Ashley O’Toole, MD, MSc, FRCPC1-3 and Melinda Gooderham, MD, MSc, FRCPC1-3

1SKiN Centre for Dermatology, Peterborough, ON, Canada
2Probity Medical Research, Waterloo, ON, Canada
3Queen’s University, Kingston, ON, Canada

Conflict of interest: A. O’Toole has been an investigator, speaker, or advisory board member for, or received a grant, or an honorarium from AbbVie, Amgen, Arcutis Biotherapeutics, ASLAN Pharmaceuticals, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Dermira, Dermavant, Eli Lilly, Galderma, GSK, Incyte, Janssen, LEO Pharma, Moonlake, Nimbus, Novartis, Pfizer, Regeneron, Sanofi-Aventis/Genzyme, Sun Pharma, UCB and Ventyx. M. Gooderham has been an investigator, speaker, or advisory board member for, or received a grant, or an honorarium from AbbVie, Akros Pharma, Amgen, AnaptysBio, Arcutis Biotherapeutics, Aristea, ASLAN Pharmaceuticals, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Coherus, Dermira, Dermavant, Eli Lilly, Galderma, GSK, Incyte, Janssen, Kyowa Kirin, LEO Pharma, MedImmune, Moonlake, Nimbus, Novartis, Pfizer, Regeneron, Reistone, Roche, Sanofi-Aventis/Genzyme, Sun Pharma, UCB and Ventyx.
Funding: None.

Abstract:
Roflumilast is a highly selective phosphodiesterase-4 inhibitor for the treatment of plaque psoriasis. Topical roflumilast 0.3% cream, approved by the US FDA and Health Canada for use in adolescents and adults, has proven efficacy and tolerability. It is non-steroidal, administered once-daily, and highly potent, with a unique delivery formulation. It can be used on most body areas, including the sensitive intertriginous regions and face. Herein, we review the safety and efficacy of roflumilast 0.3% cream, as demonstrated in clinical trials.

Keywords: roflumilast, PDE4 inhibitor, topical therapy, plaque psoriasis, intertriginous psoriasis, inverse psoriasis


Introduction

Plaque psoriasis is a chronic inflammatory skin condition with an estimated prevalence of 3%1 and is characterized by scaly plaques which can be red to violaceous depending on the background color of skin. Psoriasis most commonly presents on the extensor surfaces but can involve anywhere on the body, including the scalp, face, and intertriginous areas. Most cases of plaque psoriasis are mild to moderate in severity, where half of patients have a body surface area (BSA) ≤3% and three-quarters have a BSA ≤10%.1 Psoriasis significantly impacts quality of life, with the majority of patients reporting a “large impact” on their everyday life, even in those with limited BSA involvement.2 Impact on quality of life is greater with special site involvement (i.e., face, groin, palms/soles) compared to no special site involvement.3 Itch is considered the most bothersome symptom in plaque psoriasis by almost half of patients.3,4

The mainstay of treatment is topical including steroids, vitamin D analogs, retinoids, and calcineurin inhibitors (used off label), whether used as monotherapy in mild to moderate disease or as concomitant therapy with systemic agents in moderate to severe disease. Current topical therapies have limitations, however, including messy or greasy texture, complex or time-consuming application, local side effects, or perceived inefficacy, which can all lead to lack of adherence to treatment and poor outcomes.5 Indeed, almost 80% of patients with a BSA of ≤10% were very dissatisfied with their treatment in one US survey.2

Pathophysiology of Psoriasis and Role of Phosphodiesterase-4

Environmental, genetic, and immunologic factors play a role in this complex, chronic, multifactorial inflammatory disease that involves hyperproliferation of the keratinocytes with an increase in epidermal cell turnover rate. Phosphodiesterase-4 (PDE4) is a key enzyme involved in immune cell homeostasis. Elevated PDE4 activity in psoriatic skin leads to an increase in pro-inflammatory pathogenic mediators underlying plaque psoriasis,6 making PDE4 a suitable target in disease management. PDE4 inhibitors have been approved for use in dermatology, including oral apremilast for moderate to severe plaque psoriasis (and psoriatic arthritis) and crisaborole ointment for mild to moderate atopic dermatitis. Roflumilast is a selective and highly potent inhibitor of PDE4,7 resulting in an increase in cyclic 3′,5′-adenosine monophosphate (cAMP) activity and subsequent decrease in the expression levels of key pro-inflammatory mediators of psoriasis including interleukin (IL)-17, IL-23, interferon‐gamma and tumor necrosis factor-alpha.6 Reducing pro-inflammatory mediators helps balance the immune response and normalizes keratinocyte differentiation.6 Roflumilast has greater affinity for PDE4 than the other currently available PDE4 inhibitors used to treat skin disease; depending on the comparator and isoform analyzed, it is approximately 25-300 times more potent than apremilast and crisaborole.7-9

