Treating sarcoidosis: when less is more

Sarcoidosis is a heterogeneous condition, with some presentations associated with spontaneous remission and favourable outcome without treatment. Other presentations, including small fibre neuropathy, arthropathy and sarcoid-associated fatigue, can cause disabling symptoms that may not respond to disease-modifying therapies and must be managed with symptom-based treatments. Sarcoidosis can also present with organ- or life-threatening manifestations, which must be managed with disease-modifying therapies. Glucocorticoids have traditionally been used as first-line therapy, although a recent randomised controlled trial has suggested that methotrexate as sole therapy may be equally effective in pulmonary sarcoidosis, although with delayed efficacy. Growing evidence of glucocorticoid-related toxicities in sarcoid patients is prompting a paradigm shift in treatment towards a 'less is more' approach. In this review article, we will outline the current treatment of sarcoidosis with a particular focus on the shift away from the use of prolonged high-dose steroids.