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Excellent response to 1% benvitimod cream in a 9‐year‐old girl with vulvar psoriasis

Dear Editor, Vulvar psoriasis (VP) is a rare manifestation of psoriasis, commonly characterized by bilaterally symmetrical, well-demarcated erythema or slightly raised plaque with pruritus. The diagnosis in children is very difficult and the treatment usually requires long-term management. Benvitimod, also known as tapinarof and GSK2894512, is a new aryl hydrocarbon receptor (AhR) modulating therapeutic drug, which down-regulates IL-17 and attributes to the skin barrier normalization. Recent clinic trials have demonstrated its safety and efficacy in patients with mild to severe plaque psoriasis in adult. However, there are very few researches on the treatment for children/adolescent or sensitive skin areas. In this study, we report a 9-year-old girl with refractory VP successfully treated with benvitimod alone who had an unsatisfactory response to traditional topical treatment. A 9-year-old girl presented to our clinic with a 6-month history of well-demarcated and symmetrical erythema with absence of scale on the vulva, which gradually expanded and affected the perianal and the labia majora. There is no rash at other sites. She complained about severe itching of the genital region. She was diagnosed as tinea corporis and eczema by other hospitals, and has tried different therapies such as antifungal creams, topical corticosteroids and calcineurin inhibitors, with no any significant benefitand even worsening symptoms. Physical examination revealed well-demarcated and symmetrical erythema without scale on the vulva and perianal,the edge of the skin lesion was clear (Figure 1A). Dermoscopy showed homogeneously distributed “red dots” on erythematous background (Figure 1B). She had no vaginal discharge and infectious causes were ruled out. Pathological biopsy was not conducted considering the age and the special site of the patient. Based on clinical presentation and dermoscopy findings, the diagnosis of VP was made. Topical 1% benvitimod cream (approval number: national medicine standard H20190026, production address: Zhongshan, China) was applied thinly on the lesional area twice daily. Three weeks after the treatment, the patient exhibited remarkable improvement of the erythema and itching. After 3 months, almost complete remission of cutaneous lesions with pigmentation was observed (Figure 1C). Patient achieved PASI 95 at week 12, which PASI score decreased significantly from 4.4 at the baseline to 0.2 at week 12. Then benvitimod was applied once at night and gradually tapered to twice or once a week to avoid recurrence. The patient is still under follow-up with continuous improvement and well-tolerated without adverse effects. This study was approved by the Ethics Committee of Guangzhou Institute of Dermatology, and the parents of the patient gave their written consent for this case report to be published. Treatment of inverse psoriasis is very challenging, in which the skin is thin and tends to have local side effects, especially in children. Recent systematic reviews have revealed that most patients with VP can be managed successfully with topical immunomodulators and mid-to-high-potency topical corticosteroids. However, topical corticosteroids have a restriction on treatment duration and some skin areas like facial and intertriginous skin. Benvitimod cream is a novel nonsteroid agent and has been demonstrated its safety and efficacy in the treatment of mild-to-moderate plaque psoriasis in phase I, II, and III