The treatment of sarcoidosis is controversial and complicated because therapy must be tailored to the individual patient. Some patients require no specific therapy, whereas others may require a lifetime of treatment. Corticosteroids have been the standard form of treatment for symptomatic sarcoidosis patients since the early observations regarding their benefit in that disease.52, 100, 122 Randomized trials have not been able to demonstrate long-term benefit for corticosteroid therapy.48, 98, 121 Because of side effects associated with corticosteroid therapy, many have sought alternatives. In this article, we review treatments that have been proposed as alternatives to corticosteroids in sarcoidosis. Many of them appear in small series or case reports. These drugs have often been used for other inflammatory diseases such as rheumatoid arthritis, providing supplemental information regarding their effectiveness, toxicity, and mechanism of action. In the treatment of sarcoidosis, one has to consider the issues of chronic versus acute disease.8 Many patients with sarcoidosis have a self-limited course, often with no or minimal symptoms. Within 2 years, most patients with acute disease are left with no further active disease and no symptoms requiring treatment. A subgroup of patients with chronic disease, however, may be left with a lifetime of symptomatic disease requiring continuous treatment.16, 52, 81 During the initial evaluation of the patient with sarcoidosis, several signs and symptoms have been noted to be associated with resolving disease versus chronic disease.81 A summary of their experience with more than 800 patients at one clinic in London established the rate of resolution of sarcoidosis versus particular manifestations, as shown in Table 1. Others have noted that many sarcoidosis patients require therapy beyond 2 years.16, 52 The choice of an alternative agent for sarcoidosis depends on the expected duration of therapy. For patients with acute disease such as erythema nodosum, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) may be useful. Whether or not the patient is treated, her symptoms often resolve within 2 to 4 months and further therapy becomes unnecessary. Other manifestations of the disease require different strategies. Table 2 lists a breakdown of the different manifestations of the disease, in part, based on therapeutic approaches. A patient with sarcoid may move from one manifestation to another over time, such as from generalized to chronic disease. The table lists the usual therapies used with each manifestation as well as some alternative treatments. Most of them are discussed in the remainder of this article.

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