What is the role of pharmacologic therapy in the treatment of sarcoidosis?

Updated: Oct 01, 2020
  • Author: Joseph F Merola, MD, MMSc; Chief Editor: Dirk M Elston, MD  more...
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Answer

Answer

The need for medical therapy varies based on the symptoms and the organ systems involved in each patient. Oral corticosteroids are usually the treatment of choice for patients with hypercalcemia and for those with serious end-organ involvement, such as symptomatic stage II and all stage III pulmonary disease, as well as for patients with neurologic, cardiac, or ocular involvement. As opposed to the more severe systemic involvement requiring oral therapy, Löfgren syndrome is usually an acute process that is self-limited and that resolves without immunosuppressive treatment in weeks. Symptomatic relief can be obtained using nonsteroidal anti-inflammatory drugs (NSAIDs) or relatively low doses of corticosteroids.

Limited, nondisfiguring cutaneous involvement may be treated with topical or intralesional corticosteroids. Intralesional injections of 2-10 mg/mL [18] of triamcinolone acetonide can be used at monthly intervals. More chronic skin lesions, such as plaques or lupus pernio, require more aggressive therapy because they can lead to permanent scarring.

If intralesional corticosteroids are not effective, other standard therapies include systemic corticosteroids, low-dose oral or subcutaneous methotrexate, [19, 20, 21] or antimalarials (hydroxychloroquine [22] and chloroquine). [23] Anti–tumor necrosis factor (TNF)–alpha therapy and other biological agents represent promising options for patients with recalcitrant or disfiguring disease. [18, 24, 25, 26, 27, 28] It should also be noted that anti-TNF agents have produced granulomatous eruptions. [29]

Other agents that have been used to treat cutaneous sarcoidosis include the following:

  • Thalidomide [30, 31, 32]

  • Cyclosporine

  • Chlorambucil [33]

  • Oral isotretinoin [34]

  • Allopurinol [35]

  • Minocycline [36, 37]

  • Doxycycline

  • Tetracycline

  • Psoralen with ultraviolet A (UVA)

  • Infliximab [38, 39]

  • Etanercept

  • Adalimumab [40, 26]

  • Leflunomide

  • Pentoxifylline

  • Melatonin [41]

  • Mycophenolate mofetil [42, 43]

  • Janus kinase (JAK) inhibitors [44]

  • Topical Ganoderma lucidum (Reishi mushroom) [45]

  • Combination prednisone and hydroxychloroquine [46]

One case report describes remission of sarcoidosis after the patient was placed on an angiotensin-converting enzyme (ACE) inhibitor. [47] Another report describes improvement in two cases using photodynamic therapy with methyl aminolevulinate (Metvix). [48]  Intralesional 5-fluoruracil has been used successfully. [49]


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