Cutaneous sarcoidosis successfully treated with topical tacrolimus

Cutaneous Sarcoidosis

Sarcoidosis is a multisystem disease that most commonly affects the lungs, lymphatic system, eyes, and skin but any organ may be involved. Cutaneous sarcoidosis most commonly presents as pink-red to red-brown papules and plaques that commonly affect the head and neck. With the skin being readily accessible for evaluation and biopsy, when sarcoidosis is suspected, dermatologic evaluation may be helpful for establishing a definitive diagnosis. Treatment strategy depends on the severity and distribution of skin lesions and should incorporate patient preference and treatment considerations for other organs that may be involved.

An Impressive Finding of Sarcoid-Like Reaction to Tattooing

This case represents an impressive finding of a young male who developed cutaneous sarcoid-like reactions that arose secondarily to tattoo ink. Cutaneous manifestations of sarcoidosis can present themselves in various ways, be caused by different inducing factors, and may present themselves not only cutaneously but as one of the many findings of systemic sarcoidosis. A 24-year-old black gentleman presented to the dermatology clinic with a manifestation of papules in his tattoos that covered a majority of his body. The patient tried hypoallergenic tattoo ink to see if this would prevent the formation of these bumps; however, this only further provoked the production of these papules confined to tattooed areas. Skin findings revealed linear raised papules in a continuous fashion in areas where the patient had tattoo ink on his torso, bilateral arms and legs, and face. At presentation, he denied any constitutional, pulmonary, or ophthalmologic symptoms. Pathological findings revealed sarcoidal granulomatous dermatitis showing nodular non-necrotizing granulomatous inflammatory infiltrate involving the superficial and deep dermis. The patient was then evaluated by pulmonology to rule out any systemic findings of sarcoidosis, which showed a negative chest x-ray. The patient was started on oral prednisone and topical pimecrolimus cream, and when he returned for his one-month follow-up, there were minimal to no visible cutaneous lesions. Tattoo ink has been shown to cause a variety of cutaneous reactions such as infections, neoplasms, and inflammatory dermatoses such as eczema, lichen planus, psoriasis, vitiligo, and sarcoidosis. Cutaneous sarcoid-like reactions secondary to tattoo ink are rare findings; however, they must be taken seriously due to the risk of systemic sarcoidosis involvement both at initial presentation and in the future.

Sarcoidosis incidence after mTOR inhibitor treatment

OBJECTIVE

Mechanistic target of rapamycin (mTOR) inhibitors are effective in animal models of granulomatous disease, but their benefit in sarcoidosis patients is unknown. We evaluated the incidence of sarcoidosis in patients treated with mTOR inhibitors versus calcineurin inhibitors.

METHODS

This was a cohort study using the Optum Clinformatics® Data Mart (CDM) Database (2003-2019), IBM® MarketScan® Research Database (2006-2016), and Danish health and administrative registries (1996-2018). Patients aged ≥18 years with ≥1 year continuous enrollment before and after kidney, liver, heart, or lung transplant treated with an mTOR inhibitor or calcineurin inhibitor were included. Patients diagnosed with sarcoidosis before, or up to 90 days after, transplant were excluded. The incidence of sarcoidosis by treatment group was calculated.

RESULTS

In the Optum CDM/IBM MarketScan cohort, 1,898 patients were treated with an mTOR inhibitor (mean age 49 years; 34% female) and 9,894 patients were treated with a calcineurin inhibitor (mean age 50 years; 37% female). The mean follow-up in the mTOR inhibitor group was 1.1 years, with no incident sarcoidosis diagnosed. In the calcineurin inhibitor group, the mean follow-up was 2.2 years, with 12 incident sarcoidosis cases diagnosed. In the Danish cohort, 230 patients were treated with an mTOR inhibitor (mean age 49; 45% female), with no incident sarcoidosis diagnosed. There were 3,411 patients treated with a calcineurin inhibitor (mean age 45; 40% female), with 10 incident cases of sarcoidosis diagnosed.

