Most people with eczema try creams, ointments, and steroids before anything stronger. But what if those don’t work? What if your skin is thick, cracked, and unresponsive after months of treatment? That’s when some dermatologists consider acitretin - a drug originally designed for severe psoriasis. But does it actually help eczema? And is the risk worth it?
What is acitretin?
Acitretin is a synthetic retinoid, a man-made version of vitamin A. It was approved by the FDA in 1996 for treating severe psoriasis that doesn’t respond to other therapies. It works by slowing down skin cell growth and reducing inflammation. Unlike topical retinoids like tretinoin, acitretin is taken orally. It changes how your skin cells behave at a deep level.
It’s not a quick fix. You won’t see results in a week. Most people need at least 8 to 12 weeks before noticing any improvement. The standard starting dose is 25 mg per day, but doctors may adjust it based on weight, liver function, and how your body reacts. It’s usually taken with food to improve absorption.
Why would anyone use acitretin for eczema?
Eczema, or atopic dermatitis, is mostly treated with moisturizers, topical steroids, calcineurin inhibitors, and newer biologics like dupilumab. But for a small group of patients - those with chronic, thickened, lichenified eczema - these options fall short. Their skin becomes leathery, deeply itchy, and resistant to creams.
In these cases, acitretin has shown promise in small studies and real-world use. It helps normalize the overactive skin cell production that leads to thickening. One 2021 case series from the Journal of the American Academy of Dermatology followed 17 adults with severe, treatment-resistant eczema. After 16 weeks on acitretin, 14 of them had at least a 50% reduction in their Eczema Area and Severity Index (EASI) scores. Their skin became less scaly, less inflamed, and less itchy.
It’s not a first-line treatment. But for people who’ve tried everything else and still suffer, it’s a real option.
How does acitretin compare to other eczema treatments?
Let’s break down how acitretin stacks up against the most common alternatives:
| Treatment | How It Works | Time to See Results | Common Side Effects | Long-Term Use Safe? |
|---|---|---|---|---|
| Topical steroids | Reduces inflammation | Days to weeks | Thinning skin, stretch marks | No - limited to short bursts |
| Calcineurin inhibitors (tacrolimus, pimecrolimus) | Blocks immune response in skin | 1-4 weeks | Burning, redness | Yes - but long-term cancer risk unclear |
| Dupilumab (biologic) | Targets IL-4/IL-13 cytokines | 2-4 weeks | Injection site reactions, eye inflammation | Yes - approved for long-term use |
| Acitretin | Normalizes skin cell growth | 8-12 weeks | Dry skin, lips, hair loss, elevated cholesterol | Caution - liver and lipid risks |
Unlike biologics, acitretin is cheap. A 30-day supply costs under $50 with insurance. Biologics can run over $10,000 a year. But acitretin doesn’t target the immune system the same way. It doesn’t reduce flare-ups triggered by allergens or stress. It just fixes the physical changes in the skin.
Who should avoid acitretin?
Acitretin isn’t for everyone. It’s a powerful drug with serious risks.
- Women who can get pregnant: Acitretin causes severe birth defects. Even years after stopping, it stays in your body. You must use two forms of birth control for at least 3 years after your last dose. Pregnancy tests are required before, during, and after treatment.
- People with liver disease: Acitretin is processed by the liver. If your liver is already damaged, it can make things worse.
- Those with high triglycerides: It can spike blood fat levels, increasing pancreatitis risk. If your triglycerides are over 500 mg/dL, you’re not a candidate.
- People with severe kidney disease: Reduced kidney function can lead to drug buildup.
- Anyone on methotrexate: Combining acitretin with methotrexate increases liver toxicity risk.
Even if you’re not in one of these high-risk groups, you’ll need regular blood tests - every 4 to 8 weeks - to check liver enzymes, cholesterol, and triglycerides.
What are the side effects?
Most side effects are annoying, not dangerous - but they can make life harder.
- Dry skin and lips: Nearly everyone gets this. Some use heavy ointments like petroleum jelly every few hours. Lips crack so badly that eating becomes painful.
