Treatment of Cutaneous Sarcoidosis with tofacitinib 2% ointm
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Sarcoidosis is a chronic multisystem inflammatory disorder characterized by granuloma formation.

A 46 year-old man presented for evaluation and management of scaly papules and plaques. 9 years before, he developed non-healing crusted nodules on his scalp, arms and within multiple tattoos. A skin examination revealed violaceous, atrophic, scaly patches and thin plaques on his scalp and arms with associated cervical and submandibular lymphadenopathy. A lesion on his arm was biopsied
preferentially for ease of biopsy and cosmetic preservation.

Biopsy of the arm lesion demonstrated sarcoidal granulomatous inflammation with aggregates of histiocytes and giant cells, with minimal surrounding lymphocytic inflammation. Angiotensin converting enzyme and Vitamin D were elevated at 73 pg/dL and 84 U/L, respectively, and 25-OH Vitamin D was 11 ng/mL. Evaluation for sarcoidosis revealed subtle fibronodular changes in the right lung and bilateral hilar and mediastinal lymphadenopathy on chest imaging.

The patient was initially treated with intralesional triamcinolone acetonide injection (10 mg/cc) and topical clobetasol propionate 0.05% ointment. He had persistent active cutaneous disease, resistant to tacrolimus 0.1% ointment, tretinoin 0.025% cream, adapalene 0.1% gel, pimecrolimus 1% cream, triamcinolone acetonide 0.1% ointment, oral hydroxychloroquine at a dose of 200 mg daily due to G6PD deficiency and transaminitis at higher dose, and oral doxycycline at a dose of 100 mg twice daily.

The patient continued to use triamcinolone acetonide 0.1% ointment as needed. His cutaneous disease progressed demonstrating multiple large, scaly, violaceous, atrophic plaques with mild dyspigmentation on his scalp, and thick scaling papules on his right forearm and left posterior arm tattoo. He was prescribed compounded tofacitinib 2% ointment twice daily (30-g tube), which he used as prescribed for two weeks. He then self-adjusted his regimen to apply tofacitinib every other day in combination with self-initiated extra virgin olive oil (EVOO) to his scalp daily for two weeks, and intermittently thereafter.

On repeat assessment by his dermatologist five months later, his exam demonstrated significant improvement in erythema, scale, and induration, and the plaques appeared less violaceous. His Cutaneous Sarcoidosis Activity Morphology Instrument disease activity scores on his scalp improved from 9 to 5 and he has described continued improvement beyond that. He experienced no adverse effects during treatment. . EVOO contains oleocanthal, which is thought to have anti-inflammatory properties similar to non-steroidal anti-inflammatory agents via COX-1 and COX-2 inhibition.