Topical Pimecrolimus as a New Optional Treatment in Cutaneous Sarcoidosis of Lichenoid Type

We report the case of cutaneous sarcoidosis of lichenoid type successfully treated with pimecrolimus. For the first time in the literature, we propose the use of this topical calcineurin inhibitor for the treatment of the cases refractory to common therapy regimens. 1. Introduction Lichenoid sarcoidosis is an extremely rare cutaneous manifestation of sarcoidosis, occurring in 1%-2% of all cases and presenting with multiple erythematous or violaceous, slightly scaling maculopapules localized on the trunk, limbs, and face, without systemic involvement. Different therapeutic approaches have been described for the treatment of cutaneous sarcoidosis, but the lesions are often refractory to the common treatments. We described the case of a female patient affected by cutaneous sarcoidosis of lichenoid type successfully treated with topical calcineurin inhibitor Pimecrolimus, never been reported in the literature until now. 2. A Case Report A 66-year-old woman was referred to our department with a 6-month history of 1-2？mm diameter, violaceous, nonfollicular, infiltrated lichenoid papules with a tendency to group, located on the right knee (Figure 1(a)). The onset had been abrupt and no antecedent of trauma was found. She had been using a clobetasol ointment once daily for 2 months with no improvement of the lesions. Figure 1: (a) Infiltrated, nonfollicular, lichenoid papules with a tendency to group, located on both knees; (b) a nearly complete remission of the lesions after 6-months therapy with topical 1% pimecrolimus. She did not complain of any systemic symptoms or take any kind of drugs. In the past medical history, no relevant diseases were referred, except for a papillary thyroid carcinoma excised 4 years before. General physical examination did not reveal any abnormality or lymphadenopathy. Cutaneous biopsy of one of the lesions revealed mild thinning of the epidermis, and a nonnecrotizing lymphohstiociytic granulomatous infiltrate in the superficial and deep dermis (Figures 2 and 3). Neither eosinophils nor mucin were seen. Gram stain, stain for fungi, and special stains for mycobacteria were negative. We also performed a videodermoscopy evaluation of the lesions, showing a round to oval yellow-brown lesion with absence of white Wickham striae (Figure 4). Figure 2: H&E staining, 100x magnification. Epidermis presents rete ridges flattening and orthotopic hyperkeratosis. In the deep dermal layer a sarcoidosis-like granulomatous reaction is visible. Figure 3: H&E staining, 200x magnification. Sarcoidosis-like granulomas are composed by epithelioid