A practical approach to cutaneous sarcoidosis

Ulcerative sarcoidosis: An atypical cause of leg ulcers

We present the case of an 83-year-old woman with leg ulcers who was diagnosed with sarcoidosis. This case highlights the importance for clinicians to consider ulcerative sarcoidosis when encountering patients with leg ulcers along with hilar adenopathy, uveitis, elevated serum angiotensin-converting enzyme, and histopathological findings of epithelioid cell granulomas.

Cutaneous Sarcoidosis

Sarcoidosis is a multisystem disease that most commonly affects the lungs, lymphatic system, eyes, and skin but any organ may be involved. Cutaneous sarcoidosis most commonly presents as pink-red to red-brown papules and plaques that commonly affect the head and neck. With the skin being readily accessible for evaluation and biopsy, when sarcoidosis is suspected, dermatologic evaluation may be helpful for establishing a definitive diagnosis. Treatment strategy depends on the severity and distribution of skin lesions and should incorporate patient preference and treatment considerations for other organs that may be involved.

Unmasking sarcoidosis following SARS-CoV-2 vaccination: A case report

Sarcoidosis is an inflammatory and granulomatous disorder, developed due to dysregulation between immune response and certain environmental antigens. We hereby report an interesting case of sarcoidosis following COVID-19 vaccination (COVIran Barekat), which presented with inflammation of previous tattoo sites as well as the development of erythema nodosum and systemic lymphadenopathy, suggested a possible link between the COVID vaccination and dysregulation of the inflammatory process and served as a reminder for clinicians to have enough vigilance before proposing a vaccine booster to these patients.

Sarcoidosis in the older person: diagnostic challenges and treatment consideration

BACKGROUND

Sarcoidosis is a multi-system disorder with an increasing propensity to present in older patients. Diagnostic uncertainty is common and understandable given the higher prevalence of co-morbidities in older patients and broad differential for multi-system clinical presentations. Excluding malignancy and infection with a high degree of certainty is challenging and may require repeated confirmatory investigation where the diagnosis remains in doubt.

SUMMARY OF MAIN FINDINGS

There are a paucity of studies examining late-onset sarcoidosis. Female predominance, pulmonary, ocular, skin and systemic symptoms are common, while more classical presentations such as Lofgren's syndrome are uncommon. Positivity rates of biopsies vary between studies; however, targeted biopsies of accessible sites with organ involvement are the most successful. Therapeutic management is directed at reducing inflammation, and thereby reducing symptom burden, improving quality of life and avoiding progression of organ damage. While most older patients will require corticosteroid therapy, they are also more prone to developing adverse effects. Most older patients will experience a clinical remission; however, the risk of developing chronic sarcoidosis and organ damage is higher compared with younger counterparts. Patients with evidence of pulmonary fibrosis and pulmonary hypertension are at particular risk.

IMPACT ON CLINICAL PRACTICE

Health care providers who care for older adults should be aware of the increasing prevalence of late-onset sarcoidosis and consider the diagnosis in those who present with otherwise unexplained systemic symptoms, thoracic abnormalities on imaging and/or evidence of other organ involvement. Earlier diagnosis and therapeutic intervention to halt the development of pulmonary fibrosis and pulmonary hypertension and monitoring for treatment-related adverse effects will confer a mortality benefit.

The Evolving Landscape of Cutaneous Sarcoidosis: Pathogenic Insight, Clinical Challenges, and New Frontiers in Therapy

Sarcoidosis is a multisystem disorder of unknown etiology characterized by accumulation of granulomas in affected tissue. Cutaneous manifestations are among the most common extrapulmonary manifestations in sarcoidosis and can lead to disfiguring disease requiring chronic therapy. In many patients, skin disease may be the first recognized manifestation of sarcoidosis, necessitating a thorough evaluation for systemic involvement. Although the precise etiology of sarcoidosis and the pathogenic mechanisms leading to granuloma formation, persistence, or resolution remain unclear, recent research has led to significant advances in our understanding of this disease. This article reviews recent advances in epidemiology, sarcoidosis clinical assessment with a focus on the dermatologist's role, disease pathogenesis, and new therapies in use and under investigation for cutaneous and systemic sarcoidosis.