Topical Roflumilast

Topical roflumilast 0.3% cream (ZoryveTM) was approved by the US FDA for the treatment of plaque psoriasis including intertriginous psoriasis in adolescents (aged ≥12 years) and adults in July 2022, with Health Canada approval gained in April 2023. It is uniquely formulated as an emollient water-based cream designed to deliver the roflumilast molecule throughout the epidermis without disrupting the skin’s barrier function or extracting lipids from the epidermis. A unique and patented emulsifier blend (CrodafosTM CES) maintains the integrity of the lipid bilayer while facilitating delivery of roflumilast. The composition of CrodafosTM CES includes cetearyl alcohol, dicetyl phosphate, and ceteth-10 phosphate which allows roflumilast to diffuse through the epidermis by saturating the stratum corneum and subsequently entering the dermis via the intracellular space. The formulation does not contain ingredients such as propylene glycol or fragrance, resulting in improved tolerability (compared to some other topicals currently available). Topical roflumilast 0.3% cream is also found in higher concentrations in the skin compared to that expected with oral dosing, with levels 61.8- to 126-fold higher in the skin compared to plasma.10 The lipophilic, protein-affinity and water-insoluble properties of topical roflumilast leads to reservoir formation in the stratum corneum and prolonged release into the skin and systemic circulation. In fact, topical roflumilast has a long half-life of 4 days,10 affording the ability for once-daily dosing, high efficacy and improved tolerability. The tolerability and low rate of adverse effects are attributable to reduced bioavailability in the topical form compared to the oral form of roflumilast.10

Clinical Trials: Efficacy and Safety of Roflumilast

Topical roflumilast has proven efficacy and safety in multiple clinical trials. A Phase 1/2a randomized controlled trial (NCT03392168) tested roflumilast cream 0.5%, 0.15% vs. vehicle for 28 days in patients with ≤5% BSA.11 The primary endpoint was met with significant improvement in the Target Plaque Severity Score (TPSS) x target plaque area (TPA) with roflumilast 0.5% (P = .0007) and 0.15% cream (P = .0011) vs. vehicle; 66%-67% improvement from baseline to week 4 was noted with roflumilast vs. 38% for vehicle.11

In a Phase 2b randomized double-blinded controlled trial (NCT03638258), 331 adult patients were randomized 1:1:1 to receive roflumilast cream 0.3%, 0.15%, or vehicle once daily for 12 weeks. The primary endpoint at 6 weeks of an Investigator Global Assessment (IGA) score of clear or almost clear (0 or 1) was reached by 28% in the roflumilast 0.3% group (P < .001), 23% in the roflumilast 0.15% group (P = .004), and 8% in the vehicle group (Figure 1A). The mean change in Psoriasis Area and Severity Index (PASI) from baseline at week 6 was -50.0%, -49.0%, and -17.8%, in roflumilast 0.3%, roflumilast 0.15%, and vehicle, respectively. Important secondary endpoints included an intertriginous IGA (I-IGA) response (clear or almost clear and ≥2 grade improvement from baseline) in 73% of the roflumilast 0.3% group, 44% of the roflumilast 0.15% group, and 29% of the vehicle group in the subgroup of participants with at least mild IGA intertriginous involvement (~15% of trial population).12 Itch and itch-related sleep loss were also improved in subjects receiving roflumilast. Subjects with a baseline worst itch numeric rating scale (WI-NRS) ≥6 treated with roflumilast 0.3% cream achieved ≥4-point improvement compared with vehicle, which was significant at all time points between week 2 and week 12 (all P < .05).13 The least squares mean improvement in itch-related sleep loss was statistically significant for both doses of roflumilast as early as week 6 and maintained through week 12.13

Topical Roflumilast for Plaque Psoriasis - image
Figure 1A. Phase 2b, IGA clear or almost clear at week 6

