Sarcoidosis is a multisystem granulomatous disease of unknown etiology that affects the skin in more than 25% of patients. Lupus pernio is the most characteristic skin feature and presents as infiltrated violaceous plaques that tend to have a symmetric distribution, mainly affecting acral areas: nose, cheeks, ears, lips, and forehead.1 Multiple treatment options are currently available, but there are refractory cases in which alternative treatments are needed.

We report the case of a 54-year-old woman with no past history of interest, diagnosed 9 years previously with cutaneous sarcoidosis based on the presence of papular, erythematous–violaceous plaques on the elbows, knees, and dorsum of the nose, with necrotizing granulomas on skin biopsy. There were no clinical manifestations in other areas and the results of additional studies were normal except for slightly elevated levels of angiotensin-converting enzyme. During the first 5 years she was treated with topical and intralesional corticosteroids and chloroquine leading to acceptable control of the lesions on the elbows and knees but with persistence of lesions on the nose.

Given recurrent outbreaks, in addition to local treatment with corticosteroids she subsequently received systemic treatments with hydroxychloroquine, methotrexate, and allopurinol, leading to transient and unsatisfactory results.

After the last outbreak, which mainly affected the dorsum of the nose in the form of an erythematous–violaceous plaque (Fig. 1), we decided to begin treatment with an intense pulsed light system (Photoderm-Vasculight) that provides polychromatic light in the range of 515–1200nm, on which different cut-off filters (550, 570, 590nm, etc.) can be mounted, in combination with a long-pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) laser (1064nm). All sessions were conducted on an outpatient basis without the need for sedation or anesthesia. The 590-nm cutoff-filter was used and a double pulse of 37J/cm2 (T1: 2.8ms, T2: 2.8ms) was delivered with 20-ms delays between pulses. The sessions were conducted between June 2006 and July 2008. In each session, the energy was slightly increased up to a fluence of 45J/cm2. The response to treatment was almost complete (Fig. 2). Two years later the patient remained asymptomatic without treatment.

Figure 1.

Erythematous–violaceous plaque on the dorsum of the nose.

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Figure 2.

Almost complete response to treatment with minimal erythema.

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The guidelines remain unclear regarding the treatment of cutaneous sarcoidosis, since no randomized controlled studies have been conducted with sufficient numbers of patients by which to establish them,2 thus we have to tailor treatment to each patient based on severity, associated comorbidities, and possible adverse effects. Regarding the treatment of localized lesions, Badgwell and Rosen3 suggest that although topical and intralesional corticosteroids are the treatment of choice, laser therapy is an approach that should be considered in persistent lesions.

The first type of laser used to treat lupus pernio was the flashlamp pulsed dye laser in 1992 with good results, although relapses occurred after 6–10 months.4 Subsequently, other cases with a good clinical response to treatment were published,5,6 one of which demonstrated the persistence of granulomas on histologic study after treatment.5

Regarding carbon dioxide laser, we highlight the article by O’Donoghue and Barlow7 on 3 patients. The first patient received concomitant low-dose oral corticosteroids for systemic disease and remained asymptomatic for 6 years. The other 2 patients, treated with carbon dioxide laser alone, presented relapses at 9 months and 14 months, respectively.

There are 2 references in the literature to treatment with the Nd:YAG laser. The first was in 2005, in which the Versapulse system (532nm) was used in a patient who had previously been treated with a dye laser with limited results; Versapulse laser treatment produced significant clearance of the erythema and there was no recurrence after 3 years of follow-up.8 The second report described 2 cases with a good response to potassium titanyl phosphate laser; one of the patients was receiving concomitant methotrexate therapy.9

Complications have been minimal, the most frequent being hypopigmentation and hyperpigmentation. Green et al.10 presented a patient who developed ulcerative sarcoidosis in treated and untreated lesions after dye laser therapy.

Regarding the mechanism of action, it appears reasonable to assume that if we destroy the blood vessels through which the inflammatory mediators reach the focus, the sarcoidosis lesions, as well as those of other inflammatory processes such as lupus erythematosus, will disappear, at least temporarily.

In our opinion, treatments with pulsed light and with laser are associated with a good safety profile, are generally well tolerated, and should be considered in patients with localized cutaneous sarcoidosis refractory to conventional treatments. However, large controlled studies are needed in order for these to be considered first-line treatments.2