Recalcitrant Pediatric Facial Vitiligo Successfully Treated with Roflumilast Cream 0.3% Once Daily

Vitiligo is an autoimmune disorder that causes melanocyte damage and pigment loss. The clinical presentation of vitiligo consists of patchy areas of lighter skin and results from a loss of functioning melanocytes and may be more visible in darker skin toned patients. Vitiligo affects approximately 2 percent of children and adolescents in the United States, with half of the affected cases undiagnosed. Pediatric patients are at a high risk of experiencing psychosocial adverse events such as depression and anxiety if the vitiligo is not quickly or effectively treated due primarily to the visual presentation of the disease. These adverse events may be seen especially in patients with a darker skin tone. Treatments for pediatric vitiligo in the past has usually included phototherapy, topical corticosteroids, vitamin D and calcineurin inhibitors; topical ruxolitinib has been approved more recently for nonsegmental vitiligo in patients 12 years of age and older. In cases where disease is recalcitrant, the need for additional therapies is warranted. Roflumilast cream 0.3% is a highly selective, non-steroidal and potent topical phosphodiesterase 4 inhibitor approved in 2022 by the United States Food and Drug Administration for the treatment of psoriasis, in 2023 as a foam for the treatment of seborrheic dermatitis and in 2024, roflumilast cream 0.15% was approved for the treatment of atopic dermatitis, including in children down to six years of age. Topical roflumilast is well tolerated with a favorable safety profile among pediatric dermatology populations. We describe four cases of pediatric skin of color patients with facial vitiligo that were refractory to topical corticosteroids, ruxolitinib and phototherapy. All patients were started on roflumilast cream 0.3% once daily and demonstrated improvement in repigmentation.