CONCLUSIONS

This study indicates a potential protective effect of mTOR inhibitor treatment compared with calcineurin inhibitor treatment against the development of sarcoidosis.

Sarcoidosis and Its Dermatological Manifestations: A Narrative Review

Sarcoidosis is an enigma diagnosed by ruling out other etiologies of granulomatous inflammation. The multisystem manifestations of sarcoidosis and the clinical polymorphism pose a diagnostic challenge to all physicians. The skin is the most commonly affected organ after the lungs in sarcoidosis. Dermatological manifestations can appear before, during, or after systemic involvement, and the type of skin lesion can have prognostic significance. Also, a biopsy of skin lesions is less invasive and more accessible to perform than a biopsy of visceral organs. Thus, in certain ways, cutaneous manifestations can aid in the diagnosis and prognosis of systemic disease. This article has focused on the frequently encountered skin lesions of sarcoidosis along with their prevalence, clinical features, and management.

Cutaneous Sarcoidosis

Sarcoidosis is a chronic, multisystem, inflammatory disorder of unknown etiology that is characterized by noncaseating granulomas that impair normal organ functioning. Sarcoidosis predominantly affects the lungs, but the skin is often cited as the second most frequently involved organ. Cutaneous manifestations of sarcoidosis are highly variable and ongoing research seeks to better understand the relationship between clinical morphology and disease prognosis. Skin findings in patients with sarcoidosis can be "specific," in which sarcoidal granulomas infiltrate the skin, or they can represent a "nonspecific" reactive inflammatory process, as is seen in calcinosis cutis and erythema nodosum. Cutaneous sarcoidosis can be the initial presenting sign or develop later in the course of the disease. In some patients, the skin will be the most involved and impactful organ system and will drive therapy. In other cases, the skin will be an incidental or minor finding, but may be easily accessible for biopsy to confirm the diagnosis. There are many potential therapies for sarcoidosis, though no one therapy is universally effective.

Dermoscopy could be useful in differentiating sarcoidosis from necrobiotic granulomas even after treatment with systemic steroids

Background:

Diagnosing cutaneous sarcoidosis and necrobiotic granulomas is challenging.

Objective:

Assessing the value of dermoscopy in differentiating cutaneous sarcoidosis from necrobiotic granulomas and evaluating whether their dermoscopic features will be altered after treatment.

Methods:

Nineteen cutaneous sarcoidosis and 11 necrobiotic granuloma patients (2 necrobiosis lipoidica, 4 granuloma annulare and 5 rheumatoid nodule) were included in this study. The diagnosis was confirmed by skin biopsy. The lesions were examined using non-contact polarized dermoscope (Dermlite 2 HR-Pro; 3Gen, San Juan Capistrano, CA).

Results:

Ten out of 19 cutaneous sarcoidosis patients and 7/11 necrobiotic cases group were receiving treatments (topical, intralesional or systemic steroids ± chloroquine) but still have cutaneous lesions. Treatment duration in the sarcoidosis group ranged from 2 months to 10 years (median 3 years) and in the necrobiotic cases group ranged from 3 months to 16 years (median 2 years). Pink homogenous background, translucent orange areas, white scar-like depigmentation and fine white scales were significantly associated with the cutaneous sarcoidosis compared to necrobiotic cases group. On the other hand mixed pink, white and yellowish background was significantly associated with the necrobiotic cases group. No significant difference in the dermoscopic findings was detected between treated and non-treated patients.

Conclusion:

Some dermoscopic findings are shared between the cutaneous sarcoidosis group and the necrobiotic cases group, yet dermoscopy could be a useful aid in differentiating them even after treatment.

A practical approach to cutaneous sarcoidosis

Sarcoidosis is a chronic inflammatory disorder that has the potential to affect multiple organs, including the skin. Its cutaneous manifestations are varied and can provide clues to underlying systemic manifestations. Unfortunately, they also can be disfiguring. Therapy is usually directed at the organ system most severely affected, which often may help cutaneous disease. However, cutaneous disease may be recalcitrant to treatment directed at extracutaneous disease, or it may be severe enough to require targeted therapy. This article focuses on the dermatologist's role in recognizing and diagnosing cutaneous sarcoidosis, evaluating patients for systemic disease involvement, and treating the skin manifestations of sarcoidosis.

