Sarcoidosis: Are there differences in your skin of color patients?
2011; Elsevier BV; Volume: 66; Issue: 1 Linguagem: Inglês
10.1016/j.jaad.2010.06.068
ISSN1097-6787
AutoresCandrice Heath, Jennifer David, Susan C. Taylor,
Tópico(s)Interstitial Lung Diseases and Idiopathic Pulmonary Fibrosis
ResumoThe skin of color population is growing at an astronomical rate, making it critically important to recognize diseases, such as sarcoidosis, in patients with skin of color. Sarcoidosis is a multisystem, granulomatous disease, which manifests in a variety of organs and is found more frequently in Blacks as compared with Caucasians. In addition, Blacks have a poorer prognosis and often present with more advanced disease. Sarcoidal lesions can present with multiple morphologic features, some more common in patients with skin of color. We offer a review of the cutaneous presentations of sarcoid lesions in patients with skin of color, an overview of extracutaneous sarcoidosis, the cutaneous signs that may impact overall disease prognosis, and treatment options. The skin of color population is growing at an astronomical rate, making it critically important to recognize diseases, such as sarcoidosis, in patients with skin of color. Sarcoidosis is a multisystem, granulomatous disease, which manifests in a variety of organs and is found more frequently in Blacks as compared with Caucasians. In addition, Blacks have a poorer prognosis and often present with more advanced disease. Sarcoidal lesions can present with multiple morphologic features, some more common in patients with skin of color. We offer a review of the cutaneous presentations of sarcoid lesions in patients with skin of color, an overview of extracutaneous sarcoidosis, the cutaneous signs that may impact overall disease prognosis, and treatment options. Capsule Summary•The skin of color population is estimated to increase substantially over the next 40 years.•Education about clinical and morphologic differences in sarcoidosis in patients with skin of color will lead to better increased recognition and improved patient care.•Sarcoidal lesions can present with multiple morphologic features, some more common in patients with skin of color.•Patients with skin of color and sarcoidosis have increased rates of pulmonary involvement, a poorer long-term prognosis, and more frequent relapses, which makes proper diagnostic workup and treatment options essential.•We hope that early recognition of sarcoid lesions may lead to improved outcomes.In the year 2000, the US Census Bureau projected striking increases in the numbers of Hispanics and Asians by the year 2050.1US Census Bureau (2004, March 18). US Census Bureau news: more diversity, slower growth. Available from: URL: http://www.census.gov/Press-Release/www/releases/archives/population/001720.html. Accessed April 1, 2009.Google Scholar The Hispanic population is expected to increase 188% and comprise 24.4% of the population, up from 12.6% in the year 2000. The Black population is projected to increase from 12.7% of the general population to 14.6%. The non-Hispanic, white population may increase by only 7% and comprise 50.1% of the nation's population in 2050, compared with 69.4% in the year 2000. The skin of color population is growing at an astronomical rate, making it critical to recognize diseases, such as sarcoidosis, in patients with skin of color. Physicians will continue to see more patients from diverse ethnic groups. Recent articles emphasize the need for more visual and textual resources highlighting skin of color to prepare the field of dermatology for this shift.2Nijhawan R.I. Jacob S.E. Woolery-Lloyd H. Skin of color education in dermatology residency programs: does residency training reflect the changing demographics of the United States?.J Am Acad Dermatol. 