From the Guidelines
The treatment approach for skin sarcoidosis typically begins with assessing the need for treatment, and first-line options include topical glucocorticoids, such as high-potency steroids like clobetasol, for limited cutaneous disease. For patients with significant glucocorticoid side-effects, continued disease, or relapse, alternative options like hydroxychloroquine or chloroquine may be considered 1. In cases of continued disease or relapse, methotrexate or infliximab may be added to the treatment regimen 1. The goal of treatment is to suppress the granulomatous inflammation characteristic of sarcoidosis while minimizing medication side effects.
Some key considerations in the treatment approach include:
- Assessing the need for treatment based on disease extent and cosmetic impact
- Using topical glucocorticoids as first-line treatment for limited cutaneous disease
- Considering alternative options like hydroxychloroquine or chloroquine for patients with significant glucocorticoid side-effects
- Adding methotrexate or infliximab to the treatment regimen for cases of continued disease or relapse
- Monitoring treatment response and adjusting therapy accordingly, with regular follow-up every 3-6 months.
According to the European Respiratory Journal, the use of apremilast and tofacitinib should be considered on a case-by-case basis 1. Additionally, the guideline recommends that treatment decisions should consider disease extent, cosmetic impact, and systemic involvement 1. The treatment approach should prioritize minimizing medication side effects while effectively managing the disease.
In terms of specific treatment options, oral prednisone at 20-40 mg daily for 4-6 weeks, followed by slow tapering over several months, may be considered for more extensive or refractory skin involvement 1. Steroid-sparing agents like hydroxychloroquine (200-400 mg daily), methotrexate (7.5-25 mg weekly), or mycophenolate mofetil (1-3 g daily) may be added for maintenance 1. For resistant cases, TNF-alpha inhibitors like infliximab (3-5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks) may be effective 1.
From the Research
Treatment Approach for Skin Sarcoidosis
The treatment approach for skin sarcoidosis involves various options, including:
- Topical corticosteroids and/or hydroxychloroquine as initial treatments 2
- Methotrexate as an effective treatment for chronic cutaneous sarcoidosis, especially in patients who failed to respond to previous treatments 3, 4
- Oral corticosteroids, which have shown high response rates, but may have adverse effects 2
- Combination of hydroxychloroquine and topical steroids as a suggested first-line treatment due to its efficacy and relatively lower risk of adverse effects compared to systemic corticosteroids 2
- Thalidomide and other newer agents, such as infliximab and tetracyclines, which have shown promise in treating cutaneous sarcoidosis, but require further study to determine their role in treatment 5
Factors Influencing Treatment Response
Factors that may influence treatment response include:
- Type of cutaneous lesions, with lupus pernio being a predictor of poor cutaneous response 2
- Extent of lesions and associated symptoms 2
- Organ involvement, as treatment may need to be directed at the most severely affected organ system 6
Treatment Goals and Considerations
Treatment goals include: