Disfiguring cutaneous manifestation of sarcoidosis treated with thalidomide: a case report

Biologic and advanced immunomodulating therapeutic options for sarcoidosis: a clinical update

Introduction: Sarcoidosis is a multi-organ disease with a wide range of clinical manifestations and outcomes. A quarter of sarcoidosis patients require long-term treatment for chronic disease. In this group, corticosteroids and cytotoxic agents be insufficient to control diseaseAreas covered: Several biologic agents have been studied for treatment of chronic pulmonary and extra-pulmonary disease. A review of the available literature was performed searching PubMed and an expert opinion regarding specific therapy was developed.Expert opinion: These agents have the potential of treating patients who have progressive disease. Many of these agents have different mechanisms of action, response rates, and toxicity profiles.

Sinonasal and Laryngeal Sarcoidosis-An Uncommon Presentation and Management Challenge

Sarcoidosis is a chronic inflammatory disease of uncertain etiology characterized by the formation of noncaseating granulomas. The thorax is involved in 95% of cases, but any organ can be involved. Sinonasal or laryngeal involvement is uncommon and can be difficult to diagnose. The reported incidence of sarcoidosis in the upper airway clearly depends on study characteristics, and this creates uncertainty about the actual incidence. In a large prospective study in the United States, upper respiratory tract involvement occurred in 3% of the patients. Some patients have upper airway involvement without thoracic disease, and this presentation may cause delays in diagnosis. These patients have nonspecific symptoms which range from minimal nasal stuffiness to life-threatening upper airway obstruction. Currently, there is no established standard therapy for the management of upper airway sarcoidosis. These patients often respond poorly to nasal and/or inhaled corticosteroids and require long courses of oral corticosteroids. Patients with poor responses to oral corticosteroids or severe side effects may respond to tumor necrosis factor alpha inhibitors. In this review, we will discuss the clinical presentation, pathogenesis, diagnostic tests, drug treatment, surgical management options and the challenges clinicians have managing these patients.

Spectrum of orocutaneous disease associations: Genodermatoses and inflammatory conditions

The oral cavity and cutaneous organ systems share a close embryologic origin. Therefore, there are numerous dermatologic conditions presenting with concomitant oral findings of which the dermatologist must be aware. The second article in this continuing medical education series reviews inflammatory orocutaneous conditions and a number of genodermatoses. It is essential for dermatologists to be familiar with oral cavity manifestations associated with dermatologic diseases for prompt diagnosis, management, and appropriate referral to stomatology and dentistry.

A randomized, investigator-masked, double-blind, placebo-controlled trial on thalidomide in severe cutaneous sarcoidosis

BACKGROUND

Thalidomide use in cutaneous sarcoidosis is based on data from small case series or case reports. The objective of this study was to evaluate the efficacy and safety of thalidomide in severe cutaneous sarcoidosis.

METHODS

This study consisted of a randomized, double-bind, parallel, placebo-controlled, investigator-masked, multicenter trial lasting 3 months and an open-label study from month 3 to month 6. Adults with a clinical and histologic diagnosis of cutaneous sarcoidosis were included in nine hospital centers in France. Patients were randomized 1:1 to oral thalidomide (100 mg once daily) or to a matching oral placebo for 3 months. In the course of an open-label follow-up from month 3 to month 6, all patients received thalidomide, 100 mg to 200 mg daily. The proportions of patients with a partial or complete cutaneous response at month 3, based on at least a 50% improvement in three target lesions scored for area and infiltration, were compared across randomization groups.

RESULTS

The intent-to-treat population included 39 patients. None of them had a complete cutaneous response. Four out of 20 patients in the thalidomide group (20%) vs four out of 19 patients in the placebo group (21%) had a partial cutaneous response at month 3 (difference in proportion of -1% [95% CI, -26% to +24%] for thalidomide vs placebo, P = 1.0). Eight patients with side effects were recorded in the thalidomide group vs three in the placebo group. We observed a large number of adverse event-related discontinuations in patients taking thalidomide in the first 3 months (four patients with thalidomide, zero with placebo) and in the 3 following months (five patients).

CONCLUSIONS

At a dose of 100 mg daily for 3 months, our results do not encourage thalidomide use in cutaneous sarcoidosis.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT0030552; URL: www.clinicaltrials.gov.