2008; 59: 615-618Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 3Ebede T. Papier A. Disparities in dermatology educational resources.J Am Acad Dermatol. 2006; 55: 687-690Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar We offer a review of the cutaneous presentations of sarcoid lesions in patients with skin of color, an overview of extracutaneous sarcoidosis, and the cutaneous signs that may impact overall disease prognosis. •The skin of color population is estimated to increase substantially over the next 40 years.•Education about clinical and morphologic differences in sarcoidosis in patients with skin of color will lead to better increased recognition and improved patient care.•Sarcoidal lesions can present with multiple morphologic features, some more common in patients with skin of color.•Patients with skin of color and sarcoidosis have increased rates of pulmonary involvement, a poorer long-term prognosis, and more frequent relapses, which makes proper diagnostic workup and treatment options essential.•We hope that early recognition of sarcoid lesions may lead to improved outcomes. Sarcoidosis is a multisystem, granulomatous disease, which manifests in a variety of organs.4Minus H.R. Grimes P.E. Cutaneous manifestations of sarcoidosis in blacks.Cutis. 1983; 32: 361-364PubMed Google Scholar, 5Marchell R.M. Judson M.A. Chronic cutaneous lesions of sarcoidosis.Clin Dermatol. 2007; 25: 295-302Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 6Rybicki B.A. Major M. Popovich J. Maliank M.J. Iannuzzi M.C. Racial differences in sarcoidosis incidence: a 5-year study in a health maintenance organization.Am J Epidemiol. 2007; 145: 234-241Crossref Scopus (729) Google Scholar The most common organs involved include the lungs, lymph nodes, skin, and eyes.4Minus H.R. Grimes P.E. Cutaneous manifestations of sarcoidosis in blacks.Cutis. 1983; 32: 361-364PubMed Google Scholar, 5Marchell R.M. Judson M.A. Chronic cutaneous lesions of sarcoidosis.Clin Dermatol. 2007; 25: 295-302Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar The skin is affected in approximately 25% of sarcoidosis cases. Sarcoidosis is found more frequently in Blacks as compared with Caucasians.6Rybicki B.A. Major M. Popovich J. Maliank M.J. Iannuzzi M.C. Racial differences in sarcoidosis incidence: a 5-year study in a health maintenance organization.Am J Epidemiol. 2007; 145: 234-241Crossref Scopus (729) Google Scholar, 7Labow T.A. Atwood W.G. Nelson C.T. Sarcoidosis in the American Negro.Arch Dermatol. 1964; 89: 682-689Crossref PubMed Scopus (12) Google Scholar, 8Rybicki B.A. Maliarik M.J. Major M. Popovich J. Iannuzzi M.C. Epidemiology, demographics, and genetics of sarcoidosis.Semin Respir Infect. 1998; 13: 166-173PubMed Google Scholar Sarcoid lesions may present with multiple morphologic features, some of which are more common in patients with skin of color.4Minus H.R. Grimes P.E. Cutaneous manifestations of sarcoidosis in blacks.Cutis. 1983; 32: 361-364PubMed Google Scholar, 9James W.D. Berger T.G. Elston D.M. Andrew's diseases of the skin: clinical dermatology. 10th ed. Saunders Elsevier, Canada2006Google Scholar Sarcoidosis is more severe in blacks and other ethnic groups as compared with Caucasians.8Rybicki B.A. Maliarik M.J. Major M. Popovich J. Iannuzzi M.C. Epidemiology, demographics, and genetics of sarcoidosis.Semin Respir Infect. 1998; 13: 166-173PubMed Google Scholar, 10Evans M. Sharma O. LaBree L. Smith R. Differences in clinical findings between Caucasians and African Americans with biopsy-proven sarcoidosis.Ophthalmology. 