Macrolactam Immunomodulators (Tacrolimus and Pimecrolimus): New Horizons in the Topical Treatment of Inflammatory Skin Diseases

Tacrolimus and pimecrolimus are new macrolactam immunomodulators which were developed for the treatment of inflammatory skin diseases, mainly atopic dermatitis. In this article, we review the pharmacologic properties of the drugs, their side effects, and their clinical uses.

Topical Pimecrolimus as a New Optional Treatment in Cutaneous Sarcoidosis of Lichenoid Type

We report the case of cutaneous sarcoidosis of lichenoid type successfully treated with pimecrolimus. For the first time in the literature, we propose the use of this topical calcineurin inhibitor for the treatment of the cases refractory to common therapy regimens.

Clinical application of development of nonantibiotic macrolides that correct inflammation-driven immune dysfunction in inflammatory skin diseases

BACKGROUND

Inflammation-driven immune dysfunction supports the development of several chronic human disorders including skin diseases. Nonantibiotic macrolides have anti-inflammatory and/or immunomodulatory activity that suggests the exploitation of these in the treatment of skin diseases characterized by inflammatory disorders.

MATERIALS AND METHODS

We performed an extensive review of the nonantibiotic macrolide literature published between 2005 and 2012, including cross-references of any retrieved articles. We also included some data from our own experience.

RESULTS

Calcineurin antagonists such as tacrolimus and ascomycins (e.g., pimecrolimus) act by inhibiting the activation of the nuclear factor for activated T cells (NFAT). There are new applications for these macrolides that have been available for several years and have been applied to skin and hair disorders such as atopic dermatitis, oral lichen planus, vitiligo, chronic autoimmune urticaria, rosacea, alopecia areata, pyoderma gangrenosum, Behcet's disease, neutrophilic dermatosis, and lupus erythematosus. We also reviewed new macrolides, like rapamycin, everolimus, and temsirolimus. In addition to the literature review, we report a novel class of nonantibiotic 14-member macrocycle with anti-inflammatory and immunomodulatory effects.

CONCLUSIONS

This paper summarizes the most important clinical studies and case reports dealing with the potential benefits of nonantibiotic macrolides which have opened new avenues in the development of anti-inflammatory strategies in the treatment of cutaneous disorders.

Recurrence of granulomatous interstitial nephritis in transplanted kidney

Sarcoidosis is a multisystemic disease of unknown etiology. Minor renal involvement is not rare but kidney failure is uncommon and only rare cases of recurrent disease in a kidney transplant have been published. We report a patient who at age 10 yr developed ESRD secondary to renal sarcoidosis with GIN. Her disease subsequently recurred in the transplanted kidney despite standard immunosuppression with prednisone, tacrolimus, and mycophenolate mofetil. The recurrent disease appeared to respond to increased immunosuppression, which included infliximab. However, the patient died of disseminated histoplasmosis three yr post-transplant.

Recalcitrant cutaneous sarcoidosis: an evidence-based sequential approach

BACKGROUND

Cutaneous sarcoidosis in black-skinned people is more severe and, in a subset, recalcitrant to therapy. Management of these patients is a challenge.

AIM

To document the clinical features of recalcitrant cutaneous sarcoidosis (RCS) and its response to sequential therapy. A treatment algorithm is suggested.

METHODS

A cross-sectional retrospective analysis was made of patients with RCS. Demographic data, clinical features, histology, blood parameters, radiology and management and response to therapy were recorded.

