Sarcoidosis is an immune-mediated systemic syndrome of unknown etiology. The treatment of the granulomatous inflammation in sarcoidosis is thus dependent on nonspecific suppression of the immune response. Although steroid-sparing approaches have moved to front-line therapy for many other immune-mediated inflammatory diseases, corticosteroids remain the initial treatment of choice for most patients with sarcoidosis due in large part to the clinical variability and high rates of spontaneous remission. Given the heterogeneity of clinical phenotypes between patients, treatment approaches must be individualized. For patients with persistent disease, or for patients who are intolerant of systemic steroids, there are several steroid-sparing immune-modulating medications that have been effective for treating sarcoidosis. Besides immunosuppressives, we will also overview several sarcoidosis-related issues that contribute to patient-reported symptoms, a "sarcoidosis penumbra." Recognition and judicious therapy for these related issues are often key to optimizing outcomes and quality of life.
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