Erythematous, firm, papular lesions over the face

A 63-year-old female presented with a history of multiple asymptomatic, erythematous, non-indurated papules and plaques on the upper lip, below the nose, above the medial end of both eyebrows, and in front of both the ears, of 5 years duration [Figures 1 and 2]. The patient denied of having any other symptoms of itching, photosensitivity, chest pain, weight loss, and was otherwise in good health. Her baseline investigations were within normal limits and chest X-ray showed bilateral hilar lymphadenopathy. A skin biopsy was done from the face, which showed epitheloid cell granulomas in the dermis [Figures 3 and 4].

Figure 1.

Multiple erythematous firm papular lesions

Figure 2.

Closer view demonstrates the lesional morphology

Figure 3.

Histopathologic photograph in low power

Figure 4.

Better visualization in 100×

DISCUSSION

Sarcoidosis is a multi-system disease characterized by epitheloid cell tubercles without caseation although fibrinoid necrosis may be present at the center of few, proceeding either to resolution or to conversion of epitheloid tubercles into hyaline fibrous tissue.[1]

Between 20 and 35% of patients with systemic sarcoidosis have skin lesions, but cutaneous sarcoidosis can also occur in the absence of systemic involvement.[2,3]

Recognition of cutaneous lesions is important because they provide a visible clue to the diagnosis and are an easily accessible source of tissue for histologic examination.[4] Because lesions can exhibit many different morphologies, cutaneous sarcoidosis is known as one of the “great imitators” in dermatology.[3] Specific manifestations include papules, plaques, lupus pernio, scar sarcoidosis, and rare morphologies suchas alopecia, ulcers, hypopigmented patches, and ichthyosis.[5,6] Treatment of cutaneous lesions can be frustrating. The most effective treatment for patients with severe lesions or widespread is systemic corticosteroids.