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Year : 2022  |  Volume : 67  |  Issue : 1  |  Page : 87-89
Atypical protean manifestations of cutaneous sarcoidosis

1 Department of Dermatology, Dr Ram Manohar Lohia Hospital and Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
2 Department of Dermatology, Manipal Hospital, Dwarka, New Delhi, India
3 Department of Dermatology, Enlive Skin Care Clinic, New Delhi, India
4 Deparment of Pathology, Dr Ram Manohar Lohia Hospital and Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India

Date of Web Publication19-Apr-2022

Correspondence Address:
Pooja Arora
Department of Dermatology, Dr Ram Manohar Lohia Hospital and Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_379_21

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How to cite this article:
Arora P, Verma G, Chauhan M, Ahuja A. Atypical protean manifestations of cutaneous sarcoidosis. Indian J Dermatol 2022;67:87-9

How to cite this URL:
Arora P, Verma G, Chauhan M, Ahuja A. Atypical protean manifestations of cutaneous sarcoidosis. Indian J Dermatol [serial online] 2022 [cited 2023 May 29];67:87-9. Available from:


Sarcoidosis is a multi-system granulomatous disease of unknown etiology with protean manifestations most commonly affecting lung and lymph nodes. Approximately 25%–35% of cases of sarcoidosis develop cutaneous manifestations.[1],[2] Cutaneous sarcoidosis is a great mimicker due to its diverse clinical manifestations and diagnosis depends on histopathological evaluation. In this article, we describe a patient with polymorphic manifestations of sarcoidosis in whom the diagnosis was confirmed by biopsy.

A 45-year-old man presented to the outpatient department of our institution with alopecia and multiple asymptomatic lesions over the body of 12 months duration. The patient denied any history of systemic symptoms like dyspnoea and chest pain. On examination, there was generalized lymphadenopathy of cervical, axillary and inguinal group of nodes. Systemic examination including ophthalmological evaluation was within normal limits. Cutaneous examination showed scarring alopecia over the vertex of scalp and multiple erythematous plaques of varying sizes involving forehead, periorbital area, nape of neck, trunk, and extensor aspect of legs [Figure 1] and [Figure 2]. Diascopy of lesions over face showed apple jelly nodules. A tender plaque was present over the nose with scaling on the ala nasi [Figure 1]d. Lesions over the back appeared psoriasiform with fine scaling and surrounded by a halo [Figure 2]a. Multiple skin colored to erythematous grouped papules were present over the nape of the neck [Figure 2]b. Extensor aspect of knees had erythematous to hyperpigmented atrophic plaques [Figure 2]c. Single well-defined ulcerated lesion with yellow-colored crust was present over the right arm over a preexisting plaque. A subcutaneous non-tender nodule was present over left arm [Figure 2]d. A clinical differential diagnosis of cutaneous sarcoidosis and lupus erythematosus was made.
Figure 1: (a and b) Erythematous plaques with smooth surface present over the forehead, peri-orbital, and infra-orbital region of face. The lesions have classical morphology of sarcoidosis (c) Patch of cicatricial alopecia with dyspigmentation. (d) Erythematous tender plaque over the nose with scaling at ala nasi

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Figure 2: (a) Erythematous plaques with surrounding hypopigmentation. Few lesions were scaly. Inset: An ulcerated lesion with yellowish crust (b) Skin colored to erythematous papules coalescing to form plaques over the nape of neck. (c) Atrophic lesions over the extensor aspect of knee (d) Subcutaneous nontender nodule over the left upper arm

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Standard hematological and biochemical profiles were normal whereas angiotensin-converting enzyme (ACE) levels were found to be increased (232 IU/L; normal range: 8.3–24.1 IU/L). Mantoux test was negative suggestive of anergy. Bilateral hilar lymphadenopathy was present on chest X Ray [Figure 3]a. Pulmonary function tests and electrocardiogram (ECG) were normal and ultrasound abdomen showed periportal & peripancreatic lymphadenopathy. Fine Needle Aspiration cytology (FNAC) from cervical and axillary lymph nodes showed reactive changes. Skin biopsies were done from truncal plaque, subcutaneous nodule, margin of alopecic patch, and psoriasiform lesion over the leg. Biopsies from all sites revealed the consistent finding of multiple well-formed non-caseating epithelioid cell granulomas with sparse lymphocytic infiltrate in superficial and mid dermis [Figure 3]b, [Figure 3]c. Reticulin stain showed granulomas with reticulin fibers.
Figure 3: (a) Chest X-Ray (PA view) showing bilateral hilar lymphadenopathy. (b) Scanner view photomicrograph of skin biopsy showing multiple pandermal granulomas (H and E ×40). (c) Medium power showing noncaseating epithelioid cell granulomas with mild sprinkling of lymphocytes (H and E ×100)

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Based on the above findings, a diagnosis of cutaneous sarcoidosis was made, and the patient was started on oral steroids (methylprednisolone) and methotrexate. There was flattening of lesions after 10 weeks of treatment. However, the patient was lost to follow up later.

