INTRODUCTION
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.
DISCUSSION
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
