Roflumilast 0.3% Cream: a Phosphodiesterase 4 Inhibitor for the Treatment of Chronic Plaque Psoriasis.

Background: Plaque psoriasis is a chronic dermatologic autoimmune disease that affects adults and children. Roflumilast 0.3% cream is currently the only topical phosphodiesterase 4 inhibitor indicated for the treatment of plaque psoriasis in patients 12 years or older.

Subtherapeutic INR due to warfarin interaction with smokeless tobacco.

We report an interesting case of warfarin resistance and subtherapeutic international normalized ratio (INR) in the setting of chronic smokeless tobacco use. A 33-year-old white male with a mechanical mitral valve failed to achieve therapeutic INR despite being on warfarin doses of up to 30 mg by mouth daily. The patient admits to chewing tobacco daily for the past 16 years.