Retinoids prevent skin cancer in high-risk patients

National Report - Dermatologists have known for years that retinoids suppress the development of skin cancers. Recently this underutilized application has been dramatically illustrated in a case report.

"Patients who get many skin cancers can be put on a drug like acitretin (Soriatane, Connectics Corporation), and they will get fewer cancers," Dr. Lebwohl says. "This has been shown in transplant patients as well as patients with basal cell nevus syndrome and a host of other conditions in which patients are prone to getting skin cancers. Retinoids don't get rid of these cells, so if you stop the retinoid, it's as if the patient were never on the drug. Since these patients are at risk for skin cancer, I tell them they will be on retinoids for the rest of their lives."

To illustrate the effects of retinoid therapy, Dr. Lebwohl and colleagues reported a case involving a 41-year-old skin cancer-prone man who went on and off retinoid therapy several times (Lebwohl M, et al. J Dermatolog Treat. 2003;14 Suppl 2:3-6).

"When we put this patient on acitretin, (new) skin cancers diminished greatly in number," he says. "The patient then discontinued the drug because his wife wanted to conceive. (Even though there have been no cases of birth defects caused by the father taking acitretin, the patient decided to stop acitretin.) While off acitretin, the patient developed many skin cancers. After his wife conceived the patient went back on acitretin and again developed very few skin cancers. His wife miscarried, the patient stopped acitretin again so he and his wife could conceive again, and the patient again got many skin cancers until she conceived. The patient went back on acitretin and got many fewer skin cancers."

Dr. Lebwohl describes another case involving a different retinoid.

"An 87-year-old woman with squamous cell carcinoma (SCC) on her hand had no option other than amputation," he says. "We gave her oral etretinate and the SCC shriveled up into nothing (as shown by biopsy)."

The retinoid eventually had to be discontinued in this patient because side effects developed and the SCC returned, Dr. Lebwohl adds.

"She died of other causes at age 90, but her family was very grateful that she was able to have her hand for those three years."According to Dr. Lebwohl, the most serious adverse effect of retinoid treatment is teratogenicity.

"Acitretin should not be given to women planning a pregnancy within three years," he says. "Retinoid therapy is also associated with elevation of serum lipids, particularly triglycerides. I never use high triglycerides or cholesterol as a reason for not prescribing acitretin or isotretinoin because there are excellent medications that lower lipids; gemfibrozil normalizes triglycerides and statins lower cholesterol and triglycerides."

Nuisance adverse effects of retinoids include hair loss (high doses), chapped lips, dry eyes that require lubricants, dry nasal passages that require lubricants to prevent nosebleeds, peeling of palms and soles (fairly common), sticky feel to skin (high doses) and pyogenic granulomas (uncommon), Dr. Lebwohl adds.

As to cost, acitretin, though not cheap, is less expensive than new treatments for SCC, Dr. Lebwohl says.

"We usually give low doses to prevent side effects." Transplant physicians have just begun to give acitretin to patients likely to get skin cancers, according to Dr. Lebwohl.

"If I have a patient getting more than five or six skin cancers a year, I consider putting the patient on acitretin," he says.

Retinoids should not be used therapeutically for SCC, according to Dr. Lebwohl.