2007; 114: 325-333Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 11Edmondstone W.M. Wilson A.G. Sarcoidosis in Caucasians, blacks and Asians in London.Br J Dis Chest. 1985; 79: 27-36Abstract Full Text PDF PubMed Scopus (100) Google Scholar, 12Peckham D.G. Spiteri M.A. Sarcoidosis.Postgrad Med J. 1996; 72: 196-200Crossref PubMed Scopus (22) Google Scholar, 13Luisetti M. Beretta A. Casali L. Course and prognosis of sarcoidosis in African-Americans versus Caucasians.Eur Respir J. 2001; 18: 738PubMed Google Scholar, 14Judson M.A. Hirst K. Iyengar S.K. Rybicki B.A. El Ghormli L. Comparison of sarcoidosis phenotypes among affected African-American siblings.Chest. 2006; 130: 855-862Crossref PubMed Scopus (35) Google Scholar In addition, the prognosis is often worse in blacks.7Labow T.A. Atwood W.G. Nelson C.T. Sarcoidosis in the American Negro.Arch Dermatol. 1964; 89: 682-689Crossref PubMed Scopus (12) Google Scholar, 8Rybicki B.A. Maliarik M.J. Major M. Popovich J. Iannuzzi M.C. Epidemiology, demographics, and genetics of sarcoidosis.Semin Respir Infect. 1998; 13: 166-173PubMed Google Scholar, 10Evans M. Sharma O. LaBree L. Smith R. Differences in clinical findings between Caucasians and African Americans with biopsy-proven sarcoidosis.Ophthalmology. 2007; 114: 325-333Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 13Luisetti M. Beretta A. Casali L. Course and prognosis of sarcoidosis in African-Americans versus Caucasians.Eur Respir J. 2001; 18: 738PubMed Google Scholar, 14Judson M.A. Hirst K. Iyengar S.K. Rybicki B.A. El Ghormli L. Comparison of sarcoidosis phenotypes among affected African-American siblings.Chest. 2006; 130: 855-862Crossref PubMed Scopus (35) Google Scholar, 15Rybicki B.A. Kirkey K.L. Major M. Maliarik M. Popovich Jr., J. Chase G.A. et al.Familial risk ratio of sarcoidosis in African-American sibs and parents.Am J Epidemiol. 2001; 153: 188-193Crossref PubMed Scopus (83) Google Scholar Past studies suggest genetic and socioeconomic factors may contribute to the phenotypic differences in sarcoidosis between blacks and Caucasians.8Rybicki B.A. Maliarik M.J. Major M. Popovich J. Iannuzzi M.C. Epidemiology, demographics, and genetics of sarcoidosis.Semin Respir Infect. 1998; 13: 166-173PubMed Google Scholar, 14Judson M.A. Hirst K. Iyengar S.K. Rybicki B.A. El Ghormli L. Comparison of sarcoidosis phenotypes among affected African-American siblings.Chest. 2006; 130: 855-862Crossref PubMed Scopus (35) Google Scholar, 16Westney G.E. Judson M.A. Racial and ethnic disparities in sarcoidosis: from genetics to socioeconomics.Clin Chest Med. 2006; 27: 453-462Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 17Hunninghake G.W. Costabel U. Ando M. Baughman R. Cordier J.F. du Bois R. et al.ATS/ERS/WASOG statement on sarcoidosis.Sarcoidosis Vasc Diffuse Lung Dis. 1999; 16: 149-173PubMed Google Scholar It has been well documented that in the Black population, sarcoidosis occurs at an earlier age, and may have a more severe course than in Caucasians.7Labow T.A. Atwood W.G. Nelson C.T. Sarcoidosis in the American Negro.Arch Dermatol. 1964; 89: 682-689Crossref PubMed Scopus (12) Google Scholar, 8Rybicki B.A. Maliarik M.J. Major M. Popovich J. Iannuzzi M.C. Epidemiology, demographics, and genetics of sarcoidosis.Semin Respir Infect. 1998; 13: 166-173PubMed Google Scholar, 11Edmondstone W.M. Wilson A.G. Sarcoidosis in Caucasians, blacks and Asians in London.Br J Dis Chest. 1985; 79: 27-36Abstract Full Text PDF PubMed Scopus (100) Google Scholar, 18Sartwell P.E. Edwards L.B. Epidemiology of sarcoidosis in the US Navy.Am J Epidemiol. 