TNF and Cowden syndrome 1: Treatment for CS should be done in stages, considering the risks and benefits of the therapy, with local therapies first (topical and intralesional steroids, tacrolimus, and topical retinoids) and then systemic immunomodulatory treatments (hydroxychloroquine, chloroquine, tetracyclines, thalidomide) alone or in combination, and finally, systemic immunosuppressive drugs such as methotrexate, prednisone, azathioprine and tumor necrosis factor (TNF) inhibitors (adalimumab, infliximab) [20,31].