Subcutaneous sarcoidosis (Darier-Roussy sarcoidosis) with extensive disease on positron emission tomography: A case report and review of the literature

Cutaneous manifestations of sarcoidosis are common, but subcutaneous nodules are rare, originally described in 1904 by Darier and Roussy and thought to represent isolated skin disease. We present a 61-year-old male who presented with 3 months of subcutaneous nodules on the forearms and knees. Biopsy confirmed sarcoidosis. An [F-18] fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) showed confluent uptake in the skin of forearms and knees, along with thighs and buttocks, mediastinal, hilar and upper abdominal lymph nodes, and multiple bones. He was well and treated with hydroxychloroquine 400 mg/day. The nodules resolved and a repeat FDG PET/CT at 5 months showed a significant decrease in the uptake at all involved sites. Although a PET scan can demonstrate extensive disease in a patient presenting with subcutaneous nodules, the literature suggests prognosis is good and treatment should start simply with the least toxic approach, such as with hydroxychloroquine therapy.

Infliximab therapy in refractory sarcoidosis: a multicenter real-world analysis

Background

Infliximab is a monoclonal antibody that binds and neutralizes circulating tumor necrosis factor-alpha, a key inflammatory cytokine in the pathophysiology of sarcoidosis. Despite the paucity of randomized clinical trials, infliximab is often considered a therapeutic option for refractory disease. Our study aimed to investigate the effectiveness of infliximab in patients with refractory sarcoidosis.

Methods

Sarcoidosis patients from three tertiary centres were retrospectively identified by pharmacy records based on treatment with infliximab. Treatment with Infliximab was initiated in patients who failed first and second line immunomodulators as determined by a multidisciplinary team of Respirologists, Dermatologists, ENT specialists, Rheumatologists, and Neurologists. Participants were characterized by the primary organ for which infliximab was initiated and the total number of organs involved. Clinical outcomes were categorized as treatment success versus failure. We defined treatment success as (A) improvement of cutaneous, upper airway, lymph node, gastrointestinal, eye, or joint manifestations; or (B) improvement or no change in central nervous system (CNS) or pulmonary manifestations.

Results

33 patients with refractory sarcoidosis were identified. The proportion of treatment success was 100% (95% CI 54.1–100) in CNS, 91.7% (95% CI 61.5–99.8) in cutaneous, 78.6% (95% CI 49.2–95.3) in pulmonary and 71.5% (95% CI 29.0–96.3) in upper airway disease. The use of infliximab was associated with a reduction prednisone dose by 50%.

Conclusion

Infliximab is possibly an effective therapy for refractory sarcoidosis, with the greatest value in neurologic and cutaneous manifestations. Across all disease presentations, infliximab facilitated a clinically relevant reduction in corticosteroid dose. Relapse is common after discontinuation of infliximab.

Incidence and death rate of sarcoidosis in Korea in association with metabolic diseases

Sarcoidosis is a systemic granulomatous disease that affects a variety of organs. Although the etiology has not been fully understood, it is thought that diverse genetic and environmental factors interact with the immune system to develop granulomas. The incidence and death rate of sarcoidosis vary according to race. This study was conducted to identify the epidemiology of sarcoidosis in Korea and reveal its association with comorbid diseases such as diabetes mellitus, hypertension, and dyslipidemia in a population-based database. We retrospectively analyzed Korean National Health Insurance claims data between 2006 and 2017. The average annual incidence from 2006 to 2017 was 0.82/100 000 person-years and the all-cause death rate in sarcoidosis patients was 9.25/1000 cases. The incidence of sarcoidosis was higher in patients with diabetes mellitus, hypertension, and dyslipidemia than patients without those underlying diseases. Sarcoidosis patients with diabetes mellitus and hypertension showed an increased death rate after adjusting the confounding factors (hazard ratio [95% confidence interval], 1.66 [1.23-2.23] and 1.73 [1.29-2.31] respectively), however, patients with dyslipidemia showed a low death rate (HR = 0.64 [0.46-0.88]). In conclusion, we found that sarcoidosis is associated with diabetes mellitus, hypertension, and dyslipidemia and that diabetes mellitus and hypertension increase the risk of death in sarcoidosis patients. Extra caution is needed in sarcoidosis patients who already have these metabolic diseases.

