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Treatment of orofacial granulomatosis (OFG) is difficult and unpredictable, and currently there is not a treatment with guaranteed success. Macrolides have been suggested to give dramatic improvements in idiopathic OFG; however, this was not our experience. Following on from remarkable findings with weekly azithromycin pulse therapy reported in JAMA Dermatology, 2015, we treated 5 male patients with idiopathic OFG with the same regimen. Case 1 had a slight improvement but stopped treatment after 5 weeks due to gastrointestinal upset. Cases 2 and 3 had an initial improvement; however, symptoms returned once treatment had ceased. Case 3 received a second course of azithromycin with no improvement. Cases 4 and 5 did not have any improvement at all.We concluded that weekly azithromycin pulse therapy was not a successful treatment for idiopathic OFG. It may provide some short-term improvement in symptoms but does not dramatically resolve symptoms.