Innovative uses of thalidomide

Thalidomide is approved for treating erythema nodosum leprosum and multiple myeloma, but it has also emerged as a useful treatment option for many refractory dermatologic disorders. Some of the innovative but off-label uses of thalidomide include aphthous stomatitis, Behçet's disease, lupus erythematosus, prurigo nodularis, sarcoidosis, actinic prurigo, graft-versus-host disease, Langerhans cell histiocytosis, erythema multiforme, lichen planus, Kaposi sarcoma, Jessner lymphocytic infiltrate, uremic pruritus, pyoderma gangrenosum, scleroderma, scleromyxedema, and necrobiosis lipoidica. This article reviews the background, pharmacology, and innovative uses of thalidomide in dermatology.

A Rare Nonmalignant Mass of the Pancreas: Case Report and Review of Pancreatic Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown etiology affecting patients from all genetic backgrounds. Pancreatic involvement is rare; the first case was described on autopsy in 1937. We present a case of pancreatic sarcoidosis without a history of the disease presenting as biliary obstruction mimicking pancreatic malignancy. We also review the literature with respect to management and outcomes of similar cases. The patient described here presented with all the signs and symptoms of a pancreatic malignancy, which was confirmed on a CT scan; the positron emission tomography scan and the CA 19-9 level were also confirmatory of the suspected diagnosis. In this setting, if the mass looks resectable, a Whipple procedure would be the next logical step. However, such strategy would be aggressive management for a benign condition that could be palliated with diverting rather than resective procedures without changing the outlook of the disease. We suggest keeping a high index of suspicion in patients with a history of the disease if demographic concordance exists.

Treatment of idiopathic prurigo nodularis in Taiwanese patients with low-dose thalidomide

Prurigo nodularis is an intensely pruritic dermatosis characterized by lichenified and excoriated papules and nodules. The course of prurigo nodularis is often chronic, and some patients respond very poorly to the standard therapeutic modalities. Because the pathogenesis of this disease remains obscure, the treatment of prurigo nodularis can be disappointing and frustrating for both the patients and physicians. Thalidomide, a tumor necrosis factor-alpha antagonist, has been suggested as an alternative treatment option for recalcitrant prurigo nodularis. In the past, the regimen for treatment of prurigo nodularis often required thalidomide at 200 mg/day. We recruited patients with intractable prurigo nodularis and treated them with low-dose thalidomide. Six patients with idiopathic prurigo nodularis were successfully treated with low-dose thalidomide (50-100 mg/day) without clinical development of peripheral neuropathy. In summary, our preliminary results suggest that low-dose thalidomide may be a safe and effective treatment option for patients with recalcitrant idiopathic prurigo nodularis.

Cutaneous sarcoidosis therapy updated

The widely accepted standard therapy for cutaneous sarcoidosis includes corticosteroids, antimalarials, and methotrexate. However, a better understanding of the basic immunopathogenic properties of sarcoidosis has elucidated a number of steps critical to the persistence and progression of disease that may be vulnerable to treatment by targeted therapy. This article reviews both standard and newer therapeutic options for cutaneous sarcoidosis.

Thalidomide: dermatological indications, mechanisms of action and side-effects

Thalidomide was first introduced in the 1950s as a sedative but was quickly removed from the market after it was linked to cases of severe birth defects. However, it has since made a remarkable comeback for the U.S. Food and Drug Administration-approved use in the treatment of erythema nodosum leprosum. Further, it has shown its effectiveness in unresponsive dermatological conditions such as actinic prurigo, adult Langerhans cell histiocytosis, aphthous stomatitis, Behçet's syndrome, graft-versus-host disease, cutaneous sarcoidosis, erythema multiforme, Jessner-Kanof lymphocytic infiltration of the skin, Kaposi sarcoma, lichen planus, lupus erythematosus, melanoma, prurigo nodularis, pyoderma gangrenosum and uraemic pruritus. This article reviews the history, pharmacology, mechanism of action, clinical uses and adverse effects of thalidomide.