1974; 99: 250-257PubMed Google Scholar Some studies report an overall predominance among women as compared with men, whereas others suggest no sex predilection.6Rybicki B.A. Major M. Popovich J. Maliank M.J. Iannuzzi M.C. Racial differences in sarcoidosis incidence: a 5-year study in a health maintenance organization.Am J Epidemiol. 2007; 145: 234-241Crossref Scopus (729) Google Scholar, 7Labow T.A. Atwood W.G. Nelson C.T. Sarcoidosis in the American Negro.Arch Dermatol. 1964; 89: 682-689Crossref PubMed Scopus (12) Google Scholar, 8Rybicki B.A. Maliarik M.J. Major M. Popovich J. Iannuzzi M.C. Epidemiology, demographics, and genetics of sarcoidosis.Semin Respir Infect. 1998; 13: 166-173PubMed Google Scholar, 11Edmondstone W.M. Wilson A.G. Sarcoidosis in Caucasians, blacks and Asians in London.Br J Dis Chest. 1985; 79: 27-36Abstract Full Text PDF PubMed Scopus (100) Google Scholar, 19James D.G. Neville E. Siltzbach L.E. Worldwide review of sarcoidosis.Ann N Y Acad Sci. 1976; 278: 321-334Crossref PubMed Scopus (282) Google Scholar In a 1964 study of 141 cases of sarcoidosis from Columbia-Presbyterian Medical Center in New York, Blacks made up 72% of the cases, although representing one third of the clinic population.7Labow T.A. Atwood W.G. Nelson C.T. Sarcoidosis in the American Negro.Arch Dermatol. 1964; 89: 682-689Crossref PubMed Scopus (12) Google Scholar The disease was seen 3 times more frequently in female patients as compared with male patients.7Labow T.A. Atwood W.G. Nelson C.T. Sarcoidosis in the American Negro.Arch Dermatol. 1964; 89: 682-689Crossref PubMed Scopus (12) Google Scholar Black parents and siblings of those with sarcoidosis have a 2.5-fold increased risk for developing sarcoidosis over Blacks without a family history of sarcoidosis.15Rybicki B.A. Kirkey K.L. Major M. Maliarik M. Popovich Jr., J. Chase G.A. et al.Familial risk ratio of sarcoidosis in African-American sibs and parents.Am J Epidemiol. 2001; 153: 188-193Crossref PubMed Scopus (83) Google Scholar This increased familial risk results in 2 to 3 additional cases of sarcoidosis by age 70 years for every 100 siblings and parents compared with the risk of sarcoidosis in the general Black population.15Rybicki B.A. Kirkey K.L. Major M. Maliarik M. Popovich Jr., J. Chase G.A. et al.Familial risk ratio of sarcoidosis in African-American sibs and parents.Am J Epidemiol. 2001; 153: 188-193Crossref PubMed Scopus (83) Google Scholar Although these differences have been highlighted in the literature for Blacks, other skin of color populations with sarcoidosis may also experience similar characteristics. In a review of 3676 patients of various backgrounds including Japanese, Caucasian, Black, Puerto Rican, and Mexican, there was no sex predilection and the patients were primarily given the diagnoses before the age of 40 years.19James D.G. Neville E. Siltzbach L.E. Worldwide review of sarcoidosis.Ann N Y Acad Sci. 1976; 278: 321-334Crossref PubMed Scopus (282) Google Scholar In a retrospective study of 156 patients seen in South London (68 Caucasians, 59 Black West Indian/Africans, 29 Indo-Pakistan Asians), the authors reported that sarcoidosis occurred as commonly in Asian populations as in the Black population.11Edmondstone W.M. Wilson A.G. Sarcoidosis in Caucasians, blacks and Asians in London.Br J Dis Chest. 1985; 79: 27-36Abstract Full Text PDF PubMed Scopus (100) Google Scholar Likewise, clinical features were similar between the two groups.11Edmondstone W.M. Wilson A.G. Sarcoidosis in Caucasians, blacks and Asians in London.Br J Dis Chest. 1985; 79: 27-36Abstract Full Text PDF PubMed Scopus (100) Google Scholar Both Asians and Blacks had more extrathoracic disease than Caucasians and more disease involvement. In addition, sarcoidosis found in Asians and Blacks was more severe and extensive than that found in Caucasians.11Edmondstone W.M. Wilson A.G. Sarcoidosis in Caucasians, blacks and Asians in London.Br J Dis Chest. 