Hypopigmented Cutaneous Sarcoidosis Responsive to Minocycline
March 2012 | Volume 11 | Issue 3 | Case Report | 385 | Copyright © 2012
Hypopigmented patches and plaques are a rare presentation of cutaneous sarcoidosis. We describe a case of generalized hypopigmented cutaneous sarcoidosis that showed good response to minocycline therapy.
J Drugs Dermatol. 2012;11(3):385-389.
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A 58-year-old African-American male with a past medical history of hypertension, diabetes mellitus, tobacco use, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and hyperlipidemia presented with a two-year history of asymptomatic light spots on his trunk and upper extremities. He reported a history of cutaneous sarcoidosis a decade prior, characterized by erythematous papules and plaques that had regressed with hydroxychloroquine therapy. The newer light patches were not responsive to mid-potency topical steroids or tacrolimus 0.1% ointment. Review of systems was negative. The patient denied any new medications or history of travel outside of the metropolitan area.
Physical examination of the skin was significant for multiple hypopigmented patches on the face, neck, and extremities; hypopigmented plaques on the back (Figure 1); and annular plaques of hypopigmented papules on the chest and abdomen (Figure 2). The lesions were not hypoesthetic. There was no lymphadenopathy and physical exam was otherwise unremarkable.
A biopsy from the left arm showed a superficial and deep multinodular granulomatous infiltrate sparing the epidermis (Figure 3). The granulomas were predominantly composed of epithelioid histiocytes with a few scattered lymphocytes (Figure 4). Special stains for microorganisms were negative. There was no appreciable epidermal change or pigment incontinence. The histopathological picture was consistent with recurrent cutaneous sarcoidosis.
Computed tomography of the chest with and without contrast showed no evidence of active pulmonary sarcoidosis or lymphadenopathy. An ophthalmologic exam, abdominal ultrasound, and spirometry were within normal limits, as were serum cal cium and angiotensin-converting enzyme (ACE) levels.
Because the patient's skin manifestations had resolved with hydroxychloroquine in the past, this treatment was restarted at 200 mg twice-daily. Unfortunately, laboratory monitoring revealed hepatic transaminitis and mild anemia 2 months into the treatment course, corresponding with only minimal improvement of the hypopigmented plaques, necessitating discontinuation of hydroxychloroquine. Minocycline at a dose of 100 mg twice daily was then initiated 4 months after normalization of liver function tests. After 5 months of treatment, all hypopigmented patches, papules, and plaques had completely or partially repigmented and were appreciably smoother and flatter (Figures 5 and 6). The patient tolerated the medication well with no adverse effects.
The skin is one of myriad organs potentially affected by sarcoidosis, a multisystem idiopathic disorder characterized histologically by infiltration of noncaseating granulomas. Cutaneous manifestations of sarcoidosis are protean, including papules and plaques of various morphology and distribution, subcutaneous nodules, pruritus, ichthyosis, erythroderma, ulceration, verrucosis, nail disease, and infiltrative scars.1 In the United States, sarcoidosis is more common in African-Americans than in other ethnic groups, and cutaneous manifestations in individuals of African descent are more likely to be atypical.2