Corticosteroids in sarcoidosis: friend or foe?

Sarcoidosis is a chronic, multiorgan disorder of unknown aetiology, characterized in affected organs by an accumulation of T lymphocytes and mononuclear phagocytes, noncaseating epithelioid cell ("immune") granulomas and tissue injury [1–3]. The general paradigm of immune granuloma formation suggests a specific, T-cell-mediated response to an antigenic agent that has been processed by macrophages and presented to antigen-specific Tlymphocytes. The T-cell, in turn, directs the accumulation and differentiation of mononuclear phagocytes in the local microenvironment [1, 2, 4]. The disease can present in an acute or subacute form and is often selflimited, but in many other cases it is chronic, with variable disease activity over many years. Corticosteroids have been the mainstay of treatment for more than 30 yrs, but there is still argument about their place in management. This is coupled to a certain nihilism about a group of drugs of which the side-effect profile is receiving increasing publicity. Whilst it is entirely appropriate that potential benefits of a treatment should be balanced against the risk of side-effect and must be discussed fully with each patient, the enormous benefits gained by many patients with chronic inflammatory diseases must also be part of that discussion. The aim of this article is to review the use of corticosteroids in sarcoidosis, with particular emphasis on persistent pulmonary disease, by addressing three issues: 1) Is corticosteroid therapy a rational approach?; 2) Do they modulate disease?; and 3) Do they affect long-term outcome?