1985; 79: 27-36Abstract Full Text PDF PubMed Scopus (100) Google Scholar Although not the case with Asians, Blacks were given the diagnosis of sarcoidosis at a later age than Caucasians, 39.7 ± 11.6 years versus 34.4 ± 11.3 years in Caucasians.11Edmondstone W.M. Wilson A.G. Sarcoidosis in Caucasians, blacks and Asians in London.Br J Dis Chest. 1985; 79: 27-36Abstract Full Text PDF PubMed Scopus (100) Google Scholar In a Singapore study of 25 patients, although the Indian patients represented only 7.7% of the general population in Singapore, they made up 52% of patients with sarcoidosis in the study.20Chong W.S. Tan H.H. Tan S.H. Cutaneous sarcoidosis in Asians: a report of 25 patients from Singapore.Clin Exp Dermatol. 2005; 30: 120-124Crossref PubMed Scopus (38) Google Scholar Sarcoidosis may present acutely and become chronic and persistent or follow a course riddled with relapses and remissions.9James W.D. Berger T.G. Elston D.M. Andrew's diseases of the skin: clinical dermatology. 10th ed. Saunders Elsevier, Canada2006Google Scholar Between 10% and 35% of patients with systemic sarcoidosis have cutaneous lesions.21Samtsov A.V. Cutaneous sarcoidosis.Int J Dermatol. 1992; 31: 385-391Crossref PubMed Scopus (65) Google Scholar, 22Hanno R. Callen J.P. Sarcoidosis: a disorder with prominent cutaneous features and their interrelationship with systemic disease.Med Clin North Am. 1980; 64: 847-866PubMed Google Scholar, 23Mana J. Marcoval J. Graells J. Salazar A. Cutaneous involvement in sarcoidosis: relationship to systemic disease.Arch Dermatol. 1997; 133: 882-888Crossref PubMed Google Scholar These lesions may occur before, coincident with, or after onset of systemic involvement.5Marchell R.M. Judson M.A. Chronic cutaneous lesions of sarcoidosis.Clin Dermatol. 2007; 25: 295-302Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar Although sarcoidosis is usually a multiorgan disease, chronic cutaneous lesions may be the only manifestation.24Veien N.K. Stahl D. Brodthagen H. Cutaneous sarcoidosis in Caucasians.J Am Acad Dermatol. 1987; 16: 534-540Abstract Full Text PDF PubMed Scopus (125) Google Scholar Hence, dermatologists are often first to diagnose sarcoidosis, which may require keen clinical acumen as lesions are morphologically diverse and may be specific (showing noncaseating granulomatous histology) or nonspecific (Table I).4Minus H.R. Grimes P.E. Cutaneous manifestations of sarcoidosis in blacks.Cutis. 1983; 32: 361-364PubMed Google Scholar, 25English J.C. Patel P.J. Greer K.E. Sarcoidosis.J Am Acad Dermatol. 2001; 44: 725-746Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar A diagnosis of cutaneous sarcoid should prompt investigation for systemic disease, with chest x-rays of particular importance, as Blacks may have pulmonary disease that is more advanced as compared with Caucasians.6Rybicki B.A. Major M. Popovich J. Maliank M.J. Iannuzzi M.C. Racial differences in sarcoidosis incidence: a 5-year study in a health maintenance organization.Am J Epidemiol. 2007; 145: 234-241Crossref Scopus (729) Google Scholar Rybicki et al6Rybicki B.A. Major M. Popovich J. Maliank M.J. Iannuzzi M.C. Racial differences in sarcoidosis incidence: a 5-year study in a health maintenance organization.Am J Epidemiol. 