Tumour necrosis factor in sarcoidosis and its potential for targeted therapy

Tumour necrosis factor (TNF)-alpha is a potent cytokine involved in the inflammatory reactions of many acute and chronic diseases. Recently, agents that block TNFalpha either directly or indirectly have been successful in the treatment of a variety of immune-mediated inflammatory disorders including rheumatoid arthritis and Crohn's disease. Sarcoidosis is an immune-mediated inflammatory disorder characterised by the formation of granulomas. TNFalpha is important in the initiation and perpetuation of inflammation in sarcoidosis, contributing to the initiation of granulomas and the progression of fibrosis, as well as to nongranulomatous inflammation. Various agents used to treat sarcoidosis affect TNF, including the most widely used drug class, corticosteroids, which are usually effective in blocking TNFalpha release from cells. Other agents that nonspecifically inhibit TNFalpha release include methotrexate, azathioprine and pentoxifylline. Specific TNF-antagonising biological agents such as infliximab and etanercept are being tested in patients with sarcoidosis, with mixed success. Infliximab has been shown to produce clinical improvement and reduce the requirement for corticosteroids in a small number of patients with sarcoidosis. However, as infliximab can be associated with reactivation of tuberculosis, which could be mistaken as worsening sarcoidosis, it should be used with caution in this patient group.

Treatment of cutaneous sarcoidosis with thalidomide

BACKGROUND

Although systemic corticosteroids are effective against cutaneous sarcoidosis, alternative therapies are needed.

OBJECTIVE

We sought to assess the efficacy and tolerance of thalidomide for cutaneous sarcoidosis.

METHODS

We performed a retrospective evaluation of thalidomide (100-200 mg/d) in 12 consecutive patients with cutaneous sarcoidosis treated in a university hospital between 2000 and 2002.

RESULTS

Cutaneous lesions regressed within 1 to 5 months, with an average time of 2 to 3 months for 10 patients. In all, 4 patients achieved complete responses, 6 had partial responses, and 2 had no regression. Nasopharyngeal, pulmonary neurologic, and hepatic symptoms were also attenuated. Thalidomide was well tolerated. The main adverse effect was deep vein thrombosis in 1 patient.

CONCLUSION

Thalidomide efficacy and tolerance in patients with cutaneous sarcoidosis merits further evaluation in a controlled trial.

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.

Dermatologic and nondermatologic uses of thalidomide

OBJECTIVE

To review published data on thalidomide, with emphasis on current knowledge about mechanism of action, new and/or potential dermatologic and nondermatologic therapeutic applications, well-known and emerging adverse effects, and current indications for its safe use.

DATA SOURCES

Review articles, in vitro research studies, references from retrieved articles, case reports, and clinical trials were identified from a computerized literature search using MEDLINE and OVID (1966-January 2003) and on the Cochrane Clinical Trials Register (January 2003). Information available from meetings' abstract books, Internet, or pharmaceutical companies was also considered.

STUDY SELECTION AND DATA EXTRACTION

All articles identified as relevant, including those from non-English literature, were considered in an attempt to provide to the reader both the theoretical basis and practical guidelines for thalidomide pharmacotherapy.

DATA SYNTHESIS

Thalidomide has hypnosedative, antiangiogenic, antiinflammatory, and immunomodulatory properties. Moreover, it has been shown to selectively inhibit the production of tumor necrosis factor-alpha and reduce the expression of various integrin receptors on the membrane of leukocytes and other cell types in a dose-dependent fashion. Controlled trials demonstrated the efficacy of thalidomide in a number of diseases, including erythema nodosum leprosum, lupus erythematosus, aphthosis, graft-versus-host disease, prurigo nodularis, and actinic prurigo. Single case reports or studies in small series have also suggested a possible role for thalidomide in numerous other dermatologic and nondermatologic disorders. Possibly severe and sometimes irreversible risks related to the clinical use of thalidomide include teratogenicity and neurotoxicity.

CONCLUSIONS

Although teratogenicity and neurotoxicity are significant adverse effects requiring cautious use, thalidomide is an effective therapeutic modality in a variety of difficult-to-treat disorders and, providing careful selection of patients, should offer an acceptable risk-to-benefit ratio.

