2001 marks the 50th anniversary of the first reports of the successful treatment of sarcoidosis with cortisone1 ,2 and ACTH.3 In an early report of treatment with corticosteroids, Siltzbach4 highlighted one of the problems of evaluating the results when he wrote:

“The aetiology of sarcoidosis still eludes us, as does the definitive treatment. Part of the difficulty stems from the unpredictability of spontaneous remissions. This accounts for the many transitory successes reported at one time or another with such agents as calcium salts, gold, arsenicals, potassium iodide, chaulmoogra oil, antileprol and tuberculin.”

 It is somewhat depressing that no better therapeutic agents than steroids have emerged over the subsequent 50 years, and the sceptic might well conclude that little has changed! While the approach to treatment may have become more rational and the choice of effective agents has increased, it is at best suppressive rather than curative. Happily, as Siltzbach pointed out, in most patients the natural tendency of pulmonary sarcoidosis is towards spontaneous resolution. The therapeutic challenges remain the recognition of those patients in whom remission and resolution are less likely, and determination of the optimum treatment to minimise permanent organ damage.

Several uncontrolled and controlled studies, as well as common clinical experience, have amply confirmed the suppressive effect of steroids.5-11 In pulmonary sarcoidosis the most common indication for treatment is symptomatic, usually troublesome breathlessness and sometimes cough. Most commonly, prednisolone is started at a dose of 30–40 mg daily with later reduction titrated against symptoms, respiratory function, and radiographic appearance. Once started, treatment is usually continued for at least 1 year but patients may require more prolonged treatment if dose reduction is accompanied by recrudescence of disease activity. Whether or not steroid treatment reduces long term pulmonary damage due to fibrosis has proved difficult to …