Alitretinoin or PUVA for Hand Eczema: Four ALPHA Checks

Bring the name and duration of previous steroid treatment to your appointment, alongside how your hands affect work or sleep. The “What to Say at the Appointment” section of Skin, Head to Toe helps organize that discussion.

Check who entered the comparison

ALPHA randomized 441 adults with severe chronic hand eczema resistant to at least four weeks of potent topical steroids. Alitretinoin started at 30 mg daily; immersion PUVA was twice weekly. Both groups received topical steroids, moisturizers and education. Assessors were masked; participants were not.¹

Read the severity result correctly

At 12 weeks after planned treatment start, the adjusted ratio for Hand Eczema Severity Index (HECSI)+1, a clinical severity score, was 0.66 (95% CI 0.52–0.82), favoring capsules. This compares severity, not the percentage whose hands cleared.¹

Account for attendance and missing scores

Confirmed 12-week adherence, capsules versus PUVA, was 145/220 versus 53/221, requiring ≥80% treatment and no break exceeding seven days. Week-12 scores were missing for 51/220 versus 74/221; analysis estimated missing values. HECSI differences at 24 and 52 weeks were inconclusive; subsequent treatments were allowed, and 59 participants had only 24-week follow-up. NIHR funded ALPHA; authors disclosed industry ties.¹

Check the treatment requirements

The UK Toctino label restricts alitretinoin to adults with severe chronic hand eczema unresponsive to potent topical steroids, under an experienced prescriber. Pregnancy and breastfeeding are contraindications. It can cause severe birth defects.²

For someone who could become pregnant, the Pregnancy Prevention Programme requires one highly effective user-independent contraceptive method or two complementary user-dependent methods, from at least one month before, throughout treatment and for at least one month afterward. Pregnancy testing is required before, regularly during, and one month after treatment; monthly testing depends on local practice and individual circumstances. Discuss pregnancy plans before prescribing.²

Monitoring includes fasting lipids; liver and thyroid changes also need review. Tetracycline antibiotics cannot be combined with alitretinoin. Report mood changes or visual problems. These requirements can determine whether capsules suit you.²

Immersion PUVA requires a psoralen hand soak followed by medically supervised UVA, not a tanning bed. Hull’s current NHS service describes a 15-minute soak and twice-weekly visits. Ask whether you can keep those appointments and which medicines or creams to report. Report burning promptly; prolonged PUVA exposure carries a skin-cancer risk.³