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Acitretin, a synthetic aromatic retinoid which regulates the proliferation, differentiation, and keratinisation of epidermal cells, is usually used to treat severe psoriasis or ichthyosis. The main side effects are teratogenesis and mucocutaneous forms of xerosis such as cheilitis and blepharoconjunctivitis.1,2 The biological effects of acitretin in non-epidermal cell lines, and especially those derived from ocular tissues,3,4 could explain the beneficial actions of acitretin in diseases other than skin disorders. We report a drastic improvement in tuberculosis related interstitial keratitis in a patient treated with acitretin for severe psoriasis.
A 21 year old Moroccan man was referred to our ophthalmology department in 1992 with severe chronic bilateral interstitial keratitis associated with skin lesions. Initial examination revealed epidermal lesions clinically and histologically consistent with pustular psoriasis. The patient also had a history of tuberculosis, with likely onset at age 3 months and first treatment at age 7 years, with isoniazid, rifampicin, and streptomycin. Visual acuity was 20/400 in both eyes. Slit lamp examination revealed confluent interstitial opacities in both corneas, hindering examination of the anterior and posterior segments of the eyes. From 1992 to 1997, successive treatment courses with calcipotriol, psoralene, plus ultraviolet A irradiation and methotrexate for the skin lesions failed to improve the ocular lesions, and neither did steroid therapy given to control systemic signs of inflammation. The patient underwent keratoplasty of the left eye in 1993 to restore a degree of vision. Graft failure occurred after a few months, owing to poor compliance with ocular treatment and/or to periods of ocular inflammation during exacerbations of the skin disease. Another two corneal grafts were attempted in the left eye during the subsequent 3 years, with poor long term results. The left eye became blind and painful and was removed. Surgery was not attempted on the right eye.
In 1998, treatment was started with acitretin (30 mg/day for 1 month, then 20 mg/day) because of a relapse of the skin disease. Within 1 month acuity in the right eye had improved to 20/100 and there was a marked improvement in corneal interstitial opacities (see Fig 1). For the first time in 6 years, detailed examination of the anterior and posterior segments of the eye was possible. Synechiae were observed from the iris to the lens, together with posterior opacities in the lens, likely secondary to previous episodes of ocular inflammation. The aspect of the retina was normal. Two years after the outset of acitretin treatment, the right cornea remains clear.
Both the rapid improvement in the interstitial keratitis following acitretin introduction for this patient’s skin lesions, and the fact that none of the previous treatments for the psoriasis had improved the ocular lesions, strongly suggest that acitretin may be beneficial in some patients with sight threatening corneal opacities. This may be explained by the activity of acitretin on corneal cells, as suggested by experimental studies3 and by a case report of acitretin related keratoconus.5 Further laboratory studies and clinical trials are needed to determine whether the adverse effects of acitretin are offset by its beneficial action in chronic interstitial keratitis.
Grant supports: None.
Proprietary interest: None.