Limited coverage criteria – alitretinoin

Generic name	alitretinoin
Strength & form	10 mg, 30 mg capsule

Special Authority criteria	Approval period
For the treatment of severe chronic hand eczema in patients meeting ALL the following criteria: Refractory to 2 months of high or ultra-high potency topical steroids AND Dermatology Life Quality Index equal to or greater than 15 AND When a Special Authority request is submitted by a dermatologist	24 weeks

Practitioner exemptions

• None

Special notes

• High or ultra-high potency corticosteroids include: clobetasol proprionate 0.05%, betametasone dipropionate 0.05%, betamethasone dipropionate glycol 0.05%, desoximetasone 0.25%, fluocinonide 0.05%, halcinonide 0.1%, halobetasol propionate 0.05% and amcinonide 0.1%
• The Dermatology Life Quality Index (DLQI) is a 10-question validated questionnaire designed to measure how dermatology-specific issues affect a patient’s quality of life. The 10 questions are measured according to a three-point scale. Sum-total DLQI scores and their meaning for patients are as follows:
  • 0-1 = no effect at all on patient's life
  • 2-5 = small effect on patient's life
  • 6-10 = moderate effect on patient's life
  • 11-20 = very large effect on patient's life
  • 21-30 = extremely large effect on patient's life
• The need for continued alitretinoin treatment should be reassessed:
  • As soon as an adequate response (hands clear or almost clear) has been achieved, or
  • If the eczema remains severe at 12 weeks, or
  • If an adequate response (hands clear or almost clear) has not been achieved by 24 weeks
• PharmaCare coverage is limited to one dose per day

Special Authority request form(s)

• Log in to eForms
• HLTH 5328 - General Special Authority request (PDF, 656KB)