Systemic sarcoidosis presenting with alopecia of the scalp

Abstract

A 39‐year‐old African‐American woman was referred to the department of dermatology, Mount Sinal Hospital, New York for evaluation of a skin lesion on her scalp which had been present for 3 years and had recently changed in appearance. On examination, she was found to have erythematous plaques with hair loss extending from the frontal hairline on the right side in a “C‐shaped” distribution, terminating behind the left ear. Two years later the lesion had rapidly extended to the vertex of the scalp and left temporal area (Fig. 1). There was a 10 cm × 12 cm area of alopecia at the vertex with slight erythema, but there was no evidence of scarring, inflammation or nodularity of the scalp (Fig. 2). A skin biopsy taken from the forehead revealed granulomatous dermatitis showing noncaseating granuloma with negative acid fast bacilli (AFBC) and ammonical‐silverstain for fungus (GMS) (Fig. 3). 1 Erythematous plaque with hair loss on the left temporal area 2 Nonscarring alopecia at the vertex with slight erythema 3 Noncaseating granuloma consisting of lymphocytes, histiocytes, plasma cells and multinucleated giant cells (hematoxylin and eosin staining; magnification ×100) She complained of chronic nasal congestion for 8 months. Nasal cavity examination and laryngeal endoscopy showed multiple nodules on the nasal septum and vocal cord. At that time, a presumptive diagnosis of sarcoidal nodule of the nasal septum and vocal cord was made and corticosteroids were administered orally. A chest X‐ray demonstrated prominence of the right peritracheal and perihilar regions consistent with sarcoid. A 67 Gallium scan disclosed increased uptake in the lung and perihilar lymph nodes. A skull X‐ray showed soft tissue density of the skull, probably indicating a subcutaneous sarcoidal nodule. Computed tomography (CT) scanning of her brain and skull base showed a soft tissue mass along the outer table of the calvarium within the frontal region. Six years ago, she experienced visual changes: blurred vision, tearing, floaters on both eyes and a 1 cm × 1 cm subcutaneous, painful, firm mass on the lateral side of her left upper eyelid. A skin biopsy was performed in another hospital and revealed noncaseating granuloma. A diagnosis of sarcoidosis involving the central nervous system, lacrimal gland, nasal septum, vocal cord, lung and scalp was made, and the patient was treated with 20 mg of methylprednisone on alternate days with intralesional triamcinolone injection for skin lesions. During the follow‐up period, nasal, laryngeal, pulmonary, ocular and cutaneous lesions were slightly improved and magnetic resonance imaging (MRI) scanning will be carried out for further evaluation of the brain lesion.

Cutaneous Sarcoidosis

“…Scarring alopecia occurs more frequently and involves destruction of the hair follicles with granulomas, resulting in smooth surfaces on the scalp and an inability for hair to regrow. [86][87][88][89][90] Scaling, erythema, indurated plaques, nodules, and diffuse or localized disease can occur, with some presentations mimicking discoid lupus erythematosus. 90 African American women are most commonly affected, and most patients concurrently have other cutaneous sarcoidosis, with the frequent involvement of the face.…”

The granulomatous reaction pattern

“…74,75 This miscellaneous group represents rare cutaneous manifestations of sarcoidosis. 80 Other rare presentations have included leonine facies, 81 faint erythema, 82 palmar erythema, 83 vasculitis, 42 alopecia, 84,85 and lesions confined to the vulva. 76 Oral, eyelid, and scrotal lesions have been reported.…”

Trichoscopy as a clue to the diagnosis of scalp sarcoidosis

“…Involvement of the scalp is rare and may lead to cicatricial alopecia as a result of the destruction of the hair follicles by the granulomatous formation 2–5 . Clinically, sarcoidosis may present as papules, nodules, or plaques, in some cases resembling discoid lupus erythematosus or lipoidic necrobiosis 6–12 …”