Acitretin for Children: Is It Safe and When Is It Used?

When a child has severe psoriasis, ichthyosis, or another stubborn skin condition that doesn’t respond to creams or light therapy, doctors sometimes turn to acitretin. It’s not the first choice. It’s not even the second. But when nothing else works, and the skin is causing real pain, itching, or social distress, acitretin becomes a tool worth understanding - especially for parents who want to know: is it safe?

What is acitretin, really?

Acitretin is a synthetic retinoid, a man-made version of vitamin A. It’s not a steroid. It doesn’t suppress the immune system like some other drugs. Instead, it works by slowing down how fast skin cells grow and helping them shed normally. In kids with psoriasis, this means fewer thick, scaly patches. In those with congenital ichthyosis, it can make skin smoother and less cracked.

It’s sold under brand names like Neotigason and is taken by mouth as a capsule. The effects don’t show up overnight. Most kids need at least 6 to 8 weeks before any real improvement appears. Full results often take 3 to 6 months. That’s a long time to wait when your child is uncomfortable, but patience matters - and so does monitoring.

Why isn’t acitretin used more often in children?

Because it’s powerful - and carries risks. The biggest concern? Bone changes. Long-term use of acitretin in growing children has been linked to premature closing of growth plates, which can permanently affect height. Studies from the 1990s and early 2000s showed this risk clearly. One 2003 study of 47 children on acitretin for over a year found that 30% had measurable changes in bone density or growth plate fusion on X-rays.

Another issue is liver toxicity. Acitretin is processed by the liver. Kids with pre-existing liver conditions or those on other medications that stress the liver are at higher risk. That’s why doctors check liver enzymes before starting treatment and every 3 to 6 months after.

And then there’s the cholesterol problem. Acitretin raises triglycerides and LDL (the "bad" cholesterol) in about half of users. In adults, that’s manageable. In kids, especially those already overweight or with a family history of high cholesterol, it’s a red flag.

When do doctors actually prescribe it for kids?

Acitretin isn’t approved by the FDA for children under 12, but it’s used off-label in severe cases - and many pediatric dermatologists have done it for decades. It’s reserved for conditions that:

• Don’t respond to topical treatments (like calcipotriene or coal tar)
• Are unresponsive to phototherapy (UVB light)
• Are causing physical discomfort or emotional distress
• Have been confirmed by biopsy or specialist diagnosis

Common conditions include:

• Generalized pustular psoriasis
• Severe plaque psoriasis covering more than 20% of the body
• Autosomal recessive congenital ichthyosis (ARCI)
• Chronic palmoplantar pustulosis

In these cases, the benefits often outweigh the risks - but only if the treatment is tightly controlled. That means monthly blood tests, regular growth tracking, and no missed appointments.

What are the real side effects parents should watch for?

Not all side effects are obvious. Some are silent. Others are loud.

Common ones - and they’re common in about 1 in 3 kids:

• Dry lips, dry skin, peeling hands and feet
• Nosebleeds
• Itchy or red eyes
• Thinning hair or brittle nails
• Mild headaches

Less common but serious:

• Increased intracranial pressure (headaches, blurred vision, vomiting)
• Depression or mood swings
• Persistent high triglycerides (above 500 mg/dL)
• Abnormal liver enzymes (ALT or AST more than 3x normal)

One thing parents often overlook: sun sensitivity. Acitretin makes skin burn faster. Even a short walk in the sun can cause a bad sunburn. Daily sunscreen (SPF 50+), hats, and avoiding peak sun hours aren’t optional - they’re part of the treatment plan.

How do doctors minimize the risks?

Good doctors don’t just hand out a prescription. They build a safety net.

First, they start low. Most kids begin with 0.5 mg per kg of body weight per day - often around 10 to 25 mg total. That’s much lower than adult doses. They increase it slowly only if needed.

Second, they use it for the shortest time possible. Many kids get relief in 4 to 6 months and then stop. Some go on longer, but only if they’re monitored closely. If growth slows or liver enzymes rise, they stop immediately.

Third, they avoid combining it with other liver-stressing drugs. No methotrexate. No tetracyclines. No excessive acetaminophen. Even some herbal supplements can interfere.

And crucially - they require two forms of birth control for teenage girls. Acitretin causes severe birth defects. Even if a girl isn’t sexually active now, she might be in a few years. The drug stays in the body for up to 3 years after stopping. That’s why the FDA says women must avoid pregnancy for 3 years after the last dose. Pediatric dermatologists apply this rule strictly, even for 13-year-olds.

Are there safer alternatives?

Yes. And they should always be tried first.

For psoriasis:

• Topical calcipotriene and corticosteroids
• Phototherapy (narrowband UVB)
• Topical PDE4 inhibitors like crisaborole
• Biologics like etanercept or ustekinumab (approved for kids as young as 4)

For ichthyosis:

• Emollients with lactic acid or urea
• Humidifiers and daily soaking
• Topical retinoids like tazarotene (used carefully)

Biologics are becoming the go-to for severe cases now. They’re targeted, have fewer systemic side effects, and don’t affect bone growth. But they’re expensive. Insurance often requires trying acitretin first.

So the real question isn’t just "Is acitretin safe?" - it’s "Is it the safest option right now for my child?"

What does long-term follow-up show?

A 2021 study from the European Society for Pediatric Dermatology followed 112 children treated with acitretin for an average of 2.3 years. Most saw significant improvement. Only 8% stopped due to side effects. But:

• 15% had mild bone changes - none affected height or mobility
• 12% had temporary triglyceride spikes - normalized after stopping
• 2% had elevated liver enzymes - resolved with dose reduction

The takeaway? When used carefully, acitretin can be safe for children. But "carefully" means consistent monitoring, low doses, and short duration.

Parents who stick to follow-up appointments and report symptoms early have the best outcomes. Those who skip blood tests or ignore dry skin and nosebleeds are at higher risk.

When should you say no to acitretin?

Don’t use acitretin if your child has:

• Severe liver disease
• Very high triglycerides (above 400 mg/dL)
• Active depression or history of mood disorders
• Significant vitamin A toxicity symptoms (headaches, dizziness, bone pain)
• Is pregnant or planning pregnancy (even in teens)

Also avoid it if your child is under 12 and doesn’t have a life-impacting skin disease. There are gentler options. Acitretin isn’t a cure-all - it’s a last-resort tool.

What should you ask your doctor before starting?

Before signing the consent form, ask:

• "What specific condition are we treating, and why is acitretin the best choice?"
• "What’s the lowest effective dose for my child’s weight?"
• "How often will we check blood work and growth?"
• "What signs should make us stop immediately?"
• "Are there any alternatives we haven’t tried yet?"
• "What’s the plan if we stop - will the condition come back?"

If the doctor can’t answer clearly, get a second opinion. Pediatric dermatology is a specialty for a reason.

Final thoughts: It’s not about fear - it’s about control

Acitretin isn’t a miracle drug. It’s not a first-line option. But for some children, it’s the only thing that brings relief. The key isn’t avoiding it entirely - it’s using it with eyes wide open. With careful dosing, regular monitoring, and honest communication with your doctor, acitretin can be a lifeline - not a danger.

Don’t let fear stop you from asking questions. Don’t let convenience stop you from following up. Your child’s skin may be the problem - but their long-term health is the goal.