P048 Lenalidomide use in recalcitrant inflammatory dermatoses: a trio of successes

Abstract Lenalidomide, an immunomodulator, is licensed for use in multiple myeloma, myelodysplastic syndromes and some lymphomas. Off-label use for refractory inflammatory dermatoses is reported, with a lower incidence of peripheral neuropathy compared with thalidomide. We present three cases of successful lenalidomide use in adult patients with different inflammatory dermatoses. A 36-year-old woman with recurrent aphthous stomatitis had not responded to treatment with colchicine, pentoxifylline, azathioprine, dapsone or mycophenolate mofetil. Repeated courses of prednisolone were required for flares. Lenalidomide 5 mg daily was commenced in April 2024, with good response by June 2024 and excellent response by October 2024. No side-effects were reported and dose reduction to 2.5 mg daily is currently being trialled. A 55-year-old man with biopsy-proven Jessner lymphocytic infiltration had painful flares despite previous treatment with hydroxychloroquine, mepacrine, methotrexate, thalidomide and mycophenolate mofetil. Lenalidomide 2.5 mg daily was commenced in September 2024 with resolution of painful lesions. Lenalidomide has been well tolerated and blood monitoring has remained stable. A 49-year-old woman with severe recalcitrant cutaneous discoid lupus erythematosus (CDLE), systemic lupus and Raynaud phenomenon with chilblains had not responded to, had intolerance to or had adverse side-effects with multiple systemic agents including hydroxychloroquine, mepacrine, dapsone, rituximab biosimilar, mycophenolate mofetil, fumaric acid esters, acitretin, ciclosporin, thalidomide (tremor/loss of concentration), belimumab and methotrexate. Repeated courses of oral and intravenous glucocorticoids for control resulted in cataracts, osteopenia and cushingoid appearance. Despite conjunctional treatment with belimumab, methotrexate and prednisolone, CDLE remained active, requiring inpatient admission for intensive topical treatment. Lenalidomide 5 mg daily was commenced in June 2022 with improvement in CDLE within 2 months. Over the last 2 years the dose of prednisolone has been consistently weaned with skin control maintained. The current dose of lenalidomide is 2.5 mg on alternating days. Lenalidomide is a structural analogue of thalidomide inhibiting the secretion of proinflammatory cytokines including tumour necrosis factor-α, interleukin (IL)-1b, IL-6 and IL-12. Lenalidomide has a more favourable safety profile than thalidomide, with reduced risks of neurotoxicity, including lower sedative and neuropathic side-effects, while maintaining the anti-inflammatory and immunomodulatory effects. Monitoring for assessment of haematological parameters is essential, particularly for neutropenia and thrombocytopenia. Baseline and renal function monitoring is required for dose adjustment, and strict adherence to pregnancy prevention programmes is necessitated due to teratogenicity. Our three cases demonstrate lenalidomide to be a clinically beneficial, fast-acting and well-tolerated alternative off-label option for recalcitrant inflammatory dermatoses.