Oral Granulomatous Disease

Granulomatous diseases are chronic inflammatory disorders whose pathogenesis is triggered by an array of infectious and noninfectious agents, and may be localized or a manifestation of systemic, disseminated disease. As in the skin, oral manifestations of granulomatous inflammation are often nonspecific in their clinical appearance. Thus, in the absence of overt foreign material or a recognizable infectious agent, identifying the underlying cause of the inflammation can be challenging. This article highlights various conditions known to induce granulomatous inflammation within the oral soft tissues.

Multiple Faces of Eyelid Involvement in Sarcoidosis

Purpose: To report three cases of eyelid involvement by sarcoidosis. In one of them, it mimicked a malignant lesion.Methods: Retrospective case reports.Results: A 73-year-old man presented with destruction of the left lower eyelid for 2 years. He had granulomatous uveitis in the left eye. Chest CT scan showed parenchymal abnormalities that could correspond to sarcoidosis. Skin biopsy revealed noncaseating granuloma. Oral and topical corticosteroids resulted in improvement of the condition. A 72-year-old female patient presented with cutaneous infiltration of the left upper eyelid for 1 month. Biopsy was consistent with sarcoidosis. Endobronchial biopsies showed interstitial fibrosis. Oral prednisone improved the condition. A 65-year-old female patient presented with edema of the right upper eyelid for 2 months. Full-thickness biopsy showed granuloma without necrosis. There was an improvement with oral steroid.Conclusion: Although eyelid involvement in sarcoidosis is uncommon, different forms of presentation, including destructive lesions, can be observed.

Prevalence and characteristics of cutaneous sarcoidosis in Argentina

Background

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. The incidence is higher in women than in men, according to some studies. Studies regarding prevalence and characteristics of cutaneous sarcoidosis in our region are scarce.

Objective

This study aimed to describe the characteristics of patients with cutaneous sarcoidosis and to estimate its prevalence.

Methods

A cross-sectional study was conducted of patients with cutaneous sarcoidosis between January 1, 2004 and April 30, 2019 at the Hospital Italiano de Buenos Aires in Argentina. We included all patients age >17 years with biopsy-proven cutaneous sarcoidosis. Isolated cutaneous sarcoidosis was defined as the presence of epithelioid noncaseating granulomas on a skin biopsy without further evidence of systemic involvement. To estimate period prevalence, we only considered the subgroup of patients affiliated with our private health system.

Results

A total of 38 patients with cutaneous sarcoidosis were included. The median age at the time of diagnosis was 55.5 years. There was a striking female predominance in our series (73.7%). Overall, 15 patients (39.5%) had isolated cutaneous sarcoidosis and 23 (60.5%) had systemic sarcoidosis with cutaneous involvement. The median follow-up of the study population from histological diagnosis was 50 months (interquartile range, 24–10 months). Regarding skin involvement, 28 patients (73.7%) presented with only sarcoidosis-specific lesions, 6 (15.8%) presented with erythema nodosum, and 4 (10.5%) presented with both sarcoidosis-specific lesions and erythema nodosum. Treatment was given to 29 patients (73.6%), with systemic and topical corticosteroids being the most frequent. The crude prevalence of cutaneous sarcoidosis was 16.9 (95% confidence interval, 10.6–25.5) per 100,000 persons.

Conclusion

One of the major findings of our study was that 40% of patients had isolated cutaneous sarcoidosis.

Cutaneous Sarcoidosis

Sarcoidosis is a chronic, multisystem, inflammatory disorder of unknown etiology that is characterized by noncaseating granulomas that impair normal organ functioning. Sarcoidosis predominantly affects the lungs, but the skin is often cited as the second most frequently involved organ. Cutaneous manifestations of sarcoidosis are highly variable and ongoing research seeks to better understand the relationship between clinical morphology and disease prognosis. Skin findings in patients with sarcoidosis can be "specific," in which sarcoidal granulomas infiltrate the skin, or they can represent a "nonspecific" reactive inflammatory process, as is seen in calcinosis cutis and erythema nodosum. Cutaneous sarcoidosis can be the initial presenting sign or develop later in the course of the disease. In some patients, the skin will be the most involved and impactful organ system and will drive therapy. In other cases, the skin will be an incidental or minor finding, but may be easily accessible for biopsy to confirm the diagnosis. There are many potential therapies for sarcoidosis, though no one therapy is universally effective.