RESULTS

A total of 30 patients with cutaneous sarcoidosis were seen, of which six had recalcitrant lesions. All had black skin, with a male to female ratio of 1:5. The average age was 48.5 years (41-67) and the average duration of lesions was 11.3 years (2-29). Skin lesions were papules (three), plaques (four), annular (three), nodules (four), ulcers (one), alopecia (one) and lupus pernio (one). Extracutaneous involvement was noted in four of six patients as follows: pulmonary (three of six), dactylitis (two of six) and hepatosplenomegaly (one of six). Histopathology was undertaken in all confirmed non-caseating granulomas. None of the cases responded to systemic prednisone alone. Alternative therapies were: chloroquine (six of six), methotrexate (four of six), doxycycline (two of six), allopurinol (two of six) and isotretinoin (one of six), and azathioprine (one of six). All patients responded well to a stepwise approach to therapy using second-line agents with no relapses during the follow-up period.

CONCLUSION

Sequential therapy avoids the side effects of toxic drugs whilst controlling aggressive cutaneous lesions.

Granulomas não-infecciosos: sarcoidose

A sarcoidose é doença granulomatosa não infecciosa de etiologia desconhecida, de cuja patogênese parecem participar os fatores genéticos, imunológicos, ambientais e infecciosos. Vários órgãos podem ser afetados, causando amplo espectro de manifestações clínicas. A pele é acometida em cerca de 20 a 35% dos casos, proporcionando ao dermatologista importante papel no diagnóstico da doença. Epidemiologia, imunologia e tratamento também são discutidos para prover melhor entendimento dessa enfermidade.

A case of sarcoidosis occurring within an extensive burns scar

Scarring from burn injuries can result in cosmetic and functional deformities. In addition, late complications can also occur presenting as other pathology developing within the scarred tissue. We report a unique case of cutaneous sarcoidosis developing within a burns scar in an adult male who sustained a burns injury to his torso, right arm and thigh.

Assigning new roles to topical tacrolimus

Tacrolimus is an ascomycin macrolactam derivative with immunomodulatory and anti-inflammatory activity that belongs to the class of calcineurin inhibitors. Tacrolimus in its topical formulation has been established as a safe and effective alternative to topical corticosteroids because of its mild side effects and its minimal systemic absorption. Topical tacrolimus has been approved for the treatment of atopic dermatitis in two concentrations, 0.03 and 0.1%. In a thorough research of literature the authors review all of the available data regarding the off-label uses of the medication in other dermatoses. It seems that compared to pimecrolimus, tacrolimus has proved to be a more effective treatment. There is no causal relationship that has been established between tacrolimus and carcinogenesis. Furthermore, the authors believe that, without any evidence, the theoretical concerns are not enough to produce warnings. Tacrolimus ointment 0.1% may be recommended as a first-line choice for seborrheic dermatitis of the face and trunk, facial and intertriginous psoriasis and probably for allergic contact dermatitis and Zoon's balanitis. It has been ineffective in numerous dermatoses such as alopecia areata, necrobiosis lipoidica, internal pruritus and in thick hyperkeratotic plaques of psoriasis when administered as the commercially available formulation without occlusion. There is yet unexploited therapeutic potential regarding the use of topical tacrolimus in dermatology. Isolated cases of successful administration of the medication in various cutaneous conditions require further large-scale studies to clarify the actual effectiveness.

The role of topical calcineurin inhibitors for skin diseases other than atopic dermatitis

The topical calcineurin inhibitors (TCIs) pimecrolimus and tacrolimus are approved for atopic dermatitis but have additional potential in other inflammatory skin diseases. This article reviews their clinical use in non-atopic dermatitis diseases. In seborrheic dermatitis, asteatotic eczema, and contact dermatitis, TCIs are of great benefit and can compete with topical corticosteroids. In psoriasis, TCIs have shown clinical efficacy and safety in facial and intertriginous lesions. Further investigations into possible combinations of TCIs with other established treatments such as UVB irradiation in this disorder are necessary. Initial studies in cutaneous lupus erythematosus have been promising, whereas the response in rosacea and rosacea-like eruptions has been mixed. TCIs have been associated with good clinical responses in oral lichen planus and anogenital lichen sclerosus et atrophicus. In vitiligo, TCIs are associated with some degree of repigmentation, with better results being seen in children and in facial and neck areas. TCIs have a synergistic effect with UVB irradiation in vitiligo. There is a long list of small series and case reports documenting use of TCIs in various other skin conditions that warrant further validation. Although the established mode of action of TCIs is T-cell control, other effects also need to be considered. Specifically, TCIs reduce pruritus and erythema, which cannot be explained by T-cell interactions, and further investigations are needed in these fields.

