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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 101-103

Scar sarcoidosis: A dermatologic masquerader


1 Department of Dermatology, Dr. RMLH, ABVIMS, New Delhi, India
2 Department of Pathology, Dr. RMLH, ABVIMS, New Delhi, India

Date of Submission12-Feb-2019
Date of Decision26-Mar-2020
Date of Acceptance05-Jun-2020
Date of Web Publication19-Feb-2021

Correspondence Address:
Seema Rani
Department of Dermatology, Dr. RMLH, ABVIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_39_19

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  Abstract 


Cutaneous sarcoidosis has varied clinical presentation and is a great mimicker, which requires an initial work-up for systemic involvement, followed by periodic screening. Recognition of cutaneous lesions is important because they provide a visible clue to the diagnosis and serve as an easily accessible source of tissue for histologic examination. Scar sarcoidosis is a rare clinical entity and often missed, and clinical diagnosis is made on subsequent biopsy after excluding other causes. We report a rare presentation of cutaneous sarcoidosis.

Keywords: Rare presentation, sarcoidosis, scar


How to cite this article:
Rani S, Singh S, Bhardwaj M. Scar sarcoidosis: A dermatologic masquerader. Clin Dermatol Rev 2021;5:101-3

How to cite this URL:
Rani S, Singh S, Bhardwaj M. Scar sarcoidosis: A dermatologic masquerader. Clin Dermatol Rev [serial online] 2021 [cited 2021 Jul 25];5:101-3. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/101/309757




  Introduction Top


Sarcoidosis is a systemic noncaseating granulomatous disorder of unknown origin that involves mainly the lungs, mediastinal and peripheral lymph nodes, eyes, and skin. Scar sarcoidosis refers to lesions of cutaneous sarcoidosis that appear in preexisting scars.


  Case Report Top


A 34-year-old male presented with swelling and redness in old scars. He acquired these scars 9 years ago in a traffic accident. He underwent fractional CO2 laser treatment for facial scar 4 years back. After 2 years of the treatment, he noticed redness and swelling over scarred area. On examination, nontender, erythematous papules and nodules were present over the scar sites of the right side of the forehead, shoulder, and forearm [Figure 1],[Figure 2],[Figure 3]. We kept a provisional diagnosis of hypertrophic scar. Intralesional steroid was given. The patient was on treatment with antitubercular therapy for pulmonary tuberculosis from a private hospital. Even after repeated injection of steroids, lesions were persisted; no improvement was seen. A possibility of scar sarcoidosis was kept. Fine-needle aspiration cytology was done, which was suggestive of hypertrophic scar. Skin biopsy was done, which showed mild hyperkeratosis, acanthosis, superficial and deep dermis with multiple noncaseating epithelioid cell granulomas with occasional giant cells, and sparse chronic inflammatory infiltrate without scarring [Figure 4].
Figure 1: Clinical picture showing linear scar on the right side of the face with erythematous swelling

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Figure 2: Erythematous nodular lesions over old scar on the right shoulder

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Figure 3: Erythema and raised papular lesions over scar area on the right forearm

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Figure 4: Photomicrograph showing superficial and deep dermis with multiple noncaseating epithelioid cell granulomas with occasional giant cells and sparse chronic inflammatory infiltrate (H and E, ×10)

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High-resolution computed tomography of the chest revealed right para- and pretracheal and subcarinal lymphadenopathy with ground-glass opacities in both lung fields. Serologic tests showed raised levels of serum angiotensin-converting enzyme, erythrocyte sedimentation rate, C-reactive protein, and serum calcium. Antinuclear antibodies and rheumatoid factor (RA) were negative, but peripheral antineutrophilic cytoplasmic antibody (p-ANCA) and cytoplasmic antineutrophilic cytoplasmic antibody were positive. Sputum for acid-fast bacilli and tuberculin skin test were negative. The final diagnosis of scar sarcoidosis was made, and treatment with systemic steroid (40 mg) and hydroxychloroquine was started. Symptomatic improvement in erythema and swelling was noted after 6–8 weeks of initiating treatment.