Histopathologic features of noninfectious granulomatous disorders involving the skin

Granulomatous dermatoses may represent primary skin inflammation or can serve as the harbinger of a multitude of underlying systemic disorders or drug reactions. Taken together with clinical findings, the microscopic features from skin biopsy can allow recognition of various patterns and facilitate a precise diagnosis. Accurate classification of entities in this category of inflammatory dermatoses may prompt clinicians to investigate for underlying systemic problems, thereby allowing the pathologist to add considerable value in the care of affected patients. This review article categorizes clinical and microscopic features of common and uncommon causes of noninfectious dermal and subcutaneous granulomatous inflammation.

A case of facial atrophic sarcoidosis in an adolescent, successfully treated with the combination of prednisone and hydroxychloroquine

Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology. Cutaneous involvement occurs in up to 30% of patients and skin findings are often the initial presenting symptom. The facial atrophic form of sarcoidosis without associated ulceration in adolescents has rarely been described in the literature. We report a case of 13-year-old male patient with a facial atrophic sarcoidosis who was successfully treated with the combination of prednisone and hydroxychloroquine.

Cutaneous sarcoidosis: clinico-epidemiological profile of 72 patients at a tertiary hospital in São Paulo, Brazil

Background

Sarcoidosis is a multisystem disease of unknown cause that is characterized by the presence of granulomas in various organs. Cutaneous involvement is common and the reported incidence has varied from 9% to 37%. Studies on cutaneous sarcoidosis in Brazil are lacking.

Objectives

To describe the clinical and epidemiological aspects of patients with cutaneous sarcoidosis diagnosed at the Department of Dermatology of the University of São Paulo, from May 1994 to March 2018.

Methods

Clinical data of patients with confirmed cutaneous sarcoidosis were retrospectively reviewed and classified according to gender, ethnicity, age at diagnosis, cutaneous presentation, systemic involvement and treatment.

Results

Cutaneous sarcoidosis was diagnosed in 72 patients with a female predominance (74%). The mean age at diagnosis was 49.6 years and most of the patients were white (61%). Papules and plaques were the most common lesions. Systemic sarcoidosis was detected in 81% of patients, affecting mainly the lungs and thoracic lymph nodes (97%). Typically, cutaneous lesions were the first manifestation (74%). Systemic therapy was necessary for 72% of patients; the dermatologist managed many of these cases. Oral glucocorticoids were the most commonly used systemic medication (92%). The mean number of systemic drugs used was 1.98 per patient.

Limitations

Insufficient data in medical records.

Conclusions

This series highlights the dermatologist role in recognizing and diagnosing cutaneous sarcoidosis, evaluating patients for systemic disease involvement and treating the skin manifestations. Cutaneous sarcoidosis was once considered exceedingly infrequent in Brazil in comparison to infectious granulomatous diseases; however, the present series seems to suggest that the disease is not so rare in this region.

Periocular cutaneous sarcoid: case series and review of the literature

OBJECTIVES

To illustrate the varying clinical presentations of cutaneous sarcoidosis affecting the periocular region, which may masquerade as other clinical entities such as basal cell carcinoma or seborrheic dermatitis. Furthermore, the authors present an unusual observation of lupus pernio involving the adnexal region with the rare presence of perineural granulomas on histology following incisional biopsy.

METHODS

We report a consecutive series of four cases with lesions involving the eyelids with varying clinical appearances. All four patients presented to our adnexal service undergoing incisional diagnostic biopsy. Histology following biopsy subsequently resulted in further investigation and management of both local cutaneous lesions and systemic sarcoidosis.

RESULTS

Three of our four cases had evidence of pulmonary involvement on chest X-ray. Over an 18-month period, one of two patients responded to intralesional triamcinolone and subsequently to oral methotrexate (15 mg/week). Two patients were observed with their periocular lesions remaining stable without therapy.

CONCLUSIONS

All four patients presented to the adnexal service with lesions of varying morphology and were diagnosed with sarcoidosis following incisional biopsy highlighting the vital role of oculoplastic surgeons in diagnosing this multisystem inflammatory disease. We describe our experience of intralesional triamcinolone, oral methotrexate and watchful observation in the management of such lesions.