2007; 145: 234-241Crossref Scopus (729) Google Scholar found that Caucasians were often found to have only bilateral hilar adenopathy at the time of presentation, whereas Blacks presented with more advanced pulmonary disease.Table ICutaneous manifestations of sarcoidosisNonspecific skin lesionsSpecific skin lesionsDistinctive formsMinor formsErythema nodosumLupus pernioPsoriasiformCalcificationsScar sarcoidosisSubcutaneous nodulesPrurigoPapules and plaquesHypopigmented maculesNail clubbingUlcerativeErythrodermicIchthyosiformScalp and nails Open table in a new tab The most commonly occurring nonspecific skin lesion is erythema nodosum, the hallmark of acute sarcoidosis, which occurs in 3% to 25% of all sarcoidosis cases.22Hanno R. Callen J.P. Sarcoidosis: a disorder with prominent cutaneous features and their interrelationship with systemic disease.Med Clin North Am. 1980; 64: 847-866PubMed Google Scholar Erythema nodosum appears as tender nodules on the front of legs and usually resolves within 6 to 8 weeks (Fig 1).17Hunninghake G.W. Costabel U. Ando M. Baughman R. Cordier J.F. du Bois R. et al.ATS/ERS/WASOG statement on sarcoidosis.Sarcoidosis Vasc Diffuse Lung Dis. 1999; 16: 149-173PubMed Google Scholar Although erythema nodosum is the most common nonspecific lesion seen in sarcoidosis, it is seen significantly less frequently in Black or Asian patients as compared with Caucasian patients.4Minus H.R. Grimes P.E. Cutaneous manifestations of sarcoidosis in blacks.Cutis. 1983; 32: 361-364PubMed Google Scholar, 11Edmondstone W.M. Wilson A.G. Sarcoidosis in Caucasians, blacks and Asians in London.Br J Dis Chest. 1985; 79: 27-36Abstract Full Text PDF PubMed Scopus (100) Google Scholar, 19James D.G. Neville E. Siltzbach L.E. Worldwide review of sarcoidosis.Ann N Y Acad Sci. 1976; 278: 321-334Crossref PubMed Scopus (282) Google Scholar Erythema nodosum is most common in those of European, Puerto Rican, and Mexican descent.17Hunninghake G.W. Costabel U. Ando M. Baughman R. Cordier J.F. du Bois R. et al.ATS/ERS/WASOG statement on sarcoidosis.Sarcoidosis Vasc Diffuse Lung Dis. 1999; 16: 149-173PubMed Google Scholar In a retrospective study of 156 patients seen in South London (68 Caucasians, 59 Black West Indian/Africans, 29 Indo-Pakistan Asians), erythema nodosum was found in 41.2% of the Caucasians, 17.2% of the Asians, and 8.5% of the Blacks in the study. In a Singapore study of 25 patients with sarcoidosis (13 Indian, 11 Chinese, and 1 Eurasian), lesions identified included papules, nodules, plaques, and scarring alopecia.20Chong W.S. Tan H.H. Tan S.H. Cutaneous sarcoidosis in Asians: a report of 25 patients from Singapore.Clin Exp Dermatol. 2005; 30: 120-124Crossref PubMed Scopus (38) Google Scholar Although 72% had papular and nodular sarcoidal lesions, none of the patients had erythema nodosum, fever, arthralgia, weight loss, or lethargy.20Chong W.S. Tan H.H. Tan S.H. Cutaneous sarcoidosis in Asians: a report of 25 patients from Singapore.Clin Exp Dermatol. 2005; 30: 120-124Crossref PubMed Scopus (38) Google Scholar In addition, some unusual nonspecific lesions of sarcoidosis include calcifications, prurigo, erythema multiforme, and clubbing of the nails.26Elgart M.L. Cutaneous sarcoidosis: definitions and types of lesions.Clin Dermatol. 1986; 4: 35-45Abstract Full Text PDF PubMed Scopus (98) Google Scholar Although Blacks most commonly present with papular lesions, various specific skin lesions including hypopigmented macules, plaques, ulcerative lesions, ichthyosiform cutaneous changes, erythrodermic sarcoid, and subcutaneous nodules may be present.4Minus H.R. Grimes P.E. Cutaneous manifestations of sarcoidosis in blacks.Cutis. 1983; 32: 361-364PubMed Google Scholar In 1983, dermatologists in the District of Columbia metropolitan area observed only rare cases of 3 specific sarcoid lesions: ulcerative, ichthyosiform, and erythrodermic.4Minus H.R. Grimes P.E. Cutaneous manifestations of sarcoidosis in blacks.Cutis. 