The diagnosis
The family physician performed a 4-mm punch biopsy and the pathology showed cutaneous sarcoidosis.
Sarcoidosis is a granulomatous disease that involves multiple organ systems; the etiology is unknown. Cutaneous manifestations occur in about 25% of systemic sarcoidosis patients.
This patient had a less common presentation of sarcoidosis than last week’s case of sarcoidosis on the face (lupus pernio). Other less common types of cutaneous sarcoidosis can be maculopapular, nodular, or infiltrative within existing scars or tattoos. Erythema nodosum is a common nonspecific finding in sarcoidosis. Other less common nonspecific lesions reported in sarcoidosis include erythema multiforme, calcinosis cutis, and lymphedema. Nail changes can include clubbing, onycholysis, subungual keratosis, and dystrophy.
Chest radiographic involvement is seen in almost 90% of patients and is used to stage the disease. Stage I disease shows bilateral hilar lymphadenopathy (BHL). Stage II disease shows BHL plus pulmonary infiltrates. Stage III disease shows pulmonary infiltrates without BHL. Stage IV disease shows pulmonary fibrosis.
This patient had stage II disease and the physician referred him for pulmonary function testing and to a pulmonologist. The physician prescribed high-potency topical steroids for the cutaneous lesions. If the pulmonary evaluation revealed significant pulmonary involvement, treatment options would include oral prednisone and weekly methotrexate.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Sarabi K, Khachemoune A. Sarcoidosis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:740-744.
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