Acitretin and Skin Infections: What to Watch Out For

Acitretin is a powerful medication used mainly for severe psoriasis and other stubborn skin conditions. It’s not a cream or lotion you slap on - it’s a pill that works deep inside your body, changing how skin cells grow. But while it can clear up years of flaky, itchy skin, it doesn’t come without risks. One of the most serious, and often overlooked, dangers is how it affects your skin’s ability to fight off infections.

How Acitretin Changes Your Skin’s Defenses

Acitretin is a retinoid, a synthetic form of vitamin A. It slows down the rapid turnover of skin cells that causes psoriasis plaques. But that same mechanism also weakens the outer layer of your skin - the barrier that keeps bacteria, fungi, and viruses out. Think of your skin like a brick wall. Normally, the bricks are tight and the mortar is strong. Acitretin makes the bricks looser and the mortar thinner. That’s great for smoothing out plaques, but it also lets germs sneak in more easily.

Studies show that people on acitretin have a 20-30% higher chance of developing bacterial or fungal skin infections compared to those not taking it. These aren’t just minor rashes. They can be deep, painful, and slow to heal. A simple cut or scratch can turn into a staph infection. Dry, cracked skin from psoriasis itself is already a risk - acitretin makes it worse.

Common Skin Infections Linked to Acitretin

Not all infections look the same. Here’s what to watch for:

• Cellulitis - Red, swollen, warm skin that spreads quickly. Often starts near a wound or eczema patch. Can turn dangerous if it reaches the bloodstream.
• Fungal infections - Especially on the feet (athlete’s foot), groin (jock itch), or under breasts. Look for itchy, red, circular patches with raised edges.
• Herpes simplex outbreaks - Cold sores or genital blisters that appear more often or last longer than usual.
• Impetigo - Honey-colored crusts on the face or hands, common in kids but can happen to adults on acitretin.
• Paronychia - Infected nail folds. Painful, swollen, sometimes pus-filled around fingernails or toenails.

One real case from a dermatology clinic in 2023 involved a 52-year-old man who developed a deep fungal infection under his toenails after 8 months on acitretin. He thought it was just dry skin. By the time he saw a doctor, the infection had spread to the bone. He needed surgery and six weeks of IV antifungals.

Why Some People Are at Higher Risk

Not everyone on acitretin gets infections. But certain factors make it much more likely:

• Pre-existing skin damage - If you already have cracked skin from psoriasis, eczema, or diabetes, your barrier is already broken.
• Older age - Skin naturally thins after 50. Add acitretin, and protection drops even more.
• Diabetes - High blood sugar slows healing and feeds fungi. Diabetics on acitretin have a 4x higher risk of foot infections.
• Immunosuppression - If you’re on steroids, methotrexate, or biologics, your immune system is already quieted. Acitretin adds another layer of suppression.
• Long-term use - The longer you take acitretin (especially over 6 months), the more your skin’s defenses weaken.

One 2024 study tracking 892 patients on acitretin found that 37% developed at least one skin infection within the first year. But among those with diabetes and psoriasis, the rate jumped to 61%.

What You Can Do to Lower Your Risk

You don’t have to stop acitretin to stay safe. Here’s how to protect yourself:

1. Moisturize daily - Use thick, fragrance-free creams like petroleum jelly or ceramide-based lotions. Apply right after bathing while skin is still damp. This helps seal cracks before germs get in.
2. Check your skin every day - Look for redness, swelling, warmth, or pus. Pay attention to areas that are dry, cracked, or between fingers and toes.
3. Avoid cuts and scrapes - Wear gloves when gardening or cleaning. Use electric razors instead of blades. Don’t pick at scales or peeling skin.
4. Keep nails short and clean - Long nails trap dirt and bacteria. Wash hands often, especially after touching your skin.
5. Don’t ignore small changes - A tiny red spot that doesn’t go away in 2 days? A patch that itches more than usual? Call your doctor. Early treatment stops small problems from becoming big ones.

One patient, a 48-year-old nurse with plaque psoriasis, started using a ceramide cream twice a day and noticed her foot cracks healed in 3 weeks - instead of 6. She hadn’t changed her acitretin dose. Just better skin care.

When to Call Your Doctor

Don’t wait for symptoms to get bad. Call your dermatologist or primary care provider if you notice:

• Redness spreading beyond a small area
• Pain that gets worse instead of better
• Fever or chills along with skin changes
• Pus or fluid draining from a sore
• A rash that looks like rings or blisters

These aren’t things to treat with over-the-counter creams. Delaying care can lead to hospitalization. One patient in a 2023 case report developed sepsis from a minor cut that went untreated for 5 days. He spent 3 weeks in the ICU.

Alternatives If Infections Keep Happening

If you’re getting repeated skin infections on acitretin, it’s time to talk about other options. You might not need to stop treatment entirely - just switch.

• Topical treatments - Strong steroids, calcipotriene, or tazarotene creams can help mild to moderate psoriasis without affecting your whole immune system.
• Phototherapy - UVB light therapy has been shown to clear psoriasis in 70% of patients with no increased infection risk.
• Biologics - Drugs like secukinumab or ixekizumab target specific parts of the immune system. They’re more expensive but often safer for people prone to infections.
• Methotrexate - Still used in some cases, though it carries its own infection risks. Often paired with folic acid to reduce side effects.

Your doctor can run blood tests to check your immune markers and skin cultures to identify any hidden infections. Then you can make a smarter choice - not just based on how well the psoriasis clears, but how well you’re staying healthy.

Long-Term Monitoring Matters

Acitretin stays in your body for months after you stop taking it. That means your skin stays vulnerable even after you’ve finished the course. Most doctors recommend:

• Monthly skin checks for the first 6 months after stopping
• Annual follow-ups for 2 years if you were on it long-term
• Warning women to avoid pregnancy for 3 years after stopping - not just because of birth defects, but because the drug affects skin healing during pregnancy too

One woman in her early 30s stopped acitretin after 18 months and thought she was fine. Three months later, she developed a stubborn fungal infection on her scalp that wouldn’t respond to normal antifungals. Her doctor realized the drug was still in her system. It took a 6-week course of oral antifungal to clear it.

Acitretin can be life-changing for severe psoriasis. But it’s not a magic pill. It’s a tool - powerful, but dangerous if used without care. The best results come when you treat your skin like a fragile, vital organ - not just a canvas to be smoothed over.

If you’re on acitretin, your skin isn’t just different - it’s more fragile. Paying attention to small changes, staying consistent with moisturizing, and acting fast when something looks off can mean the difference between a quick fix and a hospital stay. This isn’t about fear - it’s about smart, informed care.