After a gap in attendance, there was still marked skin tightness and severe restriction of flexion and extension at the wrist and MCP joints, with clawing of the hands (flexion deformity of about 30° at the MCP joints and inability to make a closed fist) (Figure 1). In addition, the patient was increasingly intolerant of oral corticosteroids, describing indigestion (despite ranitidine hydrochloride prophylaxis), bloating, and marked weight gain. She was desperate to reduce corticosteroid treatment quickly but unhappy about the possible adverse effects of many immunosuppressive agents and concerned that other relatively safe treatments (cimetidine, hydroxychloroquine, azathioprine, and photochemotherapy) would be slow to exert any effect. On the basis of speed of action, and the previously reported benefit in this condition, cyclosporine, 4 mg/kg/d, was tried for 2 weeks but was not tolerated because of severe nausea. We, therefore, required a treatment that could be predicted to be effective for an inflammatory disorder including eosinophils, with a fast onset of action, low risk of gastrointestinal adverse effects, and relative safety.