Disfiguring cutaneous sarcoidosis involving the face

A 56-year-old woman presented with a 4-year history of numerous nodules on her face. Examination revealed multiple painless and infiltrated nodules, some displaying a lupoid morphology and an annular morphology with an atrophic center [Figure 1a]. Dermoscopy showed multiple arborizing blood vessels, shiny white lines, and follicular plugs on a yellow-orange background [Figure 1b]. Skin biopsy showed multiple, often confluent, non-necrotizing epithelioid granulomas, with rare multinucleated giant cells [Figure 1c and d], and no caseation was observed. Polarized light examination was negative and staining for acid–fast bacilli and fungi was negative. There was no history of foreign body exposure, and no polarizable material was seen. Based on these findings, we confirmed the diagnosis of cutaneous sarcoidosis. Computed tomography of the chest, chest X-ray, and electrocardiography did not reveal any abnormalities. Pulmonary function testing, including spirometry and measurement of gas exchange, was performed and yielded normal results. Serum chemistries (including calcium, liver function tests, and creatinine) were within normal limits. Given the severity and disfiguring nature of the lesions, systemic corticosteroid therapy was initiated at a dose of 0.5 mg/kg/day of prednisone, with hydroxychloroquine at 400 mg/day. Significant clinical improvement was observed after 1 month [Figure 2]. This case highlights the clinical polymorphism of sarcoidosis, often referred to as “the great imitator,” as it can mimic several conditions. Its uniqueness lies in the extensive and chronic cutaneous involvement without systemic disease, which is uncommon. This underscores the importance of considering it in the differential diagnosis of atypical facial nodules.

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Figure 1:

(a) Multiple infiltrated nodules, some displaying a lupoid morphology with areas of confluence. Lesions with annular morphology and an atrophic center. (b) Dermoscopic picture showing multiple arborizing blood vessels (blue arrow), shiny white lines (black arrow) and follicular plugs (black circle) on a yellow orange background (black star). (c) The dermis shows multiple, often confluent, non-necrotizing epithelioid granulomas (black circle), with rare multinucleated giant cells (Hematoxylin Eosin Stain ×100). (d) The dermis shows multiple, often confluent, non-necrotizing epithelioid granulomas (black circle), with rare multinucleated giant cells (Hematoxylin Eosin Stain ×200).

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Figure 2:

Significant clinical improvement after 1 month of follow-up.

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