Vitiligo Successfully Treated With Roflumilast Cream 0.3%

Vitiligo is an autoimmune cutaneous depigmenting disorder whereby melanocytes are damaged or destroyed, leading to white macules that typically present on the face, forearms, hands, and feet.^1-6 A diagnosis of vitiligo can have significant psychological impacts on affected patients and poses a burden to daily life.² Furthermore, for patients with deeper Fitzpatrick skin tones, the vitiligo can be more apparent and pose a more significant psychological challenge.² Therefore, it is essential to encourage early treatment and explore a variety of treatment options to limit the psychological effects of the disease.

Research investigating vitiligo pathogenesis is ongoing and has afforded more knowledge on treatment options for patients.^3-7 Topical treatments currently available for adult vitiligo include phototherapy, topical corticosteroids, vitamin D, calcineurin inhibitors, as well as therapies that have more targeted mechanisms of action, such as topical ruxolitinib, the first janus kinase (JAK) inhibitor approved for non-segmental vitiligo.^3-7 However, some patients experience recalcitrant vitiligo and require additional treatment options.⁷

Topical roflumilast is a phosphodiesterase 4 (PDE4) inhibitor that is approved to treat atopic dermatitis, plaque psoriasis, and seborrheic dermatitis. Roflumilast cream 0.3% is currently approved in Canada (12 years of age and up) and in the United States (6 years of age and up) for the topical treatment of plaque psoriasis, including intertriginous areas, and at a lower strength of 0.15% for patients 6 years of age and older with atopic dermatitis. Topical roflumilast foam 0.3% is approved for seborrheic dermatitis in patients aged nine and above. Roflumilast has been shown to promote increased melanocyte proliferation and an increase in melanogenic gene and protein expression in cultured melanocytes.⁸ It has also been shown to protect melanocytes from apoptosis.⁹ This promising evidence suggests there is potential for therapeutic use in vitiligo patients. Recent research with pediatric patients also demonstrated successful treatment of recalcitrant facial vitiligo with roflumilast cream 0.3% applied once daily.¹⁰ Here we report the case of an adult patient with skin of colour treated with roflumilast cream 0.3% following an unsatisfactory response to typical treatments. Treatment resulted in almost full repigmentation on the forehead and cheeks. Proper informed consent was obtained for photography, including for their use in publications that will be distributed.

A 37-year-old male presented with a history of vitiligo from the age of 13 years with recent spread affecting his forehead, cheeks, forearm, and hands. The patient was not treated for his condition in the past, and recently immigrated to Canada. Upon initial presentation, the patient was initiated on a trial regimen of twice-daily application of tacrolimus ointment 0.1% Monday through Friday, twice-daily application of betamethasone valerate 0.1% on weekends, and narrowband ultraviolet B therapy. He returned after two weeks and showed limited improvement, complaining of skin irritation and burning upon application (Figure 1A). The patient was switched to roflumilast cream 0.3% daily application combined with narrow ultraviolet B phototherapy. Patient returned 4 months later and demonstrated marked improvement (Figure 1B) and again returned for follow-up 7 months post initiation (Figure 1C). Patient will continue treatment with once daily application with regular follow up. No adverse reactions were noted.