Sarcoidosis is a granulomatous disease of unknown etiology with characteristic findings of non-caseating epithelioid cell granulomas, variable multinucleated giant cells, perivascular mononuclear cell infiltrates.[1] Cutaneous sarcoidosis is usually an early expression of the disease which requires evaluation for systemic involvement.[2] In 90% of patients pulmonary involvement is the most prominent systemic association. In 39% of patients' musculoskeletal involvement is seen with the most common symptoms of weakness, pain, erythema and tenderness, arthritis, arthralgia, tenosynovitis.[1] Our patient, with bilateral lymphadenopathy and elevated ACE levels, did not have any systemic involvement. Lymphadenopathy is present in 90% of patients with systemic sarcoidosis. Hilar and/or paratracheal adenopathy is the most classical presentation.[1] Elevated ACE levels are the markers of sarcoid activity because of T-cell-stimulated epithelioid cells in sarcoid granuloma that show increased expression of ACE.[1],[3]

Cutaneous lesions of sarcoidosis can be specific and non-specific. Nonspecific lesions show varying morphology and do not exhibit granulomas on biopsy. Among the specific lesions, maculopapules are the commonest followed by plaques. Both maculopapules and plaque [Figure 1] and [Figure 2] show diverse colors including red, reddish-brown, translucent violaceous or hyperpigmented. Lupus pernio is the most characteristic cutaneous lesion of sarcoidosis which presents as indurated plaque or papule involving nose [Figure 1]d, cheeks, ears, lips, and forehead. It is generally violaceous and is associated with upper respiratory involvement. The latter was absent in our patient. In 20-35% of patients with systemic sarcoidosis, subcutaneous involvement occurs. It may also occur alone without systemic disease.[4] Subcutaneous sarcoidosis appears at onset of disease and is usually the main complaint at diagnosis [Figure 2]d.

Sarcoidosis can also involve the scalp in the form of localized lesions or diffuse alopecia. Scarring alopecia [Figure 1]c is rare and affects predominantly women of African descent.[5]

Ulcerative sarcoidosis is seen worldwide in only 5% of patients with cutaneous sarcoidosis.[6] It is twice as common in black versus white individuals. Ulceration is more commonly seen in preexisting scars or cutaneous lesions but can also arise de novo. Ulcerative sarcoidosis can present in two distinct patterns. Violaceous nodules arising in an annular confluent pattern which can eventually ulcerate or necrotic yellow plaques with ulceration as seen in our patient [[Figure 2] inset].[6] Psoriasiform sarcoidosis is a rare variant of cutaneous sarcoidosis usually seen in dark-skinned patients [Figure 2]a. The lesions that heal without scarring and are most commonly seen over the lower legs.[7]

Our case highlights an unusual presentation of cutaneous sarcoidosis with multiple morphological variants present in the same patient. Various morphologies have distinct prognosis based on their chronicity but their presence simultaneously in a particular patient is an enigma that needs to be studied further.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

English JC 3rd, Patel PJ, Greer KE. Sarcoidosis. J Am Acad Dermatol 2001;44:725-43.  Back to cited text no. 1
Katta R. Cutaneous sarcoidosis: A dermatologic masquerader. Am Fam Physician 2002;65:1581-4.  Back to cited text no. 2
Kaura V, Kaura SH, Kaura CS. ACE inhibitor in the treatment of cutaneous and lymphatic sarcoidosis. Am J Clin Dermatol 2007;8:183-6.  Back to cited text no. 3
Vainsencher D, Winkelmann RK. Subcutaneous sarcoidosis. Arch Dermatol 1984;120:1028-31.  Back to cited text no. 4
Baker H. Atrophic alopecia due to granulomatous infiltration of the scalp in systemic sarcoidosis. Proc R Soc Med 1965;58:243-4.  Back to cited text no. 5
Noiles K, Belezna y K, Crawford RI, Au S. Sarcoidosis can present with necrotizing granulomas histologically: Two cases of ulcerated sarcoidosis and review of the literature. J Cutan Med Surg 2013;17:377-8.  Back to cited text no. 6
Marchell R, Judson M. Chronic cutaneous lesions of sarcoidosis. Clin Dermatol 2007;25:295-302.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


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