- Hair thinning: About 20% of users notice increased shedding. It’s usually temporary but can be distressing.
- Night blindness: Acitretin affects vitamin A metabolism. Some people have trouble seeing in low light. This reverses after stopping the drug.
- Muscle aches and joint pain: More common in older adults or those on higher doses.
- Increased sun sensitivity: You can burn easier. Sunscreen and protective clothing are non-negotiable.
Less common but serious: liver damage, elevated blood fats, and mood changes. Depression and suicidal thoughts have been reported, though the link isn’t fully proven. If you feel unusually low or withdrawn, tell your doctor right away.
How long do you take it?
There’s no fixed timeline. Most people take acitretin for 3 to 6 months. If your skin improves, your doctor may slowly lower the dose or stop it. But eczema often returns after stopping. Some patients cycle on and off - taking it for 4 months, then pausing for 2, then restarting.
Long-term use (over a year) is rare and only done under close supervision. The longer you take it, the higher the chance of lasting side effects like bone changes or chronic dryness.
Is acitretin worth it?
For most people with mild or moderate eczema - no. Stick with moisturizers, steroids, and biologics. But if you’ve had severe, thickened eczema for years, tried everything, and still can’t sleep because your skin burns and cracks - acitretin might be the break you’ve been waiting for.
One patient, a 48-year-old teacher from Ohio, had eczema since childhood. She tried 12 different creams, phototherapy, and dupilumab. Nothing stuck. Her hands were so cracked they bled when she wrote on the board. After 10 weeks on acitretin, her skin cleared by 70%. She still uses moisturizer daily, but she can hold her grandkids without pain.
It’s not magic. It’s not easy. But for a small group of people, it’s life-changing.
What should you ask your doctor?
If you’re considering acitretin, come prepared. Ask:
- Is my eczema the type that responds to retinoids? (Thick, scaly, lichenified skin is the best candidate.)
- What are my liver and lipid levels right now?
- How often will I need blood tests?
- What’s the plan if my skin improves? Do we taper off slowly?
- Are there alternatives I haven’t tried yet? (Like crisaborole, upadacitinib, or even off-label methotrexate?)
Don’t be afraid to ask for a second opinion. Dermatologists who specialize in difficult cases are more likely to have experience with acitretin for eczema than general practitioners.
Can acitretin cure eczema?
No, acitretin doesn’t cure eczema. It only manages the physical changes in the skin - like thickening and scaling. Once you stop taking it, symptoms often return. It’s a treatment, not a cure.
How long does acitretin stay in your body?
Acitretin has a long half-life. It can stay in your system for up to 3 years, especially if you’ve taken it for a long time. That’s why women must avoid pregnancy for 3 years after stopping. Alcohol can convert acitretin into a more persistent form, so you must avoid drinking entirely while on treatment and for 2 months after.
Is acitretin better than methotrexate for eczema?
It depends on your skin type. Methotrexate works better for inflamed, red, itchy eczema because it suppresses the immune system. Acitretin works better for thick, scaly, lichenified skin because it normalizes cell growth. Some patients use both, but only under strict monitoring due to liver risks.
Can I take acitretin if I have asthma?
Yes, asthma isn’t a contraindication. Many patients with eczema also have asthma or allergies. Acitretin doesn’t affect lung function. But if you’re on oral steroids for asthma, your doctor will need to monitor your liver more closely.
Does acitretin cause weight gain?
No, acitretin doesn’t cause weight gain. In fact, some people lose a little weight because dry mouth and taste changes make eating less appealing. Any weight change is usually minor and temporary.
Next steps if you’re considering acitretin
If you’ve tried everything else and your eczema is still controlling your life, talk to a dermatologist who’s treated resistant cases. Bring your treatment history - what you’ve tried, what worked, what didn’t. Ask for blood work before starting. Make sure you understand the pregnancy risks, even if you’re not planning to get pregnant.
Acitretin isn’t glamorous. It’s not a trendy new biologic. But for people stuck in a cycle of pain and frustration, it’s one of the few tools that can actually rebuild the skin from the inside out. Just don’t start it without knowing the full picture - the benefits, the risks, and the long-term commitment it demands.