1983; 32: 361-364PubMed Google Scholar The most common cutaneous lesion found in sarcoidosis is the papule (Fig 2). Small papules, 1 to 5 mm in size, are initially orange or yellow-brown in color, turn brownish-red or violaceous, then involute to form faint macules.27Mahajan V.K. Sharma N.L. Sharma R.C. Sharma V.C. Cutaneous sarcoidosis: clinical profile of 23 Indian patients.Indian J Dermatol Venerol Leprol. 2007; 73: 16-21Crossref PubMed Scopus (33) Google Scholar, 28Yanardag H. Pamuk O.N. Karayel T. Cutaneous involvement in sarcoidosis: analysis if the features in 170 patients.Respir Med. 2003; 97: 978-982Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar, 29Olive K.E. Kartaria Y.P. Cutaneous manifestations of sarcoidosis to other organ system involvement, abnormal laboratory measurements, and disease course.Arch Intern Med. 1985; 145: 1811-1814Crossref PubMed Scopus (71) Google Scholar This form of sarcoidosis occurs primarily on the face and neck with a predilection for periorbital skin.5Marchell R.M. Judson M.A. Chronic cutaneous lesions of sarcoidosis.Clin Dermatol. 2007; 25: 295-302Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar The number of lesions may be great and hundreds have been reported on a single patient alone.27Mahajan V.K. Sharma N.L. Sharma R.C. Sharma V.C. Cutaneous sarcoidosis: clinical profile of 23 Indian patients.Indian J Dermatol Venerol Leprol. 2007; 73: 16-21Crossref PubMed Scopus (33) Google Scholar Papular lesions often resolve without significant scarring after treatment or after spontaneous resolution. Papules may evolve into plaques particularly on the extremities, face, scalp, back, and buttocks.23Mana J. Marcoval J. Graells J. Salazar A. Cutaneous involvement in sarcoidosis: relationship to systemic disease.Arch Dermatol. 1997; 133: 882-888Crossref PubMed Google Scholar When compared with papules, plaques have more pronounced erythema, are greater than 5 mm, tend to infiltrate more deeply, and most commonly appear on the face, scalp, back, limbs, and buttocks.23Mana J. Marcoval J. Graells J. Salazar A. Cutaneous involvement in sarcoidosis: relationship to systemic disease.Arch Dermatol. 1997; 133: 882-888Crossref PubMed Google Scholar, 26Elgart M.L. Cutaneous sarcoidosis: definitions and types of lesions.Clin Dermatol. 1986; 4: 35-45Abstract Full Text PDF PubMed Scopus (98) Google Scholar Sarcoidal plaques are round or oval and tend to be found in patients with more chronic sarcoidosis.23Mana J. Marcoval J. Graells J. Salazar A. Cutaneous involvement in sarcoidosis: relationship to systemic disease.Arch Dermatol. 1997; 133: 882-888Crossref PubMed Google Scholar In patients with skin of color, plaques can develop a hypopigmented surface.26Elgart M.L. Cutaneous sarcoidosis: definitions and types of lesions.Clin Dermatol. 1986; 4: 35-45Abstract Full Text PDF PubMed Scopus (98) Google Scholar Distinguishing plaque sarcoidosis from papular sarcoidosis has prognostic value.23Mana J. Marcoval J. Graells J. Salazar A. Cutaneous involvement in sarcoidosis: relationship to systemic disease.Arch Dermatol. 1997; 133: 882-888Crossref PubMed Google Scholar, 26Elgart M.L. Cutaneous sarcoidosis: definitions and types of lesions.Clin Dermatol. 1986; 4: 35-45Abstract Full Text PDF PubMed Scopus (98) Google Scholar Patients with plaques are more likely to have chronic disease26Elgart M.L. Cutaneous sarcoidosis: definitions and types of lesions.Clin Dermatol. 1986; 4: 35-45Abstract Full Text PDF PubMed Scopus (98) Google Scholar and permanent scarring compared with patients with papular lesions.22Hanno R. Callen J.P. Sarcoidosis: a disorder with prominent cutaneous features and their interrelationship with systemic disease.Med Clin North Am. 1980; 64: 847-866PubMed Google Scholar Lupus pernio (Fig 3) is likely the most characteristically recognized chronic skin lesion of sarcoidosis.23Mana J. Marcoval J. Graells J. Salazar A. Cutaneous involvement in sarcoidosis: relationship to systemic disease.Arch Dermatol. 