Drug Bests Phototherapy for Severe Hand Eczema

TOPLINE:
The retinoid alitretinoin is superior to phototherapy for rapidly alleviating severe chronic eczema of the hands and nets better compliance, albeit with a higher rate of adverse events.
METHODOLOGY:
Investigators conducted a phase 3 randomised controlled trial among patients from UK dermatology outpatient clinics with severe chronic hand eczema unresponsive to potent topical corticosteroids (the ALPHA trial).
A total of 441 adult patients were assigned to alitretinoin 30 mg/d or phototherapy consisting of twice-weekly immersion PUVA (psoralen with ultraviolet A light) for 12-24 weeks, with follow-up for up to 52 weeks.
The main outcome was disease severity (calculated as the natural log of the hand eczema severity index +1).
TAKEAWAY:
The median relative change in the hand eczema severity index at 12 weeks favoured alitretinoin over phototherapy (30% vs 50% of baseline).
Alitretinoin was superior to phototherapy in adjusted analysis (estimated fold change, 0.66; P = .0003).
There was no significant difference between groups at 24 or 52 weeks.
Patients in the alitretinoin and phototherapy groups were similarly likely to achieve clear/almost clear skin at some time during the trial (59.4% and 61.5%).
Treatment compliance was higher for the drug therapy (65.9% vs 24.0%).
Patients in the alitretinoin group were more likely to experience adverse events (25.0% vs 10.9%) but similarly likely to experience serious adverse events.
IN PRACTICE:
“ALPHA…was a pragmatic real-life study with direct relevance to UK dermatology care,” the authors wrote. “[Alitretinoin] works faster and is more effective at week 12 when comparing Immersion PUVA with [alitretinoin]” and “is more cost-effective…,” they noted. “Immersion PUVA leads to a reduction in symptoms for chronic severe [hand eczema] and has the potential to be cost-effective after 10 years post treatment. However, access…is limited in the United Kingdom. There is a strong clinical need to improve access to this treatment for a larger group of patients,” the authors concluded. 
SOURCE:
The study was led by Miriam Wittmann, MD, University of Leeds, Leeds, UK, and University Medical Centre of Johannes Gutenberg University Mainz, Mainz, Germany, and was published online in Health Technology Assessment.
LIMITATIONS:
Limitations included possible recruitment bias, differing compliance rates, and difficulty comparing long-term efficacy as second-line therapies were used during follow-up. 
DISCLOSURES:
The study was funded by the National Institute for Health and Care Research. Miriam Wittmann disclosed affiliations with companies that manufacture drugs used to treat eczema.
 
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