nodosum is the most common nonspecific skin finding in patients. However, it can have other causes such as fungal and bacterial infections, leprosy, and inflammatory bowel disease.
Differential diagnoses: Erysipelas, Thrombophlebitis, Nodular Vasculitis.
Lofgren Syndrome
Lofgren syndrome includes erythema nodosum in addition to bilateral hilar lymphadenopathy, symmetric polyarthralgia, anterior uveitis, and fever. It predominantly affects patients of African, Puerto Rican, and Scandinavian descent and has a favorable prognosis with resolution of all symptoms within 2 years of the initial diagnosis.6
Differential diagnoses: Infectious (Coccidioidomycosis, Histo-plasmosis, Tuberculosis), Inflammatory bowel disease.
Dermatologic Manifestations in Skin of Color
Sarcoidosis is a multisystemic disease and cutaneous manifestations occur in approximately 25% of cases, with some patients only manifesting cutaneous symptoms.6 Sarcoidosis affects all races, but in the United States, African Americans have a higher prevalence of disease.6 Additionally, due to the variety of skin manifestations, African American patients are more likely to be diagnosed when they are already in an advanced stage of the disease.2 Factors influencing poorer prognosis in African Americans include access to healthcare, income, and level of education.2 African American patients present earlier in life with more advanced disease, and have higher rates of hospitalization and higher rates of mortality.1 These trends all lead to a poorer prognosis for African American patients with sarcoidosis.6
Treatment
The majority of cutaneous manifestations associated with sarcoidosis resolve without treatment. The prognosis of the disease is determined by the systemic symptoms and cannot be determined by the skin manifestations alone.6 While the dermatologic changes are not an indication of disease severity, they can help clinicians diagnose and treat the disease earlier. Since sarcoidosis cannot be cured, treatment is based on providing symptomatic relief and preventing disease progression.
First-line agents used for cutaneous sarcoidosis are corticosteroids, which work by inhibiting the inflammatory response in the production of non-caseating granulomas.6 If the cutaneous sarcoidosis is localized to a distinct area on the skin, then topical treatments such as clobetasol may be used. If the skin lesions include plaques and papules, then injections of triamcinolone every 4 weeks may be more effective.6 If the cutaneous sarcoidosis does not respond to initial topical corticosteroid treatment, there is extensive skin involvement, or there is a potential for scarring, then systemic corticosteroids such as prednisone are employed.6
Antimalarials such as chloroquine and hydroxychloroquine may also be used for cutaneous sarcoidosis and work similarly to prevent granuloma formation.6 Second-line treatments include immunosuppressive therapies such as methotrexate and cyclosporine. Additional options for refractory cutaneous sarcoidosis are monoclonal antibodies (infliximab), thalidomide, and isotretinoin.6
First-line agents used for cutaneous sarcoidosis are corticosteroids, which work by inhibiting the inflammatory response in the production of non-caseating granulomas.6 If the cutaneous sarcoidosis is localized to a distinct area on the skin, then topical treatments such as clobetasol may be used. If the skin lesions include plaques and papules, then injections of triamcinolone every 4 weeks may be more effective.6 If the cutaneous sarcoidosis does not respond to initial topical corticosteroid treatment, there is extensive skin involvement, or there is a potential for scarring, then systemic corticosteroids such as prednisone are employed.6
Antimalarials such as chloroquine and hydroxychloroquine may also be used for cutaneous sarcoidosis and work similarly to prevent granuloma formation.6 Second-line treatments include immunosuppressive therapies such as methotrexate and cyclosporine. Additional options for refractory cutaneous sarcoidosis are monoclonal antibodies (infliximab), thalidomide, and isotretinoin.6
Conclusions
Cutaneous sarcoidosis can present in multiple forms and locations on the body. While the cutaneous manifestations may not be an indication of the severity of the disease, they can be an important clue for the prompt diagnosis of sarcoidosis. African American females are disproportionately affected by sarcoidosis. These populations are more likely to not only develop the disease but also have higher rates of hospitalization and worse outcomes. Given these higher incidence rates, it is critical to recognize the potential cutaneous manifestations that can be seen in African American patients.
Disclosures
The authors have no conflicts of interest to declare.
REFERENCES
- Hena KM. Sarcoidosis epidemiology: race matters. Front Immunol. 2020;11. Doi: https://doi.org/10.3389/fimmu.2020.537382.
- Heath CR, David J, Taylor SC. Sarcoidosis: are there differences in your skin of color patients? JAAD. 2012;66(1):121.e1-121.e14. Doi: https://doi.org/10.1016/j. jaad.2010.06.068.
- Hunt RD, Gonzalez ME, Robinson M, et al. Ulcerative sarcoidosis. Dermatol Online J. 2012;18(12). Doi:https://doi.org/10.5070/d31mw632hh.
- Wanat KA, Rosenbach M. Cutaneous sarcoidosis. Clin Chest Med. 2015;36(4):685-702. Doi: https://doi.org/10.1016/j.ccm.2015.08.010.
- Katta R. Cutaneous sarcoidosis: a dermatologic masquerader. Am Fam Phys. 2002;65(8):1581-1584.
- Taylor SC, A. Paul Kelly, Lim H, et al. Taylor and Kelly’s Dermatology for Skin of Color 2/E. New York: McGraw Hill Professional. 2016.
- Koneti J, Cherukuri SP, Gadde S, et al. Sarcoidosis and its dermatological manifestations: a narrative review. Cureus. 2022:14(8):e28053. Doi: https://doi. org/10.7759/cureus.28053.
- UpToDate. Cutaneous manifestations of sarcoidosis. Available at: https://www. uptodate.com/contents/cutaneous-manifestations-of-sarcoidosis?search=c utaneous+sarcoidosis&source=search_result&selectedTitle=1~46&usage_ type=default&display_rank=1#H797125. Accessed May 27, 2022.
- Redissi A, Penmetsa GK, Litaiem N. Lupus Pernio. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK536968/. Accessed May 27, 2022.
- Seve P, Pacheco Y, Durupt F, et al. Sarcoidosis: a clinical overview from symptoms to diagnosis. Cells. 2021;10(4):766.
- Soto-Gomez N, Peters JI, Nambiar AM. diagnosis and management of sarcoidosis. Am Fam Phys. 2016;93(10):840-848.
AUTHOR CORRESPONDENCE
Jessica Williams MS jessica.williams1@bison.howard.edu