Tofacitinib Treatment and Molecular Analysis of Cutaneous Sarcoidosis

There is evidence that Janus kinase (JAK)-signal transducer and activator of transcription (STAT) signaling plays a role in the pathogenesis of sarcoidosis. We treated a patient with cutaneous sarcoidosis with the JAK inhibitor tofacitinib; the patient had not previously had a response to medications and had not received systemic glucocorticoids. This treatment resulted in clinical and histologic remission of her skin disease. Sequencing of RNA and immunohistochemical examination of skin-lesion samples obtained from the patient before and during therapy and immunohistochemical testing of lesion samples obtained from other patients with cutaneous sarcoidosis support a role for JAK-STAT signaling in cutaneous sarcoidosis. (Funded by the Ranjini and Ajay Poddar Resource Fund for Dermatologic Diseases Research and others.).

The natural history of cutaneous sarcoidosis. Clinical spectrum and histological analysis of 40 cases

BACKGROUND

Cutaneous lesions of sarcoidosis can allow physicians to establish the diagnosis of a systemic disease, but the need of monitoring patients presenting skin limited sarcoidosis in order to detect further extracutaneous involvement has rarely been evaluated.

OBJECTIVES

To review clinical and histological features of patients with cutaneous sarcoidosis and the risk of progression to systemic disease. To characterize the phenotype of patients with isolated cutaneous sarcoidosis and to assess the temporal relationship between cutaneous and systemic disease.

METHODS

Retrospective review of a series of patients with cutaneous sarcoidosis. Clinical, histopathological, and evolutive features were reviewed.

RESULTS

Forty patients were included in the study. Systemic disease was present in 82.5% of patients. Previous or concurrent cutaneous involvement occurred in 81.8% of them. Seven out of 14 patients with cutaneous lesions evolved to a systemic sarcoidosis in a mean time of 6 years, with a range between 4 and 9 years. No clinical or histological differences were found between patients with systemic sarcoidosis and those who showed persistent isolated cutaneous lesions.

CONCLUSIONS

Sarcoidosis may be manifested as an isolated cutaneous disorder. No clinical or histopathological features seem to be helpful to discriminate cases of a persistent isolated cutaneous disease from those that will develop systemic involvement. Since the development of systemic involvement in cases of isolated cutaneous sarcoidosis can occur many years afterward, careful monitoring seems advisable, and a long follow-up is recommended.

Scar sarcoidosis: A rare entity found by 18F-FDG-PET/CT

¹⁸F-labeled fluoro-2-positron deoxyglucose emission tomography/computed tomography has been widely used in malignancy assessment, however, is not tumor-specific and may be taken up by non-malignant conditions such as sarcoidosis. Sarcoidosis is a systemic inflammatory disorder and scar sarcoidosis is a rare manifestation of the disease. A 60-year-old man with a past medical history of synchronous colon adenocarcinoma and clear cell renal cell carcinoma with clinical suspicion of tumor recurrence. ¹⁸F-labeled fluoro-2-positron deoxyglucose emission tomography/computed tomography scan demonstrated lesions with increased fluorodeoxyglucose uptake in mediastinal and left supraclavicular lymph nodes, along with hypermetabolic cutaneous foci that corresponded with previous surgical scars. Skin biopsy was suggestive of sarcoidosis.

Cutaneous Granulomatosis: a Comprehensive Review

Cutaneous granulomatosis is a heterogeneous group of diseases, characterized by a skin inflammatory reaction triggered by a wide variety of stimuli, including infections, foreign bodies, malignancy, metabolites, and chemicals. From a pathogenic point of view, they are divided into non-infectious and infectious granulomas. Pathophysiological mechanisms are still poorly understood. Non-infectious granulomatous skin diseases include granuloma annulare, necrobiosis lipoidica, rheumatic nodules, foreign body granulomas, cutaneous sarcoidosis, and interstitial granulomatous dermatitis. Necrobiosis lipoidica is more frequent in diabetic patients. Infectious granulomas of the skin are caused by mycobacteria, in particular Mycobacterium tuberculosis or atypical mycobacteria; parasites, such as Leishmania; or fungi. Pathogenic mechanisms of M. tuberculosis-related granuloma are discussed. From a clinical point of view, it is useful to divide cutaneous granulomatosis into localized and more disseminated forms, although this distinction can be sometimes artificial. Three types of localized granulomatous lesions can be distinguished: palisaded granulomas (granuloma annulare, necrobiosis lipoidica, and rheumatoid nodules), foreign body granulomas, and infectious granulomas, which are generally associated with localized infections. Disseminated cutaneous granulomas can be divided into infectious, in particular tuberculosis, and non-infectious forms, among which sarcoidosis and interstitial granulomatous dermatitis. From a histological point of view, the common denominator is the presence of a granulomatous inflammatory infiltrate in the dermis and/or hypodermis; this infiltrate is mainly composed of macrophages grouped into nodules having a nodular, palisaded or interstitial architecture. Finally, we propose which diagnostic procedure should be performed when facing a patient with a suspected cutaneous granulomatosis.