Thalidomide for treatment of severe generalized discoid lupus lesions in two patients with systemic lupus erythematosus

We describe 2 patients with systemic lupus erythematous whose widespread discoid lupus erythematosus was unresponsive to systemic steroids and antimalarial agents. They showed dramatic improvement to thalidomide at a dose of 300 mg/d, with maximum benefit achieved within 15 weeks of therapy. Dosages of 50 to 100 mg/d were effective in maintaining remission for 1 year. However, thalidomide-induced neuropathy was observed in both cases.

Thalidomide for the treatment of recalcitrant oral Crohn's disease and orofacial granulomatosis

It has been suggested that thalidomide may be effective in the management of Crohn's disease, including the associated oral lesions. We detail the clinical response to low-dose thalidomide of 5 patients with clinical features of orofacial granulomatosis or oral Crohn's disease recalcitrant to recognized immunosuppressant therapy. All patients had clinical resolution of their symptoms and signs. Transient somnolence was the only reported adverse effect. Remission was maintained by extending the period between thalidomide doses. Thalidomide should be considered an effective therapy for the short-term treatment of severe orofacial granulomatosis in appropriately counseled patients.

Difficult treatment issues in sarcoidosis

The management of sarcoidosis includes several crucial decisions. Not all patients with sarcoidosis need treatment. At least a third of patients will never be treated. It is unclear whether asymptomatic patients ever need therapy, even if they have extensive lung disease. One reason that clinicians are reluctant to start therapy is that many patients who are started on corticosteroids have a difficult time getting off therapy, even after 2 years. In the chronic patient, alternatives to corticosteroids have been developed. These include drugs such as methotrexate, azathioprine and hydroxychloroquine. These agents have been the standard second line of therapy for patients with chronic disease. However, these drugs do not always work. In addition, they are associated with their own toxicities. Another group of sarcoidosis patients have also emerged. These are the refractory patients, who have progressive disease whilst on therapy. For these patients, new agents such as thalidomide and the monoclonal antibodies to tumour necrosis factor have been occasionally helpful. This paper reviews several important issues in the management of sarcoidosis.

The cytokine network in sarcoidosis and its clinical relevance

In recent years, analysis of the cytokine network has substantially improved our knowledge of the immunopathogenesis of sarcoidosis. There is increasing evidence from clinical immunology that analysis of the cytokine network may be helpful for clinicians to assess the extent and activity of sarcoid inflammation. Genetic polymorphisms may contribute to interindividual differences in the regulation of cytokine release. Thus, disease phenotype-associated haplotypes should exist and their analysis might disclose risk profiles of individual patients. Furthermore, serological assessment of cytokines or soluble cytokine receptors may become suitable parameters in clinical practice to detect an ongoing inflammation in chronic sarcoidosis.

Therapeutic options for sarcoidosis: new and old

The treatment of patients with sarcoidosis remains an important part of management. The role of corticosteroids has been questioned by some, while others have reported its value even in asymptomatic patients with interstitial lung disease. Cytotoxic agents have become standard therapy for some forms of chronic disease. Newer agents that modulate the immune response have been studied. A key cytokine in chronic sarcoidosis appears to be tumor necrosis factor. Drugs that inhibit its release or block its effect have been reported as effective for sarcoidosis.

Thalidomide for chronic sarcoidosis

STUDY OBJECTIVES

Thalidomide therapy has been shown to modify granulomatous diseases, such as tuberculosis and leprosy. Lupus pernio is a skin manifestation of sarcoidosis that does not remit spontaneously, and was used as a marker of efficacy of thalidomide for sarcoidosis.

DESIGN

An open-label, dose-escalation trial of thalidomide.

SETTING

Patients were seen at one of four specialized sarcoidosis clinics in the United States.

PATIENTS

Fifteen patients with lupus pernio and other manifestations of sarcoidosis unresponsive to prior therapy were enrolled.

INTERVENTIONS

Skin lesions were assessed with visual examination by the treating physician, and photographic evaluation by a blinded panel of physicians reviewing photographs of the lesions before and after therapy.

