Adalimumab for Treatment of Cutaneous Sarcoidosis

The patient, a 46-year-old black woman, was referred to the dermatology clinic at Washington University, St Louis, Mo, for evaluation of reddish-purple nodules on her face and shins. The patient’s medical history was significant for hypothyroidism and an arrhythmia. Findings from a punch biopsy from her right nasal ala showed confluent granulomas with central caseous necrosis in the dermis. Findings from a wedge biopsy specimen from her right shin showed granulomas in the dermis and subcutis with necrotizing foci. Acid-fast bacteria and Giemsa stains of both specimens were negative for mycobacteria and fungal organisms. Because of continued concern that she had an infection, an excisional biopsy specimen from the right leg was taken. Tissue culture for bacteria, mycobacteria, and fungi failed to grow any organisms. Histologic examination of this specimen revealed a septal panniculitis consistent with a diagnosis of erythema nodosum. Despite the caseating granulomas found on histologic examination of the specimens from the initial 2 biopsies, a diagnosis of sarcoidosis was made based on exclusion of an infectious etiology and the clinical appearance of the lesions. Further evaluations included a complete blood cell count with differential cell count and complete metabolic panel, both of which revealed no significant abnormal findings. The patient had no reaction to purified protein derivative but did react to Candida antigen. A computed tomographic scan of her chest revealed a 4-mm nodule in the left upper lobe of the lung and a 1.3-cm left axillary lymph node. A 2.2-cm rim-enhancing lesion in the right hepatic lobe consistent with a hemangioma was noted. Pulmonary function tests revealed a forced expiratory volume in 1 second (FEV1) of 1.72 (72% predicted of normal for the patient’s age group) and a forced vital capacity (FVC) of 2.02 (70% predicted), with an FEV1/FVC ratio of 85%. Her diffusion capacity of carbon monoxide was 65% predicted of normal for her age group. These abnormalities in the findings were not felt to be clinically significant by the patient’s pulmonologist. The patient was treated with minocycline hydrochloride, 100 mg twice daily, and 0.05% clobetasol propionate cream. The minocycline therapy was discontinued after she developed headaches and tinnitus. The patient subsequently developed ulcerations of the nodules on her legs. Findings from a repeated biopsy from an ulcerating nodule on her left leg revealed a granulomatous panniculitis. Acid-fast bacteria and Giemsa stains were again negative for mycobacteria or fungal organisms, as were tissue cultures for bacteria, mycobacteria, and fungi. Antineutrophil cytoplasmic antibodies were not detected in her blood. The patient was treated with Unna wraps and 0.05% clobetasol ointment to her legs and continued treatment with 0.05% clobetasol cream to her face. A 3-week trial of 40 mg of prednisone daily led to modest improvement. She subsequently failed treatment with hydroxychloroquine sulfate (Plaquenil; Sterling Winthrop Inc, New York, NY), 200 mg, twice daily; pentoxifylline, 400 mg, 4 times daily; and multiple intralesional injections of triamcinolone acetonide (Kenalog; Bristol-Myers Squibb Co, New York, NY), 5 mg/cm, to the nose. Physical examination at this time revealed reddish-purple nodules on her nose (Figure 1), eyebrows, chin, and upper lip, as well as numerous hyperpigmented patches and nodules with atrophic centers and erosions on her legs (Figure 2). An alternative treatment was needed.