Two identical pivotal Phase 3 trials, DERMIS-1 (NCT04211363) and DERMIS-2 (NCT04211389), enrolled patients older than 2 years of age, with 2% to 20% BSA and an IGA of at least 2 (mild).14 A total of 439 and 442 subjects were enrolled (DERMIS-1 and DERMIS-2, respectively) and randomized 2:1 to receive roflumilast cream 0.3% or vehicle. The primary endpoint was achieving IGA success (clear or almost clear [0 or 1] with ≥2 grade improvement from baseline) at 8 weeks. IGA success was achieved by participants receiving roflumilast 0.3% cream vs. vehicle by 42.4% and 6.1% (DERMIS-1) and by 37.5% and 6.9% (DERMIS-2), respectively (P < .001 for both) as shown in Figure 1B. Important secondary endpoints included I-IGA success at week 8, 75% improvement in PASI (PASI75) at week 8, and itch improvement as measured by WI-NRS at weeks 2, 4, and 8. In participants with an I-IGA score of at least 2 at baseline (approximately 20% of trial population), I-IGA success at week 8 was achieved by 71.2% vs. 13.8% (DERMIS-1) and 68.1% vs. 18.5% (DERMIS-2) in roflumilast 0.3% cream vs. vehicle, respectively.14 The majority of patients achieving I-IGA success also achieved an I-IGA score of clear (0) with 63.5% vs. 10.3% (DERMIS-1) and 57.4% vs. 7.4% (DERMIS-2) (P < .001) clearing intertriginous areas with roflumilast 0.3% vs. vehicle, respectively. PASI75 was reached with roflumilast 0.3% vs. vehicle in 41.6% vs. 7.6% (P < .001) and 39% vs. 5.3% (P < .001) in DERMIS-1 and DERMIS-2, respectively. Itch, the most bothersome symptom of psoriasis, also improved in patients with a baseline WI-NRS score of ≥4 at baseline. WI-NRS reduction of at least 4 points from baseline was achieved as early as week 2 in 34.9% vs. 22% (DERMIS-1, P = .12) and 41.9% vs. 21.1% (DERMIS-2, P = .003) and at week 8 in 67.5% vs. 26.8% (DERMIS-1, P < .001) and 69.4% vs. 35.6% (DERMIS-2, P < .001).14

Figure 1B. Phase 3 (DERMIS-1, DERMIS-2) IGA success at week 8

Topical roflumilast was well tolerated with rates of treatment emergent adverse effects (TEAEs) similar in both groups: DERMIS-1 (roflumilast: 25.2% and vehicle: 23.5%) and DERMIS-2 (roflumilast: 25.9% and vehicle: 18.9%).14 Less than 1% of patients in any group experienced a serious adverse event. Rates of discontinuation due to TEAEs were low and similar between groups. The most commonly reported TEAEs were headache and diarrhea consistent with the effects of oral PDE4 inhibition, but present at much lower rates than seen with oral agents. Diarrhea was mild to moderate and reported in 3.5% and 2.8% of participants receiving roflumilast in DERMIS-1 and DERMIS-2, respectively, compared to none in the vehicle group. No patients interrupted therapy or discontinued due to diarrhea.14 Headache was reported in 1% and 3.8% in the roflumilast group and 1.3% and 0.7% in the vehicle group. The cream was well tolerated with low rates of application site pain: DERMIS-1 (roflumilast: 0.7% and vehicle: 0.7%) and DERMIS-2 (roflumilast: 1.4% and vehicle: 0%). Investigator-rated tolerability was consistent with patient-rated tolerability, with 98- 99% of roflumilast patients and 98% of vehicle patients showing no signs of irritation and 99% of patients reporting ‘no or mild’ sensation with application when assessed at both weeks 4 and 8.14

Long-term Use of Topical Roflumilast

Long-term use of roflumilast was investigated in a 52-week openlabel extension (OLE) of the Phase 2b study.15 There were two cohorts in the OLE: cohort 1 (n=230) was comprised of patients who completed the initial 12-week phase of the Phase 2b study (for a total of 64 weeks of therapy), and cohort 2 (n=102) had naïve patients with a diagnosis of at least mild psoriasis for a minimum of 6 months. The completion rate after 52 weeks was 73.5%, with low rates of discontinuation due to TEAEs or inefficacy, and the majority of discontinuations were due to withdrawal or loss of follow-up. The proportion of patients achieving IGA success was consistent over time, with 34.8% of cohort 1 patients and 39.5% of cohort 2 patients achieving IGA success with 64 weeks and 52 weeks of as-needed therapy, respectively. I-IGA success was achieved by 60% at week 12 and maintained by 66.7% of cohort 2 patients by week 52 but was not recorded in cohort 1 patients. Of the patients who achieved clear or almost clear skin during the open label portion, the mean durability of maintaining their response was 10 months.16 Topical roflumilast was well tolerated in the OLE, with the majority of TEAEs rated mild or moderate, 97% considered unrelated to treatment, and ≥97% showed no signs of irritation on physician assessment.15

