppressive treatment. It is attractive to speculate that at least an additive or possibly a synergistic effect can be expected in case of combination of acitretin with a biologic. The efficacy of acitretin in chronic plaque psoriasis as a monotherapy is below methotrexate and cyclosporine. However, acitretin in combination with phototherapy has an efficacy at least comparable with the other classical systemic treatments. Based on several clinical studies it can be concluded that acitretin is an important treatment option in case of contraindications for immunosuppression, such as patients with infections or cancer-prone patients. Furthermore, some evidence is available for high efficacy of the combination of acitretin and biologics.