Morpheaform sarcoidosis: report of three cases

Morpheaartige Hautmanifestation einer Sarkoidose

Sarcoidosis is an idiopathic systemic disease, which is characterized by the presence of non-caseating granulomas in the affected organs. Cutaneous manifestations are frequently the first clue to the diagnosis; however, the clinical picture of the lesions is heterogenous. Here we report on a 66-year-old woman with localized indurations of the skin on both forearms that were diagnosed as a rare morphea-like skin involvement of a systemic sarcoidosis.

A case of morpheaform sarcoidosis

Sarcoidosis is an idiopathic multisystem disease with various cutaneous presentations, and it is characterized by the presence of non-caseating granulomas in the affected organs. The specific manifestations are papules, plaques, nodules, ulcers and scar. We report here on a variant of sarcoidosis on a 71-year-old woman who showed an indurated plaque on the forearm. Her lesion's appearance was clinically similar to that of a morphea and the appearance of the lesion was unlike the commonly observed manifestations of sarcoidosis.

Clinical and histopathological analysis of specific lesions of cutaneous sarcoidosis in Korean patients

BACKGROUND

Sarcoidosis is a multi-systemic, non-caseating, granulomatous disorder of unknown origin.

OBJECTIVE

The purpose of our investigation was to describe the clinicopathological characteristics of specific lesions of cutaneous sarcoidosis and treatment outcomes in Korean patients.

METHODS

A retrospective review was made of 31 patients who were diagnosed with sarcoidosis at Severance Hospital, Yonsei University Health System in Korea between 2000 and 2008; these patients were enrolled in this study. The diagnosis of cutaneous sarcoidosis was made in 17 of the patients. They were confirmed by histopathologic examinations. The clinical features were analyzed through review of medical records, and histopathologic and radiologic examinations.

RESULTS

The patients' primary complaints were cutaneous symptoms (51.6%) and respiratory symptoms (32.3%). The most common presentation of cutaneous sarcoidal lesions was the nodule-plaque form (41.2%) and systemic organ involvement was observed in six cases (35.3%). Treatment modalities included steroid, hydroxychloroquine, cyclosporine, topical tacrolimus, and pulsed dye laser. In our series, five patients (30%) achieved complete resolution of the cutaneous lesions and 10 patients (60%) showed partial resolution after corticosteroid treatment. Also, patients without extracutaneous symptoms responded better to corticosteroid treatment compared to patients with systemic involvement.

CONCLUSIONS

These data reveal the diversity of clinical and histopathologic findings of cutaneous sarcoidosis in Korea.

Granulomas não-infecciosos: sarcoidose

A sarcoidose é doença granulomatosa não infecciosa de etiologia desconhecida, de cuja patogênese parecem participar os fatores genéticos, imunológicos, ambientais e infecciosos. Vários órgãos podem ser afetados, causando amplo espectro de manifestações clínicas. A pele é acometida em cerca de 20 a 35% dos casos, proporcionando ao dermatologista importante papel no diagnóstico da doença. Epidemiologia, imunologia e tratamento também são discutidos para prover melhor entendimento dessa enfermidade.

Chronic cutaneous lesions of sarcoidosis

Sarcoidosis involvement of the skin is common. The skin lesions of sarcoidosis may be nonspecific, showing a nondiagnostic inflammatory reaction pattern on histologic evaluation. Nonspecific skin lesions are often associated with an acute presentation of sarcoidosis and, in general, portend a good prognosis. Specific sarcoidosis skin lesions reveal typical sarcoid granulomas on histologic examination. These lesions tend to be chronic and require therapy for resolution. This article will review the epidemiology, diagnostic evaluation, and description of the various chronic skin lesions of sarcoidosis. Various images of these skin lesions will be demonstrated.

Cutaneous sarcoidosis: differential diagnosis

Sarcoidosis is a multisystem disease with cutaneous lesions present in 20%-35% of patients. Given the wide variability of clinical manifestations, it is one of the "great imitators," making it necessary to consider clinical, epidemiological, radiographic, laboratory, and histopathological criteria to make the diagnosis. Cutaneous lesions have been classified as specific and nonspecific, depending on the presence of noncaseating granulomas on histologic studies. Specific lesions include maculopapules, plaques, nodules, lupus pernio, scar infiltration, alopecia, ulcerative lesions, and hypopigmentation among others. Nail, mucosal, and childhood sarcoidosis represent a distinct subset of the disease process. The most common nonspecific lesion is erythema nodosum. Others include calcifications, prurigo, erythema multiforme, nail clubbing, and Sweet syndrome. The importance of considering cutaneous sarcoidosis in the clinical differential diagnosis of a given skin lesion relies on the association with systemic involvement and the convenience of the skin as a tissue source for histologic analysis.

Subcutaneous sarcoidosis: is it a specific subset of cutaneous sarcoidosis frequently associated with systemic disease?