Current and emerging strategies for the management of sarcoidosis

Sarcoidosis is a systemic inflammatory disorder of unknown etiology. Although any organ may be involved, the lungs are most frequently affected. The clinical course of the disease is highly variable, with up to two-thirds of untreated patients experiencing spontaneous remission within 12-24 months of onset of symptoms. When therapy is required, corticosteroids are considered standard, but studies demonstrating their ability to modify the long-term outcome in this disease are lacking. Often, the myriad of adverse side effects of corticosteroids necessitate the addition of immunosuppressants, cytotoxic agents or biologic therapies to maintain disease remission. Unfortunately, optimal therapeutic regimens have not been described. Patients who do not respond to therapy often experience progressive fibrotic changes and end-organ damage, which ultimately may result in significant morbidity or death. Agents commonly used to treat patients with sarcoidosis and emerging therapeutic options are discussed.

A 14-year-old girl with lichenoid sarcoidosis successfully treated with tacrolimus

We report a case of lichenoid sarcoidosis in a young girl treated by oral tacrolimus and methylprednisolone. The patient had had a skin eruption from 1 year of age and had developed uveitis at 2 years of age. Her sight had become affected by the uveitis at 8 years of age. When she was 14, she was admitted to the ophthalmology department of our hospital to start treatment with tacrolimus (FK506). She was referred to the department of dermatology for her skin lesions, which were flat, pinkish or normal skin-colored papules scattered on her extremities and the backs of her hands. Upon histology, epithelioid granulomas were seen in the upper dermis and around the erector pili muscles. She received tacrolimus (FK506) 6 mg/day for 3 months for her uveitis. The eye lesions subsided somewhat, and the skin lesions were almost healed after the 3-month course of tacrolimus. However, 4 months after stopping the tacrolimus, her skin and eye lesions relapsed. At that point, she was started on methylprednisolone 16 mg/day for her uveitis. With the methylprednisolone treatment, the inflammation of the eye lesion immediately healed, as did the skin lesions.

Topical macrolide immunomodulators: a role in the treatment of vitiligo?

Recently, topical macrolide immunomodulators have been successfully introduced in the treatment of atopic dermatitis. With the growing interest in this new line of topical immunosuppressants, research into the efficacy of these medicines in other T-cell-mediated skin diseases, such as psoriasis, lichen planus, and even vitiligo, is expanding rapidly. It is generally accepted that autoimmune factors play an important role in vitiligo. In this article, the possible use and mechanism of topical macrolide immunomodulators in the treatment of vitiligo are discussed, together with the current state of clinical studies and case reports. These limited reports indicate that topical macrolide immunomodulators may play a role in the treatment of vitiligo, particularly in areas where use of potent corticosteroids is contraindicated.

Childhood granulomatous periorificial dermatitis: lupus miliaris disseminatus faciei in children?

BACKGROUND

Childhood granulomatous periorificial dermatitis (CGPD) is a granulomatous disease characterized by monomorphous, small papular eruptions around the mouse, nose and eyes, and is thought to be closely related to perioral dermatitis. This condition has always been believed to occur more commonly in dark-skinned patients; however, recent observations have revealed CGPD to occur also in white patients.

OBSERVATION

We report an 11-year-old Japanese boy with the characteristic features of CGPD. Although sarcoidosis and acne/granulomatous rosacea could be differentiated from CGPD, we could find no essential differences between CGPD and lupus miliaris disseminatus faciei (LMDF). The cases of LMDF in children, which were recorded in the Japanese literature, had highly similar clinicopathological features to those of CGPD. This case responded dramatically to topical tacrolimus in combination with the oral administration of minocycline.

