LAUSR

Dear Editor, Chronic actinic dermatitis (CAD) is an immune-mediated photosensitive skin disease, characterized by persistent eczematous skin lesions, predominantly affecting sun-exposed areas. Severe, refractory disease entails use of systemic immunosuppressants like corticosteroids. Apremilast is a phosphodiesterase-4 (PDE-4) inhibitor with broadspectrum anti-inflammatory action. We report a case of steroiddependent CAD patient who responded dramatically to apremilast. A 36-year-old female presented with multiple erythematous lesions on face since 8 years. The lesions were itchy with aggravation on sunlight exposure. Exacerbation was reported in summer season. There was no history of joint pains, muscle weakness or Raynaud's phenomenon. On examination, multiple well-defined erythematous plaques were found on forehead, malar area of cheeks, nose, and philtrum (Figure 1A). Her work-up was unremarkable and antinuclear antibodies were not detected. A diagnosis of CAD was made and she was started on corticosteroids (topical and oral) along with strict photoprotection. Although initial improvement was noted, exacerbation of lesions would occur on tapering steroids. There was no response to steroid-sparing agents including azathioprine, cyclosporine, and hydroxychloroquine. The patient became steroid dependent and started developing steroid toxicity features like weight gain, hypertension, and peptic ulcers. After discussing treatment options with the patient, she was started on oral apremilast (Aprezo, Glenmark Pharmaceutical Ltd, India), initially at 10 mg/day, gradually hiked to 30 mg/day over 1 week. Topical low-potency steroids and low dose oral corticosteroids were continued. Significant improvement in skin lesions was noted within 4 weeks of starting apremilast and by 6 weeks of therapy, there was complete clearance of lesions for the first time in 8 years (Figure 1B). Steroids (topical as well as oral) were completely tapered over next 4 weeks and apremilast was continued. No recurrence of lesions