Alitretinoin versus phototherapy as the first-line treatment in adults with severe chronic hand eczema: the ALPHA RCT

Wittmann, Miriam and Smith, Isabelle L and Brown, Sarah Tess and Berekméri, Anna and Vargas-Palacios, Armando and Sunderland, Lesley and Barker, Amy and Cowdell, Fiona and Ersser, Steven and Gilberts, Rachael and Green, Cathy and Hampton, Philip and Smith, Catherine and Nixon, Jane (2024) Alitretinoin versus phototherapy as the first-line treatment in adults with severe chronic hand eczema: the ALPHA RCT. Health Technology Assessment, 28 (59). ISSN 2046-4924

Preview

Text
3046260-1.pdf - Published Version
Available under License Creative Commons Attribution.
Download (5MB)

Official URL: http://dx.doi.org/10.3310/TWQC0141

Abstract

Background

Hand eczema is common and a cause of morbidity and occupational disability. When education, irritant/contact allergen avoidance, moisturisation and topical corticosteroids are insufficient to control chronic hand eczema, ultraviolet therapy or systemic immune-modifying drugs are used. There is no treatment pathway generally accepted by UK dermatologists.
Primary objective

Compare alitretinoin and ultraviolet therapy as first-line therapy in terms of disease activity at 12 weeks post planned start of treatment.
Design

Prospective, multicentre, open-label, two-arm parallel group, adaptive randomised controlled trial with one planned interim analysis, and an economic evaluation.
Setting

UK secondary care dermatology outpatient clinics.
Participants

Patients with severe chronic hand eczema unresponsive to at least 4 weeks of treatment with potent topical corticosteroids.
Primary end point

Natural logarithm of the Hand Eczema Severity Index + 1, 12 weeks post planned start of treatment.
Randomisation

Participants randomised 1 : 1 by minimisation to alitretinoin or ultraviolet therapy for 12 to 24 weeks.
Blinding

Blinded primary end-point assessor.
Results

Intention-to-treat population: 441 (100.0%) participants; 220 (49.9%) alitretinoin and 221 (50.1%) ultraviolet therapy. At least one dose was received by 212 (96.4%) alitretinoin and 196 (88.7%) ultraviolet therapy participants.
Primary outcome

The unadjusted median (interquartile range) relative change in hand eczema severity index at 12 weeks was 30% (10–70%) of that at baseline for alitretinoin compared with 50% (20–100%) for ultraviolet therapy. There was a statistically significant benefit of alitretinoin compared with ultraviolet therapy at 12 weeks, with an estimated fold change or relative difference (95% confidence interval) = 0.66 (0.52 to 0.82), p = 0.0003 at 12 weeks. There was no evidence of a difference at 24 or 52 weeks, with the estimated fold change (95% confidence interval) equal to 0.92 (0.798 to 1.08) and 1.27 (0.97 to 1.67), respectively.
Primary analysis results were consistent for secondary end points

Fifty-nine per cent allocated to alitretinoin and 61% allocated to ultraviolet therapy achieved a clear/almost clear assessment during the trial period.

Differential treatment compliance observed: 145 (65.9%) alitretinoin and 53 (24.0%) ultraviolet therapy participants confirmed compliance (≥ 80% received, no treatment breaks > 7 days during first 12 weeks). High levels of missing data were observed.
Safety

One hundred and thirty-five reportable adverse events across 79 participants, 55 (25.0%) alitretinoin and 24 (10.9%) ultraviolet therapy. Four serious adverse events (two alitretinoin, two ultraviolet therapy). Four pregnancies reported (three alitretinoin, one ultraviolet therapy). No new safety signals were detected.
Conclusion

As a first-line therapy, alitretinoin showed more rapid improvement and superiority to ultraviolet therapy at week 12. This difference was not observed at later time points.

Alitretinoin is cost-effective at weeks 12 and 52. Ultraviolet therapy is cost-effective after 10 years, with a high degree of uncertainty.

Hand eczema severity index may be a useful primary outcome measure for hand eczema trials; ALPHA results will inform future trials.
Limitations

Treatment compliance was poor for ultraviolet therapy. Regular twice weekly treatment was not received by most patients. Assessment of long-term effects of randomised treatments was complicated by use of second-line treatments post treatment phase.
Further work

Further analysis of substudies and pilot data will provide valuable information for future studies.

A clear need for better therapeutic approaches for severe chronic hand eczema remains. Future studies will need to further address long-term benefits of treatments given.

Item Type:	Article
Identification Number:	10.3310/TWQC0141
Dates:	Date Event 1 October 2024 Accepted 1 October 2024 Published Online
Subjects:	CAH02 - subjects allied to medicine > CAH02-04 - nursing and midwifery > CAH02-04-02 - adult nursing
Divisions:	Faculty of Health, Education and Life Sciences > College of Nursing and Midwifery
Depositing User:	Gemma Tonks
Date Deposited:	17 Oct 2024 14:09
Last Modified:	17 Oct 2024 14:09
URI:	https://www.open-access.bcu.ac.uk/id/eprint/15906