Sarcoidosis presenting as cutaneous manifestations.

We present a sixty three year old female with erythematous itching rash over the lower limbs since 4 years, rash over abdomen since 2 years, rash over forehead and scalp since 1 year. She denied any other systemic complaints. Clinically she had pallor and well defined erythematous, hyperpigmented plaques over the shin bilaterally, symmetrical with few depigmented areas over the lower aspect of the plaque. She had multiple erythematous scaly nummular plaques on abdomen and two annular erythematous, hyperpigmented plaques over the forehead near the hairline (Fig. 1). Her systemic examination was normal. Investigations showed anemia, raised ESR, A/G ratio reversal, borderline high calcium level. Chest X-ray showed bilateral reticulonodular opacities. CT chest revealed enlarged lymph nodes in anterior mediastinum, right paratracheal and subcarinal region with mild dilatation of main pulmonary artery and patchy ground glass opacities throughout the lung fields with areas of air trapping. In view of the above findings possibility of tuberculosis versus sarcoidosis was considered hence skin biopsy was done to confirm the diagnosis, which showed naked non caseating granulomas comprising Langhans giant cells suggestive of sarcoidosis (Fig. 2). Her collagen markers were negative and serum ACE level was elevated. Sarcoidosis is an idiopathic systemic disorder characterized by accumulation of lymphocytes and monocytes in many organs forming non caseating, epithelioid granulomas and subsequent conformational changes in the involved organs. Lung is the most prominent organ involved. Skin is involved in 32% of total cases of sarcoidosis. Of the total cases of sarcoidosis 20% manifest only as skin lesions before systemic onset and our case also shows similar presentation. 50% of patients have simultaneous appearance and in 30%, skin lesions appear 10 years after systemic disease. Skin lesion can be specific or non specific. Specific skin lesions contain granulomas and non specific lack them. Of the total skin lesions only 10-15% have itching. Sarcoid skin lesions can manifest as maculopapular, nodular, plaque, sub-cutaneous nodules, scar sarcoid, lupus pernio, acquired ichthyosis, ulcerative lesions etc. We treated our patient with steroids and azathioprine to which she responded well and is presently being followed up as an outpatient. It was surprising that inspite of such a long standing illness and significant findings on imaging, patient had no pulmonary symptoms and signs. Our main aim of presentation is to make fellow physicians aware of the possibility of sarcoidosis in a patient presenting with long standing skin lesions without any systemic complaints.