CONCLUSIONS

The entity 'facial idiopathic granulomas with regressive evolution' is considered to include LMDF (a common adult form), CGPD (a rare childhood form) and perioral dermatitis (a peculiar form exacerbated by topical corticosteroids). Topical tacrolimus may be recommended as one of the therapies for LMDF as well as CGPD.

Safety and efficacy of topical calcineurin inhibitors in the treatment of childhood atopic dermatitis

Approximately 10-20% of infants in industrialized countries experience atopic dermatitis. In recent decades topical corticosteroids have been the first-choice therapy for treatment of flares. However, this form of therapy may induce skin atrophy, especially after application to facial lesions or with long-term use. Thus, development of new anti-inflammatory topical agents for the treatment of childhood atopic dermatitis was needed. The topical calcineurin inhibitors tacrolimus and pimecrolimus have an effect on various cells of the cutaneous immune system, specifically on T cells, by inhibiting the phosphatase calcineurin and preventing the transcription of proinflammatory cytokines. In several clinical studies of children and adults with atopic dermatitis, topical calcineurin inhibitors were found to be effective both on the face and the trunk and extremities, in both short- and long-term treatment regimens. Tachyphylaxis or rebound were not observed. In most patients an improvement of their eczema occurred during the first week of treatment, as measured by subjective and objective clinical signs of atopic dermatitis. Treatment significantly reduced the incidence of flares and the need for corticosteroids in children and adults. Treatment success, commonly defined as 'excellent improvement' or 'clearing of all lesions', was observed in more than one-third of all children treated with 0.03% or 0.1% tacrolimus or 1% pimecrolimus. Topical application of pimecrolimus and tacrolimus does not lead to significant blood concentrations of these agents in the majority of children with atopic dermatitis, and any increase in blood concentrations decreases after a few days of therapy. No changes in laboratory parameters were observed in short- and long-term studies in patients with atopic dermatitis. The most common adverse effect following the application of topical calcineurin inhibitors is mild to moderate symptoms of irritation such as burning, erythema and pruritus, which occurred in up to 20% of all children treated with tacrolimus and 10% of children treated with pimecrolimus, and usually faded after a few days. In contrast to topical corticosteroids, calcineurin inhibitors do not induce skin atrophy, even after long-term use. Topical calcineurin inhibitors have been proven to be effective and have a good safety profile during short-term and long-term use for up to 1 year with pimecrolimus and up to 4 years with tacrolimus. Given the lack of extensive experience with use of topical calcineurin inhibitors over longer periods, regular use of these agents, particularly in children, should be undertaken only after careful consideration of individual cases. Sun protection should also be advised.

Patient and graft outcomes following liver transplantation for sarcoidosis

End-stage liver disease as a consequence of hepatic sarcoidosis is a rare indication for liver transplantation. Consequently, there is a paucity of information on the pre-transplant findings and post-operative course of individuals transplanted for hepatic sarcoidosis. The purpose of this study was to evaluate our experience with liver transplantation for sarcoidosis. Cases were identified by review of the Mount Sinai Hospital liver transplant database. For each case, two control patients with other causes of liver failure matched for age, gender and date of transplant were selected for comparison. Hepatic sarcoidosis was the indication for liver transplantation in only seven of 2117 (0.3%) adult transplants performed from September 1988 to June 2004. The diagnosis of sarcoidosis was established by findings of extensive, non-caseating granulomas in pre-transplant liver biopsy specimens or in the native liver explant. Extrahepatic disease was limited to pulmonary involvement in four patients. Sarcoid cases were statistically more likely to have diabetes mellitus (100% vs. 21%, p = 0.001) and less likely to have antibodies to hepatitis C (0% vs. 50%, p = 0.047). Rates of acute cellular rejection were 57% in cases and 36% in controls (p = 0.397). Hepatic granulomas were identified in one patient at 5.6 yr of follow-up. Among cases, the 1-yr graft and patient survival rates were 100% and 5-yr graft and patient survival rates were 86%. The 1- and 5-yr graft and patient survival rates were comparable with those of patients transplanted for other indications.

