What is the best course of treatment for a patient with sarcoidosis who develops skin lesions on the palm?

Treatment of Sarcoidosis Skin Lesions on the Palm

For cosmetically important sarcoidosis skin lesions on the palm that cannot be controlled with topical therapy, oral glucocorticoids (prednisone) should be initiated as first-line systemic treatment, with consideration for steroid-sparing agents like hydroxychloroquine or methotrexate for chronic disease, and infliximab reserved for refractory cases. 1, 2

Initial Treatment Approach

Topical Therapy for Limited Lesions

• High-potency topical corticosteroids (clobetasol or halobetasol propionate) should be attempted first for localized palm lesions, though evidence for their efficacy is limited 1, 3
• Intralesional triamcinolone acetonide injections may be more effective than topical preparations for discrete lesions on the palm 1, 3
• However, topical or intralesional approaches are often impractical for widespread lesions 1

Systemic Glucocorticoids as First-Line

• Oral prednisone is indicated for cosmetically important active skin lesions that cannot be controlled by local treatment 1, 4
• Treatment with systemic glucocorticoids achieves improvement or remission in up to two-thirds of patients 1, 3
• The typical response occurs during active treatment, but recurrences are common upon tapering 1
• A critical limitation is that desired effects are often limited to the duration of treatment, requiring additional immunosuppressive therapy 1, 3

Steroid-Sparing Alternatives

When to Consider Alternative Agents

• Steroid-sparing alternatives should be considered whenever possible, especially for chronic lesions, given the substantial side-effects of prolonged glucocorticoid use 1
• Palm lesions that persist despite initial glucocorticoid therapy warrant escalation to alternative immunosuppressive agents 1

Hydroxychloroquine/Chloroquine

• Hydroxychloroquine or chloroquine represents a third-line option for steroid-sparing or continued disease 2
• Open-label prospective trials and case series have confirmed positive responses to these antimalarials for cutaneous sarcoidosis 1

Methotrexate

• Methotrexate is recommended as fourth-line therapy for continued disease or relapse 2
• Multiple case series have reported effectiveness in treating cutaneous disease in both adults and children 1

Advanced Therapy for Refractory Disease

Infliximab for Treatment-Resistant Cases

• For patients with cutaneous sarcoidosis who have been treated with glucocorticoids and/or other immunosuppressive agents and have continued cosmetically important active skin disease, infliximab should be added 1
• Prospective randomized controlled trials demonstrated statistically significant improvement in skin lesion severity with infliximab compared to glucocorticoid alone 1
• Infliximab has the strongest evidence base for refractory cutaneous sarcoidosis based on randomized controlled trials 2

Adalimumab as Alternative

• Adalimumab has been studied in one double-blind, placebo-controlled trial and was found more effective than placebo for chronic cutaneous sarcoidosis 1
• Adalimumab represents an additional option for continued disease after infliximab 2

Clinical Considerations and Pitfalls

Prognostic Implications

• Skin involvement is often the initial manifestation of sarcoidosis, occurring in up to 30% of patients 3, 5
• A workup for systemic sarcoidosis should be undertaken in every patient with sarcoid cutaneous granulomas 6
• Specific cutaneous lesions may predict systemic disease severity and chronicity 5, 7, 8

Common Pitfalls to Avoid

• Do not rely solely on topical therapy for palm lesions if they are cosmetically significant or widespread 1
• Avoid prolonged high-dose glucocorticoid monotherapy without considering steroid-sparing agents, as long-term adverse effects are substantial 1
• Recognize that recurrence upon glucocorticoid tapering is common and should prompt early consideration of alternative immunosuppressive therapy 1
• Monitor for systemic involvement even in apparently isolated cutaneous disease, as progression can occur years later 9

Treatment Algorithm Summary

1. Limited palm lesions: High-potency topical corticosteroids or intralesional triamcinolone 1, 3
2. Cosmetically important lesions not controlled locally: Oral prednisone 1, 2
3. Chronic disease or steroid-sparing needed: Hydroxychloroquine or methotrexate 2
4. Refractory disease: Infliximab 1, 2
5. Continued refractory disease: Adalimumab 2