Atypical Cutaneous Presentations of Sarcoidosis: Two Case Reports and Review of the Literature

PURPOSE OF REVIEW

The goal of this review is to provide the reader with an updated summary of the cutaneous manifestations of systemic sarcoidosis, with a particular emphasis on the predilection of sarcoidosis for scars, tattoos, and other areas of traumatized skin.

RECENT FINDINGS

While the mechanism underlying the propensity for traumatized skin to develop sarcoidosis lesions remains unclear, several theories have been proposed including the idea that cutaneous sarcoidosis represents an exuberant, antigen-driven foreign-body response, as well as the theory that traumatized skin represents an immunocompromised district with altered local immune trafficking and neural signaling. In this review, we present two cases in which the development of cutaneous lesions in scars and tattoos was integral to the diagnosis of systemic sarcoidosis. We then review the various cutaneous manifestations of systemic sarcoidosis, the clinical characteristics and differential diagnosis of scar and tattoo sarcoidosis, the proposed mechanism by which traumatized skin is prone to developing sarcoidosis lesions, and current treatments for cutaneous sarcoidosis.

Cutaneous sarcoidosis

PURPOSE OF REVIEW

Cutaneous sarcoidosis occurs in up to 30% of patients with sarcoidosis and skin findings are often the initial presenting symptom. Cutaneous sarcoidosis is a rare skin disease and many aspects of the disease presentation and treatment are not well understood. This review will highlight developments in the epidemiology, clinical presentation, diagnosis and treatment of cutaneous sarcoidosis over the past several years.

RECENT FINDINGS

Epidemiological studies from several different populations reaffirm that cutaneous sarcoidosis is more common in women and is often the presenting symptom of systemic sarcoidosis. Recently, more cases are being reported in association with oncologic immune modulators, which will be of great interest as use of those agents increases. Also, ultrasound has shown promise for the imaging of cutaneous granulomas for disease assessment and measuring response to treatment. Finally, the treatment of cutaneous sarcoidosis remains difficult and is based largely on retrospective data with a paucity of large, prospective trials. There have been recently introduced and validated cutaneous scoring tools which show promise and may lead to more high-quality studies going forward.

SUMMARY

The recent developments in cutaneous sarcoidosis have identified many new pharmacologic and physical triggers of disease, but the evidence for effective treatment is still lacking. Further research is necessary to improve the care of patients with cutaneous sarcoidosis.

Neurosarcoidosis

Neurosarcoidosis occurs in 3% to 10% of patients with sarcoidosis. Cranial neuropathy and meningeal involvement are the most common manifestations, but any part of the nervous system can be affected. Definite diagnosis requires the presence of noncaseating granuloma in the nervous system, although histopathologic confirmation is often not obtainable. Moderate to high dose of glucocorticoids is the main therapy for neurosarcoidosis. Relapse often occurs after the dose of glucocorticoids is tapered down, often necessitating the use of steroid-sparing immunosuppressive agents.

Clinical Characteristics of Sarcoid Arthropathy: A Population-Based Study

OBJECTIVE

The epidemiology and clinical characteristics of sarcoid arthropathy are not well described, as only referral-based studies have been reported. This study aimed to use the data from a geographically well-defined population to characterize the clinical characteristics of sarcoid arthropathy.

METHODS

An inception cohort of patients with incident sarcoidosis in the years 1976-2013 in a geographically well-defined population was identified based on comprehensive individual medical records review. Inclusion required physician diagnosis supported by histopathology and radiologic features of intrathoracic sarcoidosis, compatible clinical presentation, and exclusion of other granulomatous diseases. Patients with joint pain were then identified from this cohort.