1997; 133: 882-888Crossref PubMed Google Scholar It occurs most commonly in Black women and consists of indurated, red-brown to purple plaques on the nose, lips, cheeks, and ears.17Hunninghake G.W. Costabel U. Ando M. Baughman R. Cordier J.F. du Bois R. et al.ATS/ERS/WASOG statement on sarcoidosis.Sarcoidosis Vasc Diffuse Lung Dis. 1999; 16: 149-173PubMed Google Scholar, 23Mana J. Marcoval J. Graells J. Salazar A. Cutaneous involvement in sarcoidosis: relationship to systemic disease.Arch Dermatol. 1997; 133: 882-888Crossref PubMed Google Scholar When lupus pernio involves the nose, the nasal bone and mucosal surfaces may undergo granulomatous infiltration.23Mana J. Marcoval J. Graells J. Salazar A. Cutaneous involvement in sarcoidosis: relationship to systemic disease.Arch Dermatol. 1997; 133: 882-888Crossref PubMed Google Scholar Frequently, lupus pernio is associated with pulmonary fibrosis, bone cysts, and a prolonged course.17Hunninghake G.W. Costabel U. Ando M. Baughman R. Cordier J.F. du Bois R. et al.ATS/ERS/WASOG statement on sarcoidosis.Sarcoidosis Vasc Diffuse Lung Dis. 1999; 16: 149-173PubMed Google Scholar Angiolupoid lesions, often classified as lupus pernio, are rare violaceous-pink papules and plaques with pronounced telangiectasias that are found on the face.5Marchell R.M. Judson M.A. Chronic cutaneous lesions of sarcoidosis.Clin Dermatol. 2007; 25: 295-302Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 27Mahajan V.K. Sharma N.L. Sharma R.C. Sharma V.C. Cutaneous sarcoidosis: clinical profile of 23 Indian patients.Indian J Dermatol Venerol Leprol. 2007; 73: 16-21Crossref PubMed Scopus (33) Google Scholar The lesions of classic lupus pernio are more extensive and less discrete than angiolupoid lesions.30Callen J.P. Jorrizzo J.L. Dermatological signs of internal disease. 3rd ed. Saunders Elsevier Science Limited, Philadelphia2003: 257-263Google Scholar, 31Gawkrodger D.J. Sarcoidosis.in: Champion R.H. Burton J.L. Burns D.A. Rock/Wilkinson/Ebling textbook of dermatology. Blackwell Science, Oxford1998: 2670-2702Google Scholar Development of sarcoidal lesions in or on scars (Fig 4) is a specific but uncommon manifestation of cutaneous sarcoidosis.32Nayar M. Sarcoidosis on ritual scarification.Int J Dermatol. 1993; 32: 116-118Crossref PubMed Scopus (14) Google Scholar Cutaneous sarcoidosis occurs preferentially within scar tissue, at traumatized sites, and around imbedded foreign material such as tattoos (Fig 5) and silica.33Chudomirova K. Velichkva L. Anavi B. Recurrent sarcoidosis in skin scars accompanying systemic sarcoidosis.J Eur Acad Dermatol Venerol. 2003; 17: 360-361Crossref PubMed Scopus (29) Google Scholar, 34Kim Y.C. Triffet M.K. Gibson L.E. Foreign bodies in sarcoidosis.Am J Dermatopathol. 2000; 22: 408-412Crossref PubMed Scopus (72) Google Scholar The noncaseating granulomas of this specific lesion have even been found in sites of prior needle sticks for phlebotomy or tuberculin skin tests.4Minus H.R. Grimes P.E. Cutaneous manifestations of sarcoidosis in blacks.Cutis. 1983; 32: 361-364PubMed Google Scholar Previously silent scars become infiltrated, assume an erythematous or violaceous hue, but remain asymptomatic and represent benign disease.5Marchell R.M. Judson M.A. Chronic cutaneous lesions of sarcoidosis.Clin Dermatol. 2007; 25: 295-302Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 27Mahajan V.K. Sharma N.L. Sharma R.C. Sharma V.C. 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