MEASUREMENTS AND RESULTS

Fourteen patients completed 4 months of therapy. All patients experienced some improvement in their skin lesions subjectively, and 10 of 12 evaluable patients showed improvement using photograph scoring. Five patients were better after 1 month (treated with 50 mg/d of thalidomide), seven more patients improved after 2 months (treated with 100 mg/d of thalidomide in the second month), and two patients required an additional month of 200 mg of thalidomide to achieve a response. Patients reported increased somnolence (n = 9), numbness (n = 7), dizziness (n = 2), constipation (n = 6), rash (n = 1), and increasing shortness of breath (n = 1). One patient discontinued therapy because of new-onset dyspnea, due to probably unrelated new-onset congestive heart failure.

CONCLUSION

Thalidomide was an effective form of treatment for chronic cutaneous sarcoidosis. The drug was well tolerated and may be a useful alternative to systemic corticosteroids.

Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown cause that most commonly affects the lungs, lymph nodes, skin, eyes, spleen, bone, and glandular tissue. The diagnosis is made when characteristic histologic findings are demonstrated and other granulomatous processes are excluded. It can be an acute or chronic debilitating disease, but in patients with acute disease the process can be self-limited. Multiple therapeutic options have been described both for the cutaneous and systemic lesions of sarcoidosis. Steroids, however, remain the cornerstone of therapy.

Targeting tumor necrosis factor alpha. New drugs used to modulate inflammatory diseases

Since its discovery, the understanding of the roles for TNF-alpha in human biology and disease has grown. Receptors for TNF are found on virtually all cell types, and many physiologic processes seem to be altered by TNF-alpha. The understanding of how TNF-alpha is involved in the pathophysiology of diseases, such as inflammatory diseases, has allowed the development of new drugs that can interfere with excess TNF-alpha and thus has allowed novel therapies for rheumatoid arthritis and Crohn's disease. As the role of TNF-alpha in other diseases becomes better understood, such TNF-alpha-modulating drugs may find further applications. In the skin, TNF-alpha is prominent cytokine that seems to be important in allergic and irritant contact dermatitis and inflammatory skin conditions. Modulating TNF-alpha activity in the skin may provide therapeutic benefits for a variety of skin conditions (Table 4). Tumor necrosis factor-alpha levels are elevated in skin lesions of psoriasis. A few reports have already suggested that etanercept and infliximab may offer a therapeutic effect in patients with psoriasis. Clinical studies evaluating the true efficacy of these drugs in psoriasis are under way. Specifically, the authors and others are involved in a double-blind, placebo-controlled study to assess the efficacy of etanercept for psoriasis. Thalidomide has been used off-label with some success to treat a number of dermatologic diseases, including several inflammatory skin conditions. Etanercept and infliximab might perhaps prove efficacious for inflammatory skin conditions as well. Finally, it is possible that drugs targeting TNF-alpha may have yet-unrecognized serious side effects. Because TNF-alpha seems to be a central cytokine in UVR-induced apoptosis, the chronic use of TNF-alpha-altering drugs might increase the risk for skin cancers. Tumor necrosis factor-alpha also plays some role in cutaneous wound healing; the effect these drugs might have on this process is also unknown at this time. Certainly, much is already [table: see text] known about TNF-alpha and how it plays many central roles. This understanding has allowed the development of useful new drugs for intractable disease. As the understanding of TNF-alpha and other cytokine biology increases, so will the number of potential therapeutic agents.

Sarcoidosis

Sarcoidosis is a systemic noncaseating granulomatous disorder of unknown origin. The cutaneous manifestations of sarcoidosis often enable the dermatologist to be the first physician to make the diagnosis. This article reviews essential sarcoidosis pathophysiology, clinical polymorphisms, systemic evaluation, and treatment modalities for cutaneous sarcoidosis to further enhance the dermatologist's understanding of this disease entity.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the theories of the pathogenesis of sarcoidosis, its cutaneous manifestations, its various syndromes and associations, and its presentation in children. Participants should also be more knowledgeable about diagnostic evaluation, measurement of disease progression, treatment modalities, and the prognosis and mortality data of sarcoidosis.

Thalidomide

Thalidomide has been successful in the treatment of several dermatologic conditions unresponsive to other agents. Further experience may lead to a better understanding of its mechanism of action in these various diseases. Thalidomide should be considered an extremely valuable therapeutic option in selected patients when the benefits clearly outweigh the risks of teratogenicity and peripheral neuropathy.