SARCOIDOSIS -------------------------------------------------------- From: HalReh@aol.com Have a 55 yr. old BF with systemic Sarcoidosis Rx'd by internist with Prednisone with two ping pong ball sized nodules on fingers. Excised X 2 by surgeon, but recurs. Rx with Methotrexate and antimalarials not tolerated. Intralesional steroids work well on facial lesions, but too painful on fingers. Any experience with Isotretinoin or Thalidomide(if I could get it)? Are these sarcoidal nodules radiosensitive? Harold Rehbein -------------- Thalidomide can be had by getting a private investigational new drug permit from the FDA. Contact Rosemary Cook at the anti-infective division for details. Its really not a big deal to do. There's a company in NJ that makes the stuff, Carville used to do it but now is out of that business. Guy Webster ----------- I have had success treating cutaneous sarcoidosis with a combination of allopurinol and azathioprim. Consider a digital nerve block before injecting the lesions on the fingers. Harry Goldin, M.D. ------------------ Try a digital nerve block if pain is the only problem with the IL steroids. Chris Clay ---------- We have a patient in our clinic with sarcoidosis of the index finger that has been well controlled for the past 5 years with intralesional injections of TMC 2.5 mg per cc . The pain is not as severe as the problem itself since she has progressive bone destruction of the ip joint space. Hope this is of some help. L.J. Gregg, Tulsa. ------------------ I have also seen some improvement in about half of cases treated with allopurinol - not a magic bullet but sometimes useful. KC Smith MD FRCPC ----------------- I am looking for treatment suggestions for a 35 y.o. BM with a one year hx of small hyperpigmented nodules in the medial canthus. CXR consistent with hilar sarcoid. Skin biopsy: sarcoidal granuloma. Patient is otherwise healthy. I have tried intralesional triamcinolone 3 and 5 mg/cc with only transient improvement. Would a higher concentration of triamcinolone be indicated in such close proximity to the eye? Would liquid nitrogen be helpful? The patient is not interested in systemic therapy. Ethan D. Nydorf, M.D. ----------- Small shots of kenalog are often helpful for bits of sarcoid - I'd inject him again, 3 mg / ml. Photographs are useful, otherwise he and you may no appreciate the incremental improvement. Kevin C. Smith MD FRCPC ------------ Opthalmology might be able to offer some other ablative modalites. If the lesions are superficial, they may be able to use a laser to resurface the area (akin to what we do for disfiguring sarcoidosis on the nose). You might also get a sense from them about the safety of occluded steroids in that area, perhaps with a prosthetic device worn at night (there have been similar reports in the Archives and JAAD for the vaginal mucosa and for the nose). The one very important lesson I learned rounding with some friends at the Schie Eye Institute was that ocular absorption of steroids can increase intraocular pressure and precipitate or aggravate glaucoma in susceptible individuals. Ahmet Tangoren ------------ I wouldn't take a chance on electrodessicating sarcoid. Sarcoidal skin lesions tend to localize in scars; one of my veteran patients developed many small papules of sarcoid (real sarcoid, not just histologic "sarcoidal granulomas"; he has it in his lungs,too) on his arms, each corresponding to a small shrapnel wound scar. Sarcoid tends to recur in the same place, so you may end up injecting Kenalog as for keloids. Maybe he will let you use Aristospan injections; they last a lot longer. Yelva Lynfield --------- Question to Kevin Smith and others on the list with experience using cyclosporin in sarcoidosis: how effective is it in comparison (safety/efficacy) with antimalarials or methotrexate for steroid resistant cases of cutaneous sarcoid. A collegue of mine has such a patient (30 y/o black woman, otherwise healthy) who has disfiguring facial disease and I would like the advice of the group. Mark Naylor, M.D. --------- I don't think I've used cyclosporine for sarcoid, but it would be worth a try. Be sure to check the renal function and monitor it closely in patients with sarcoid. My impression is that sarcoid is pretty tough, and you might wind up considering combined cyclosporine / MTX. KC Smith MD FRCP ------------ Brechtel, B, Haas, N., Henz, BM, et al.: Allopurinol: a therapeutic alternative for disseminated cutaneous Sarcoidosis. Br.J Dermatol.1996; 135: 307-309. Reports clinical & histologic clearing with no relapse in 3 months of post-Rx followup. Gene Sienkiewicz, M. D. -------