BACKGROUND

Skin is involved in 25% of cases of sarcoidosis. The lesions are specific and nonspecific depending on the presence or absence of granulomas, respectively. Specific lesions are not thought to have prognostic significance and are not associated with systemic disease.

OBJECTIVE

We sought to evaluate for the presence or absence of systemic disease in patients with subcutaneous sarcoidosis.

METHODS

With diagnostic criteria of subcutaneous sarcoidosis, 33 cases were identified in the literature and 21 cases in our institutional database. A retrospective clinical and pathologic review of these cases was conducted.

RESULTS

Subcutaneous sarcoidosis is characterized by a peak incidence during the fourth decade; female predisposition; asymptomatic to slightly tender lesions typically involving the upper extremities; cutaneous lesional clustering and multiplicity; autoimmune disease associations at time of diagnosis in a subset of cases; systemic disease associations at diagnosis in most patients, typically consisting of bilateral hilar adenopathy; and a favorable response to oral corticosteroid therapy.

LIMITATIONS

Retrospective analysis with inadequate documentation of therapeutic regimens and their responses in some cases is a limitation of this study.

CONCLUSIONS

The confirmatory diagnosis of subcutaneous sarcoidosis depends on identifying pannicular noninfectious sarcoidal or epithelioid granulomas with minimal lymphocytic inflammation. Subcutaneous sarcoidosis is the only specific subset of cutaneous sarcoidosis frequently associated with systemic disease.

Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown cause that most commonly affects the lungs, lymph nodes, skin, eyes, spleen, bone, and glandular tissue. The diagnosis is made when characteristic histologic findings are demonstrated and other granulomatous processes are excluded. It can be an acute or chronic debilitating disease, but in patients with acute disease the process can be self-limited. Multiple therapeutic options have been described both for the cutaneous and systemic lesions of sarcoidosis. Steroids, however, remain the cornerstone of therapy.

Sarcoidosis

Sarcoidosis is a systemic noncaseating granulomatous disorder of unknown origin. The cutaneous manifestations of sarcoidosis often enable the dermatologist to be the first physician to make the diagnosis. This article reviews essential sarcoidosis pathophysiology, clinical polymorphisms, systemic evaluation, and treatment modalities for cutaneous sarcoidosis to further enhance the dermatologist's understanding of this disease entity.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the theories of the pathogenesis of sarcoidosis, its cutaneous manifestations, its various syndromes and associations, and its presentation in children. Participants should also be more knowledgeable about diagnostic evaluation, measurement of disease progression, treatment modalities, and the prognosis and mortality data of sarcoidosis.

Sarcoidosis presenting as nail dystrophy

A 45-year-old woman was referred to the dermatology clinic for assessment of "refractory onychogryphosis." She had a 3-year history of lesions involving distal phalanges of the first and third of her left foot. Initially she described periungual erythema and swelling. Three weeks later she noted a whitish growth and thickening of her third toenail. X-ray films of the digit were reported as normal. Several months later the same changes occurred in her great toe. These lesions were asymptomatic. There was no history of trauma. Numerous fungal cultures were negative. No light microscopic examinations were undertaken. She had a trial of both topical and systemic terbinafine of 3-months duration with no clinical improvement. Several clinical opinions were obtained from two dermatologists, a surgeon, and a chiropodist. Past medical history of note was significant for tubal ligation, cervical cancer, and chronic sinusitis. The latter condition in retrospect was thought to be secondary to sarcoidosis. Physical examination revealed periungual violaceous discolouration of the first and third toes of the left foot. There was evidence of significant nail changes including dystrophy, onycholysis, and hyperkeratosis (Fig. 1). The fingernails were normal. There were no other skin abnormalities. A punch biopsy of the tip of the third toe showed granulomatous inflammation. There was evidence of hyperkeratosis, exocytosis, and a dense infiltrate composed of collections of histiocytes and a few giant cells forming granulomas (Fig. 2). Repeat x-ray films of the foot showed soft tissue swelling of the first and third digits. There was bony resorption in the distal phalanges with a lacey trabecular pattern compatible with sarcoidosis (Fig. 3). Chest x-ray films revealed marked hilar adenopathy. The patient was sent to a respirologist who concurred with the diagnosis of sarcoidosis. Further investigations included a low serum calcium of 2.07 mmol/L, serum ACE of 70 U/L (upper limit of normal is 75), Wintrobe erythrocyte sedimentation rate (ESR) of 10 mm per hour, thyroid stimulating hormone concentration of 0.65 mU/L, and a urinary calcium excretion rate that was elevated at 7.3 mmol/day. Pulmonary function tests were unremarkable. The patient was initially treated with clobetasol under occlusion and intralesional triamcinolone with minimal improvement. She was subsequently started on prednisone, 15 mg per os daily because of the lung and bone involvement with significant improvement noted in the toe lesions with diminution of both the swelling and violaceous discolouration.