Discussion

PDE4 inhibition with topical roflumilast is a promising non-steroidal option for patients with plaque psoriasis of varying severities. Key data from the pivotal trials, DERMIS-1 and DERMIS-2, report IGA success in approximately 40% of study participants with psoriasis ranging from mild to severe. Results are supported by earlier phase studies measured at earlier time points. IGA success was noted as early as week 4, and responses were maintained to week 64 with as-needed use, suggesting that once a response is obtained, it can likely be sustained over time. Itch, the most bothersome symptom of plaque psoriasis, improved by 2 weeks (the first assessed time point) in all studies and itch improvement maintained over time. Itch-related sleep loss also improved compared to vehicle. Early responses such as itch and sleep improvement can encourage adherence to therapy and improve outcomes.

Given the spectrum of obstacles in the treatment of plaque psoriasis, including patient adherence and tolerance with topical therapies, as well as the management of itch and special sites (e.g., scalp and intertriginous areas), topical roflumilast appears to address these challenges. Individuals with psoriasis are often prescribed multiple topical medications to treat different skin areas, which contributes to a complicated treatment regimen and patient non-adherence. Topical roflumilast addresses this significant unmet need with its once-daily, non-steroidal and carefully designed vehicle that is appropriate for use on most body areas, avoiding the need for multiple prescriptions and simplifying the treatment regimen. A foam formulation is also being developed for use on the body and scalp.

The PASI75 responses noted with topical roflumilast were also comparable with a recent trial of oral apremilast for patients with mild to moderate psoriasis (ADVANCE trial, NCT03721172).17 With similar baseline characteristics (PASI 6-7, BSA 6-7% and the majority of patients with IGA 3 or moderate severity) in DERMIS-1/ DERMIS-2 and the ADVANCE trial, the proportion of patients achieving PASI75 were similar or better with roflumilast compared to oral apremilast. In ADVANCE, 21.6% of those receiving oral apremilast 30 mg twice daily achieved PASI75 compared to 4.1% receiving placebo at 16 weeks. In DERMIS-1 and DERMIS-2, after 8 weeks of therapy, 41.6% and 39% of roflumilast patients achieved PASI75 compared to 7.6% and 5.3% of vehicle patients, respectively. The comparability of a topical therapy demonstrating efficacy that is similar to or better than an oral PDE4 agent such as apremilast, can be explained by the properties of topical roflumilast, which include the lipophilicity and reservoir in the stratum corneum combined with the higher affinity of roflumilast for PDE4. In patients with mild to moderate psoriasis, topical roflumilast may potentially delay or even avoid the need for oral therapy by providing similar efficacy. The limitation will be patients with higher BSA where the risk of TEAEs, such as diarrhea, may be higher or those with psoriatic arthritis where a systemic therapy may be preferred.

Conclusion

Targeting PDE4 with a highly selective inhibitor such as roflumilast is a proven effective strategy for the treatment of plaque psoriasis. Topical roflumilast cream 0.3%, already approved by Health Canada and the FDA for use in adolescents and adults, has demonstrated efficacy and tolerability. It is non-steroidal, administered oncedaily, and highly potent, yet delivered in a cosmetically elegant formulation that is well tolerated by patients. It can be used on most body areas, including the sensitive intertriginous regions and face, making one product suitable for treating all areas of involvement. Topical roflumilast will offer patients and their health care providers a simple, convenient, safe, effective, and durable therapeutic option for the management of psoriasis.

References



  1. Papp KA, Gniadecki R, Beecker J, et al. Psoriasis prevalence and severity by expert elicitation. Dermatol Ther (Heidelb). 2021 Jun;11(3):1053-64.