RESULTS

In 1976-2013, all 345 incident cases of sarcoidosis were identified. Symptoms of joint pain occurred in 42 patients (mean age 41.2 years, 57.1% female, and 95% white), and 35 patients had swollen joint(s) on physical examination. Most patients had arthralgia prior to the diagnosis of sarcoidosis, with an average time to diagnosis of 21 days. Of the 35 cases, oligoarthritis (2 to 4 joints) was the most common pattern (88% of cases), followed by monoarthritis (6%) and polyarthritis (6%). Ankles were involved in 91% of cases. In the majority of patients (88%), the arthritis resolved within 6 weeks. Classic Lofgren's syndrome was observed in 11 patients (26%).

CONCLUSION

Inflammatory arthritis occurs in a minority of patients with sarcoidosis. Acute oligoarthritis with bilateral ankle involvement was the most common pattern of sarcoid arthropathy. It should be noted that the generalizability of the results may be limited, as the cohort was predominantly white.

Epidemiology of cutaneous sarcoidosis, 1976-2013: a population-based study from Olmsted County, Minnesota

BACKGROUND

The epidemiology of cutaneous sarcoidosis is not well-characterized as only referral-based studies are available.

OBJECTIVES

To characterize the epidemiology of cutaneous sarcoidosis, with emphasis on annual incidence and clinical characteristics, from 1976 to 2013.

METHODS

Inception cohorts of patients with incident isolated cutaneous sarcoidosis and incident systemic sarcoidosis with cutaneous involvement in 1976-2013 in Olmsted County, Minnesota, United States were identified based on comprehensive individual medical record review. Inclusion in the isolated cutaneous sarcoidosis cohort required physician diagnosis and skin biopsy showing non-necrotizing granuloma. Inclusion in the systemic sarcoidosis with cutaneous involvement cohort required presence of systemic sarcoidosis and cutaneous lesions. Presence of systemic sarcoidosis was determined by physician diagnosis supported by histopathology of non-necrotizing granuloma, characteristic radiologic features of intrathoracic sarcoidosis and exclusion of other granulomatous diseases. Cutaneous lesions were defined as either sarcoidosis-specific or non-specific.

RESULTS

There were 62 cases with sarcoidosis-specific cutaneous lesions (36 cases of sarcoidosis-specific cutaneous lesions and 26 cases of isolated cutaneous sarcoidosis) which corresponded to an incidence of 1.9 per 100 000 population. The female to male ratio was 2.1 : 1. Plaques, papules and subcutaneous nodules were the most commonly observed cutaneous lesions. There was no significant difference in cutaneous presentation between those who had isolated skin disease and those who had skin disease in association with systemic sarcoidosis. Prognosis of cutaneous sarcoidosis was favourable, as over 90% of patients had a good response to either glucocorticoids, hydroxychloroquine or tetracycline antibiotics. This study has a significant limitation, in that the studied population was predominantly Caucasians who generally have a lower prevalence of skin disease.

CONCLUSIONS

The incidence of sarcoidosis-specific cutaneous lesions was about 1.9 per 100 000 population with female predominance. The cutaneous presentations were similar among those with and without systemic sarcoidosis.

Sarcoidosis: radiographic manifestations in the nails and distal phalanges

Sarcoidosis is a granulomatous disease which can affect multiple organ systems. Clinical and radiologic manifestations depend on the organ system involved and the chronicity of disease. Nail involvement in sarcoidosis is rare, but is clinically relevant as it indicates chronic systemic disease. Nail abnormalities can be identified radiographically, and when seen in patients with known or suspected sarcoidosis, should prompt careful evaluation of the underlying bone for osseous involvement. We describe a case of sarcoidosis with radiographic findings in the nails and distal phalangeal tufts, which were indicative of nail and osseous sarcoid involvement and strongly supported the presence of chronic systemic disease. Although the nail findings resolved clinically and on radiographs after treatment, the osseous findings showed only minimal improvement. To our knowledge, the radiographic findings of nail sarcoidosis have not been previously addressed in the literature.

The Management of Sarcoidosis: A Primary Care Approach

Sarcoidosis is an idiopathic inflammatory disorder characterized by noncaseating granulomas, which can affect any organ system. The lungs are most commonly affected but extrapulmonary sites may cause the initial and/or sole symptoms. In this review, the disease manifestations and treatment are described, with particular emphasis on the management of each affected organ system. Diagnosis and management can be difficult and greatly affect quality of life, but despite these challenges, it is possible to successfully manage patients with sarcoidosis in the primary care setting.