We report the case of a 30-year-old patient with subcutaneous sarcoidosis who refused standard treatment with corticosteroids and received allopurinol instead, resulting in a poor therapeutic response.
A 30-year-old man presented to our clinic with a massively superinfected, 6.5 × 3.2-cm, nodular ulceration on his right thigh; a firm, painful swelling around his distal right radius (Figure 1) and several painless, plum-sized lumps and enlarged, freely mobile lymph nodes in his groin and axillae. The skin overlying all these nodules was immobile and bluish. Pronounced finger-clubbing was present. Radiographic imaging revealed enlarged bilateral mediastinal lymph nodes and a 60 × 15-mm soft-tissue tumor of his right radius with cortical thickening. Histological findings revealed a normal epidermis and papillary dermis (Figure 2). The lower aspects of the reticular dermis and subcutaneous fat tissue contained epithelioid granulomas with slight necrosis and a sparse rim of lymphoid cells ("naked" tubercles). The diagnosis of a subcutaneous sarcoidosis was made; the most important differential diagnoses, the diagnoses of deep mycoses, tuberculosis, and immunological disorders, were excluded. The angiotensin-converting enzyme (ACE) level was elevated at 46 U/L (normal range, 8-21 U/L). Treatment with allopurinol was initiated at 200 mg/day. It was later increased to a maximum of 600 mg/day and was well tolerated. An initial regression of both mediastinal and cutaneous nodular lesions was observed. However, follow-up examinations revealed progression of the disease after 6 months of treatment and increased angiotensin-converting enzyme values. Allopurinol was therefore replaced by prednisolone (Decortin H) 100 milligrams/day for 5 days and then tapered over 5 months as disease symptoms lessened.
Voelter-Mahlknecht S, Benez A, Metzger S, Fierlbeck G. Treatment of Subcutaneous Sarcoidosis With Allopurinol. Arch Dermatol. 1999;135(12):1560–1561. doi:10-1001/pubs.Arch Dermatol.-ISSN-0003-987x-135-12-dlt1299
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