Evidence-Based Therapy for Cutaneous Sarcoidosis

Sarcoidosis: a comprehensive review and update for the dermatologist: part I. Cutaneous disease

Sarcoidosis is a common systemic, noncaseating granulomatous disease of unknown etiology. The development of sarcoidosis has been associated with a number of environmental factors and genes. Cutaneous sarcoidosis, the "great imitator," can baffle clinicians because of its diverse manifestations and its ability to resemble both common and rare cutaneous diseases. Depending on the type, location, and distribution of the lesions, treatment can prevent functional impairment, symptomatic distress, scarring, and disfigurement. Numerous therapeutic options are available for the treatment of cutaneous sarcoidosis, but there are few well designed trials to guide practitioners on evidence-based, best practice management. In part I, we review the current knowledge and advances in the epidemiology, etiology, pathogenesis, and genetics of sarcoidosis, discuss the heterogeneous manifestations of cutaneous sarcoidosis, and provide a guide for treatment of cutaneous sarcoidosis.

[Cutaneous and pulmonary sarcoidosis. Successful therapy with fumaric acid esters]

A 43-year-old man with cutaneous and pulmonary sarcoidosis was treated with fumaric acid esters (Fumaderm®) for 11 months because of the cutaneous lesions. During the treatment the cutaneous lesions and pulmonary changes vanished completely. In addition, serum angiotensin converting enzyme (ACE) levels normalized after end of therapy. This case report is one of a few examples of the successful treatment of cutaneous and pulmonary sarcoidosis with fumaric acid esters (Fumaderm®).

Sarcoidosis and molecular mimicry--important etiopathogenetic aspects: current state and future directions

Sarcoidosis is a disease of uncertainty in terms of its cause, presentation, and clinical course. The disease has a worldwide distribution and affects all ages, races, and both sex. Sarcoidosis of the skin may have an extremely heterogeneous clinical presentation, so that the definitions of 'great imitator' and 'clinical chameleon' have long been used. The factors that influence clinical picture and severity of the disease are probably linked to the etiopathogenesis of sarcoidosis, which continues to be shrouded in mystery. The current state of the art on the pathogenesis of sarcoidosis is that it is an immunological response in a genetically susceptible individual to an as-yet undefined antigenic stimulus. How exposure occurs in genetically predisposed patients is not completely clear, but the most likely explanation is that these agents or antigens are either inhaled into the lungs or enter through contact with the skin, as these are the common target organs that are constantly in contact with the environment. An autoimmune etiology of sarcoidosis could possibly occur through a process of molecular mimicry of infectious or other environmental antigens to host antigens. This could lead to a cross-mediated immune response and induction of autoimmune disease. This molecular mimicry may probably be responsible for the heterogeneous clinical presentations of the disease. Several investigations and studies have provided valuable evidence on the etiopathogenesis of sarcoidosis, which may lead to the future development of targeted and innovative treatment strategies. Nevertheless, we are still a long way from unravelling the underlying cause of this mysterious disease.

Cutaneous simulants of infectious disease

Many cutaneous conditions can mimic infection. If these lesions are not accurately recognized, they may be treated with antimicrobial agents, which adds cost, potential risk, and inconvenience to the patient and the healthcare system. The presenting signs and symptoms of many ulcerating, pustular, morbilliform, bullous, neoplastic, granulomatous, autoimmune, and neutrophilic conditions, as well as clinical vasculitis, cellulitis, folliculitis, and panniculitis, have been mistaken for infection. This review emphasizes the clinical presentation, physical exam, and diagnostic workup of many of these conditions to assist the clinician in ascertaining the correct diagnosis. In addition, general treatment options are provided for each disease category.

Innovative uses of thalidomide

Thalidomide is approved for treating erythema nodosum leprosum and multiple myeloma, but it has also emerged as a useful treatment option for many refractory dermatologic disorders. Some of the innovative but off-label uses of thalidomide include aphthous stomatitis, Behçet's disease, lupus erythematosus, prurigo nodularis, sarcoidosis, actinic prurigo, graft-versus-host disease, Langerhans cell histiocytosis, erythema multiforme, lichen planus, Kaposi sarcoma, Jessner lymphocytic infiltrate, uremic pruritus, pyoderma gangrenosum, scleroderma, scleromyxedema, and necrobiosis lipoidica. This article reviews the background, pharmacology, and innovative uses of thalidomide in dermatology.

A case of morpheaform sarcoidosis

Sarcoidosis is an idiopathic multisystem disease with various cutaneous presentations, and it is characterized by the presence of non-caseating granulomas in the affected organs. The specific manifestations are papules, plaques, nodules, ulcers and scar. We report here on a variant of sarcoidosis on a 71-year-old woman who showed an indurated plaque on the forearm. Her lesion's appearance was clinically similar to that of a morphea and the appearance of the lesion was unlike the commonly observed manifestations of sarcoidosis.

An operative approach to the treatment of refractory cutaneous nasal sarcoid: a case report and review of the literature

The treatment of cutaneous sarcoid is often frustrating, because lesions may be refractory to treatment, or recurrent. There is little information in the literature regarding the surgical treatment of cutaneous sarcoid. Such treatment may become necessary in cases that do not respond to systemic treatments and create functional impairments. We present a 7-year follow-up of a patient with cutaneous nasal sarcoid that was successfully treated surgically.

Osteopontin and the skin: multiple emerging roles in cutaneous biology and pathology

Osteopontin (OPN) is a glycoprotein expressed by various tissues and cells. The existence of variant forms of OPN as a secreted (sOPN) and intracellular (iOPN) protein and its modification through post-translational modification and proteolytic cleavage explain its broad range of functions. There is increasing knowledge which receptors OPN isoforms can bind to and which signaling pathways are activated to mediate different OPN functions. sOPN interacts with integrins and CD44, mediates cell adhesion, migration and tumor invasion, and has T helper 1 (Th1) cytokine functions and anti-apoptotic effects. iOPN has been described to regulate macrophage migration and interferon-alpha secretion in plasmacytoid dendritic cells. Both sOPN and iOPN, through complex functions for different dendritic cell subsets, participate in the regulation of Th cell lineages, among them Th17 cells. For skin disease, OPN from immune cells and tumor cells is of pathophysiological relevance. OPN is secreted in autoimmune diseases such as lupus erythematosus, and influences inflammation of immediate and delayed type allergies and granuloma formation. We describe that OPN is overexpressed in psoriasis and propose a model to study OPN function in psoriatic inflammation. Through cytokine functions, OPN supports immune responses against Mycobacteria and viruses such as herpes simplex virus. OPN is also implicated in skin tumor progression. Overexpression of OPN influences invasion and metastasis of melanoma and squamous cell carcinoma cells, and OPN expression in melanoma is a possible prognostic marker. As OPN protein preparations and anti-OPN antibodies may be available in the near future, in-depth knowledge of OPN functions may open new therapeutic approaches for skin diseases.

Cutaneous sarcoidosis presenting as multiple erythematous macules and patches

Sarcoidosis is an idiopathic multisystemic disorder with variable cutaneous presentations that are classified as specific or non-specific according to the presence of non-caseating granulomas on histologic examination. Specific manifestations can include papules, scar sarcoidosis, ulcers, or even alopecia. Herein, we present a case of cutaneous sarcoidosis that presented as multiple erythematous macules and patches on the trunk and extremities of a 32-year-old man. The clinical appearance was unlike any other form reported in the literature.