  2. Stern RS, Nijsten T, Feldman SR, et al. Psoriasis is common, carries a substantial burden even when not extensive, and is associated with widespread treatment dissatisfaction. J Investig Dermatol Symp Proc. 2004 Mar;9(2):136-9.

  3. Lebwohl M, Langley RG, Paul C, et al. Evolution of patient perceptions of psoriatic disease: results from the understanding psoriatic disease leveraging insights for treatment (UPLIFT) survey. Dermatol Ther (Heidelb). 2022 Jan;12(1):61-78.

  4. Lebwohl MG, Bachelez H, Barker J, et al. Patient perspectives in the management of psoriasis: results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis Survey. J Am Acad Dermatol. 2014 May;70(5):871-81 e1-30.

  5. Bewley A, Page B. Maximizing patient adherence for optimal outcomes in psoriasis. J Eur Acad Dermatol Venereol. 2011 Jun;25 Suppl 4:9-14.

  6. Li H, Zuo J, Tang W. Phosphodiesterase-4 inhibitors for the treatment of inflammatory diseases. Front Pharmacol. 2018 9:1048.

  7. Schafer PH, Parton A, Capone L, et al. Apremilast is a selective PDE4 inhibitor with regulatory effects on innate immunity. Cell Signal. 2014 Sep;26(9):2016-29.

  8. Hatzelmann A, Morcillo EJ, Lungarella G, et al. The preclinical pharmacology of roflumilast–a selective, oral phosphodiesterase 4 inhibitor in development for chronic obstructive pulmonary disease. Pulm Pharmacol Ther. 2010 Aug;23(4):235-56.

  9. Dong C, Virtucio C, Zemska O, et al. Treatment of skin inflammation with benzoxaborole phosphodiesterase inhibitors: selectivity, cellular activity, and effect on cytokines associated with skin inflammation and skin architecture changes. J Pharmacol Exp Ther. 2016 Sep;358(3):413-22.

  10. Thurston AW, Jr, Osborne DW, Snyder S, et al. Pharmacokinetics of roflumilast cream in chronic plaque psoriasis: data from phase I to phase III studies. Am J Clin Dermatol. 2023 Mar;24(2):315-24.

  11. Papp KA, Gooderham M, Droege M, et al. Roflumilast cream improves signs and symptoms of plaque psoriasis: results from a phase 1/2a randomized, controlled study. J Drugs Dermatol. 2020 Aug 1;19(8):734-40.

  12. Lebwohl MG, Papp KA, Stein Gold L, et al. Trial of roflumilast cream for chronic plaque psoriasis. N Engl J Med. 2020 Jul 16;383(3):229-39.

  13. Stein Gold L, Alonso-Llamazares J, Draelos ZD, et al. Effect of roflumilast cream (ARQ-151) on itch and itch-related sleep loss in adults with chronic plaque psoriasis: patient-reported itch outcomes of a phase 2b trial. Am J Clin Dermatol. 2023 Mar;24(2):305-13.

  14. Lebwohl MG, Kircik LH, Moore AY, et al. Effect of roflumilast cream vs vehicle cream on chronic plaque psoriasis: the DERMIS-1 and DERMIS-2 randomized clinical trials. JAMA. 2022 Sep 20;328(11):1073-84.

  15. Stein Gold L, Gooderham M, Papp K, et al. Long-term safety and efficacy of roflumilast cream 0.3% in adult patients with chronic plaque psoriasis: results from a 52-week, phase 2b open-label study. Presented at: Innovations in Dermatology: Virtual Spring Conference 2021; March 16-20, 2021.

  16. Stein Gold L, Gooderham M, Papp K, et al. Long-term safety and efficacy of roflumilast cream 0.3% in adult patients with chronic plaque psoriasis: results from a 52-week, phase 2b open-label study. Presented at: Innovations in Dermatology: Virtual Spring Conference 2021; March 16-20, 2021.

  17. Lebwohl M, Stein Gold L, Gooderham M, et al. Durability of efficacy and safety of roflumilast cream 0.3% in adults with chronic plaque psoriasis from a 52-week, phase 2 open-label safety trial. Presented at: Winter Clinical Dermatology Conference Hawaii 2023; January 13-18, 2023.

  18. Stein Gold L, Papp K, Pariser D, et al. Efficacy and safety of apremilast in patients with mild-to-moderate plaque psoriasis: results of a phase 3, multicenter, randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol. 2022 Jan;86(1):77-85.


Purchase Article PDF for $1.99