Management of erosive lichen planus with topical tacrolimus and recurrence secondary to metoprolol

Metoprolol, a widely prescribed beta-adrenergic receptor blocker, has occasionally been associated with a diversity of cutaneous reactions. We present a 79-year-old male patient with erosive lichen planus (LP) on the feet and hands who was successfully treated with topical tacrolimus. Six months after the lesions had been cured the patient received the beta-receptor blocker metoprolol for the treatment of hypertonus. Within only 2 weeks of metoprolol intake the erosive lesions on the palms and feet recurred. After discontinuation of the drug and repetitive topical treatment with tacrolimus a complete remission of the lesions could be achieved. The recurrence of erosive LP probably secondary to metoprolol and the therapeutic success of topical tacrolimus in the treatment of LP are discussed.

[Successful treatment of skin and lung sarcoidosis with fumaric acid ester]

A 61-year old female patient with cutaneous sarcoidosis was treated with fumaric acid esters (Fumaderm). After 12 months of therapy, lesions were markedly improved and treatment was discontinued. 18 months later, the cutaneous lesions recurred, angiotensin converting enzyme (ACE) serum levels were increased and a chest X-ray demonstrated pulmonary involvement. Therapy with fumaric acid esters was again started. The skin showed improvement after 2 months and completely cleared within 17 months, within 4 months ACE levels normalized, and within 10 months radiologic changes markedly resolved. This case demonstrates a possible role for fumaric acid esters not only in the treatment of cutaneous but also systemic sarcoidosis.

[Successful topical treatment of cutaneous sarcoidosis with tacrolimus]

A 56-year old female patient with cutaneous sarcoidosis in the face was treated with fumaric acid esters and doxycycline without any effect. Topical tacrolimus led clinically and histologically to a nearly complete remission within three months, which continued after 4 months of follow-up.

Newer therapies for cutaneous sarcoidosis: the role of thalidomide and other agents

Skin involvement occurs in a third of patients with sarcoidosis. The type of lesions can range from the transient erythema nodosum to the chronic facial lesion lupus pernio. For some patients with sarcoidosis, lesions on the face or elsewhere on the body may be the major or only indication for therapy. These lesions are often chronic and the use of corticosteroids may lead to more long-term complications. Conventional alternatives to corticosteroids include antimalarial agents, methotrexate, and azathioprine. Recently, several drugs have been studied for chronic cutaneous sarcoidosis; thalidomide has been the most widely used. Thalidomide has been demonstrated to suppress tumor necrosis factor (TNF) release, which may be important at both the initial and chronic phases of the inflammation of sarcoidosis and appears to be crucial as part of the initial granulomatous response. Thalidomide has a different toxicity profile than corticosteroids or immunosuppressives. The usual dosage has recently been investigated in a dose-escalation trial, with the majority of patients responding to 100 mg/day. Drug toxicity has been reported in the sarcoidosis trials. The most serious adverse effect has been peripheral neuropathy, which often resolves by reducing the dose or discontinuing the medication. Other drugs that have been studied for sarcoidosis include infliximab and tetracyclines. Infliximab is a chimeric monoclonal antibody against TNF, and several published reports have shown it to be effective for the treatment of cutaneous sarcoidosis. The efficacy of tetracyclines for cutaneous sarcoidosis could be on the basis of their immunologic properties. In addition, these drugs have potent antimicrobial activity against Propionibacterium acnes; there is increasing evidence to suggest this may be one of the causes of sarcoidosis. However, most of the newer agents for cutaneous sarcoidosis have only been studied in small series. Over the next few years, it is hoped that there will be clinical trials to determine the role of each new therapy in the treatment of cutaneous sarcoidosis.

[Medium-dose UV-A1 phototherapy. Successful treatment of cutaneous sarcoidosis]

A 82-year-old female had a 2-year history of cutaneous sarcoidosis without systemic involvement. Various treatments including local glucocorticosteroids and tacrolimus ointment had failed. Therefore, we treated our patient with medium-dose UVA1 phototherapy. After 50 sessions with a total dose of 2.640 J/cm(2) all lesions had disappeared. Clinical follow up showed no recurrence of skin lesions after 5 months.