  Discussion Top


Cutaneous sarcoidosis has a variable clinical presentation and is a “great mimicker.” Among these, scar sarcoidosis is rare, accounting for 5.4%–13.8% of sarcoidosis cases.[1] Scar sarcoidosis can involve scars resulting from surgery, trauma, acne, venepuncture, vaccination, herpes zoster, postlaser therapy, or Mantoux test.[2],[3] Laser could be inciting agent for the development of scar sarcoidosis and it can be used as a therapeutic intervention. In an earlier report, Q-switched ruby laser was effectively used to treat scar sarcoidosis in traumatic tattoo without any adverse effects.[4] A previous study reported that 30% of patients with isolated cutaneous lesions developed systemic involvement after a period of 1 month to 1 year.[5] However, it is commonly associated with long-lasting pulmonary and mediastinal involvement, uveitis, peripheral lymphadenopathy, bony cysts, and parotid infiltration.[6],[7] Sarcoidosis could be an exaggerated immune response to various kinds of antigens that include infectious, environmental, and autoantigens.[8] Immune dysregulation has been theorized to result from a persistent antigen of low virulence that is poorly cleared by the immune system, leading to a chronic T cell of the Th1 subtype response and causing granuloma formation.[9] Foreign material frequently present in scars can act as an antigenic stimulus for the induction of granulomas. Differential diagnosis of scar sarcoidosis includes infectious skin diseases such as mycobacterium infections, Crohn's disease, rosacea, foreign body granuloma, and hypertrophic scar or keloid.[10] The treatment and prognosis of cutaneous sarcoidosis is primarily dependent on the degree of systemic involvement. Scar sarcoidosis is usually associated with long-term disease involving multiple organs but has also been reported in acute forms and as a sign of recurrence of sarcoidosis in remission or may be the presenting symptom of systemic sarcoidosis.[11]

Topical steroid therapy may be sometimes effective for purely cutaneous sarcoidosis. For disfiguring lesions unresponsive to initial topical therapy or in the case of systemic involvement, oral therapy with prednisolone, hydroxychloroquine, and methotrexate may be instituted.


  Conclusion Top


Cutaneous sarcoidosis has a variable clinical presentation and is a great mimicker. Scar sarcoidosis is often missed, and clinical diagnosis is made on subsequent biopsy after excluding other causes. Scar sarcoidosis is a rare clinical entity and therefore not well understood; hence, it is essential that patients with inflammation at the sites of preexisting scars should be examined and investigated for scar sarcoidosis and systemic involvement.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mañá J, Marcoval J, Graells J, Salazar A, Peyrí J, Pujol R. Cutaneous involvement in sarcoidosis. Relationship to systemic disease. Arch Dermatol 1997;133:882-8.  Back to cited text no. 1
    
2.
Kormeili T, Neel V, Moy RL. Cutaneous sarcoidosis at sites of previous laser surgery. Cutis 2004;73:53-5.  Back to cited text no. 2
    
3.
Mantese SA, Berbert AL, Cesário TS, Silva HB. Sarcoidosis on skin scars: A case report. An Bras Dermatol 2010;85:903-5.  Back to cited text no. 3
    
4.
Grema H, Greve B, Raulin C. Scar sarcoidosis--treatment with the Q-switched ruby laser. Lasers Surg Med 2002;30:398-400.  Back to cited text no. 4
    
5.
Rybicki BA, Hirst K, Iyengar SK, Barnard JG, Judson MA, Rose CS, et al. A sarcoidosis genetic linkage consortium: The sarcoidosis genetic analysis (SAGA) study. Sarcoidosis Vasc Diffuse Lung Dis 2005;22:115-22.  Back to cited text no. 5
    
6.
Gawkrodger DJ. Sarcoidosis. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Textbook of Dermatology. 8th ed., Ch. 61. Oxford: Wiley Blackwell; 2010. p. 1-23.  Back to cited text no. 6
    
7.
Scadding JG, Mitchell DN. Sarcoidosis of the skin. In: Scadding JG, Mitchell DN, editors. Sarcoidosis. London: Chapman & Hall Medical; 1985. p. 181-206.  Back to cited text no. 7
    
8.
Katchar K, Söderström K, Wahlstrom J, Eklund A, Grunewald J. Characterisation of natural killer cells and CD56+ T-cells in sarcoidosis patients. Eur Respir J 2005;26:77-85.  Back to cited text no. 8
    
9.
Selim A, Ehrsam E, Atassi MB, Khachemoune A. Scar sarcoidosis: A case report and brief review. Cutis 2006;78:418-22.  Back to cited text no. 9
    
10.
Su O, Onsun N, Topukçu B, Ozçelik HK, Cakiter AU, Büyükpinarbasili N. Disseminated scar sarcoidosis may predict pulmonary involvement in sarcoidosis. Acta Dermatovenerol Alp Pannonica Adriat 2013;22:71-4.  Back to cited text no. 10
    
11.
Cervigón I, Palomo A, Torres LM. Cutaneous lesions on scars. Actas Dermosifiliogr 2007;98:433-4.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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