Roflumilast Cream 0.3% for the Treatment of Recalcitrant Lichen Nitidus

Abstract

Introduction:
 Lichen nitidus is a rare chronic inflammatory condition that presents as shiny, flat-topped papules. The pathophysiology of lichen nitidus is not well understood but has been theorized to stem from allergens that cause antigen presenting cells to activate, thus causing a cell-mediated response that ultimately creates the distinct inflammatory papules1. Cytokines produced by this cell-mediated response may cause an increase in T-helper 2 cells which have the potential to produce the superficial dermal granulomas seen in lichen nitidus2.  Currently, no FDA approved treatments for lichen nitidus exist. Due to the inflammatory nature of the disease, off-label therapies may include topical corticosteroids, topical calcineurin inhibitors and UV light1. Lichen nitidus can be a chronic condition and in cases where long term topical corticosteroid use is required, has been associated with hypopigmentation in African Americans. Roflumilast cream 0.3% is a highly selective, non-steroidal and potent topical phosphodiesterase 4 (PDE4) inhibitor approved in 2022 by the FDA for the treatment of psoriasis, including intertriginous disease. Here, we report the case of a 51-year-old African American patient with lichen nitidus that is pruritic and refractory to typical off-label treatments including emollients, triamcinolone and clobetasol. The patient was started on roflumilast cream 0.3% daily with complete resolution of lesions and pruritus in 4 weeks.
  
 Case Report:
 We report the case of a 51-year-old African American patient presenting to the clinic with a history of firm, pruritic, white colored papules on both of his hands that made it hard for him to drive. These lesions had been present for 2 years and did not respond to previous treatment with emollients and topical corticosteroids including triamcinolone cream 0.1% and clobetasol ointment 0.05% both twice daily. A biopsy was performed and demonstrated lymphocytic infiltrate in the upper dermis and the classic “claw and ball” configuration consistent with lichen nitidus. The patient was subsequently started on topical roflumilast 0.3% daily which resulted in complete resolution of lesions and pruritus within 4 weeks.
  
 Conclusion:
 We reported a case of a 51-year-old African American papules on both hands that were consistent with lichen nitidus. In this case, the patient’s lichen nitidus was refractory to topical corticosteroids and emollients. Long term corticosteroid use is also associated with hypopigmentation in this population. After starting topical roflumilast 0.3% daily, the patient reported complete resolution of the lesions and puritus. This report suggests reduction of inflammation with roflumilast cream 0.3%, can offer a treatment option for patients with lichen nitidus.