|IMAGES IN RHEUMATOLOGY
|Year : 2016 | Volume
| Issue : 4 | Page : 232-233
Isolated cutaneous sarcoidosis with two different skin lesions
BN Shiva Prasad1, HM Omprakash2, KL Narendra3
1 Department of Rheumatology and Clinical Immunology, Vikram Jeshta, Mysore, Karnataka, India
2 Department of Dermatology, Vikram Perfect, Mysore, Karnataka, India
3 Department of Pathology, Vikram Jeshta, Mysore, Karnataka, India
|Date of Web Publication||8-Nov-2016|
Dr. B N Shiva Prasad
Vikram Jeshta, Mysore, Karnataka
Source of Support: None, Conflict of Interest: None
Keywords: Cutaneous sarcoidosis, erythema nodosum, non caseating granuloma
|How to cite this article:|
Shiva Prasad B N, Omprakash H M, Narendra K L. Isolated cutaneous sarcoidosis with two different skin lesions. Indian J Rheumatol 2016;11:232-3
A 38-year-old female without any comorbidity presented with a 2-month history of erythematous skin lesions over the face, chest, arm, and upper back, without any itching or pain. These lesions gradually increased in size from pinpoint to five centimeters with some lesions coalescing. Six weeks later, she developed erythematous painful nodules over the bilateral shin region. There were no other features of systemic involvement and eye symptoms. On examination, reddish papules of varying sizes were present on the upper back, ear zone, face, and extensor surface of the arm and forearm [Figure 1]. Erythematous tender nodules with 5–10 mm diameter, about 4–6 in each limb, were present over the shin region. There was no scarring, nerve thickening, hypopigmented patches, or oral ulcers. Hairs, mucosa, and nails were normal. Eye examination was normal. Complete hemogram, biochemical and microbiological evaluation, chest X-ray, and computed tomography of the chest were normal. HIV and hepatitis B and C serology tests were negative. Mantoux test and QuantiFERON® Gold tuberculosis (TB) test were also negative. Serum angiotensin-converting enzyme level was 53 U/L. Skin biopsy of the papules revealed normal epidermis with well-formed noncaseating epithelioid granulomas composed of epithelioid histiocytes, Langhans giant cells, and sparse lymphocytic infiltrate [Figure 2]. Adnexa were normal. Acid-fast Bacillus/Gram-stains for typical and atypical mycobacteria were negative. There was no evidence of fungal elements. Polymerase chain reaction for Mycobacterium TB was negative. With this, a diagnosis of isolated cutaneous sarcoidosis was made. She was treated with steroids at 0.5 mg/kg and hydroxychloroquine. She responded to the treatment, and steroids were tapered over 6-month duration. The patient had a follow-up after 1 year of diagnosis, and there was no recurrence of the lesions or any other manifestations of sarcoidosis. This patient had specific and nonspecific lesions in the skin, and there were no other systemic manifestations.
Sarcoidosis is a chronic multisystem, inflammatory granulomatous disease. Nearly, 25–30% of the individuals have cutaneous involvement. In 20% of the cases, the skin lesion precedes systemic disease. Fifty percentage of the cases have skin lesion accompanying systemic disease, and in 30% of the cases, the skin lesion follows systemic manifestations. Lesions assume a vast array of morphologies; cutaneous sarcoidosis is known as one of the “great imitators” in dermatology. Clinically, the skin lesions could be (a) elevated, papular, nodular, plaque, and psoriasiform; (b) flat, hypopigmented, ichthyosiform, and erythrodermic; (c) subcutaneous; or (d) ulcerated. Lupus pernio is a papular sarcoid on the nose region. The presence of erythema nodosum indicates a good prognosis. Most authors divide the lesions of cutaneous sarcoidosis into nonspecific and specific types. Nonspecific lesions occur in association with systemic sarcoidosis; no granulomas are found on biopsy. All specific cutaneous lesions exhibit noncaseating granulomas on biopsy. Despite the same histologic appearance, clinical appearance of the lesions may be markedly variable. Erythema nodosum is the most common nonspecific cutaneous lesion of sarcoidosis. The most common types of specific lesions are papules. They commonly occur on the face, but may also occur anywhere on the body. While only a few papules may be noted, multiple scattered or confluent lesions are more common. Papules of sarcoidosis may be of various colors, including red, reddish-brown, violaceous, translucent, or hyperpigmented. Most of them exhibit little surface change and are indurated on palpation. Plaques are larger, flat-topped lesions that are located on the face, trunk, or extremities. The lesions may be single or multiple. When plaques are multiple, distribution of the lesions tends to be symmetric. As with papules, plaques can also be of various colors. Plaques on the face can imitate discoid lupus, particularly when central atrophy and scaling are present. Lupus pernio is one of the few cutaneous manifestations that are characteristic of sarcoidosis. Lesions are chronic, indurated papules or plaques that affect the midface, particularly the alar rim of the nose. Other unusual manifestations include hypopigmented patches, ichthyosis of the lower legs, subcutaneous nodules, and erythroderma. Lesions of cutaneous sarcoidosis can also appear in the pre-existing scars. This condition is known as scar sarcoidosis.
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[Figure 1], [Figure 2]