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Australasian Journal of Dermatology (2015) ••, ••–••
doi: 10.1111/ajd.12328
BRIEF REPORT
Sarcoidosis presenting as non-scarring non-scalp alopecia Luke Dan1 and John Relic2 1
Network 6 NSW Health, and 2Royal Newcastle Centre and Lake Macquarie Dermatology Private Practice, Newcastle, New South Wales, Australia
ABSTRACT In this article we describe a 39-year-old man who presented with non-scarring non-scalp alopecia of his limbs as the initial presentation of sarcoidosis. Alopecia is a rare cutaneous manifestation of sarcoidosis. A literature review has found only one other example of sarcoidosis presenting as non-scarring non-scalp alopecia in an area other than the scalp in a patient who was otherwise asymptomatic. Several reported cases have described scarring alopecia of the scalp, which is the area of skin most commonly affected by sarcoidosis. There has been one documented case of sarcoidosis manifesting as total body non-scarring alopecia in a patient who had systemic symptoms of sarcoidosis. Other cases have presented rare cutaneous manifestations of sarcoidosis but in all these cases several other organ systems have been involved, and the patient has had systemic symptoms on presentation or the cutaneous presentation did not include non-scalp non-scarring alopecia. Key words: alopecia, sarcoidosis.
races and all ages, but is most common in those aged 20–40 years, and it affects both men and women.2
CASE REPORT A 39-year-old man presented with a 12-month history of isolated areas of localised alopecia involving the dorsal surfaces of all four limbs (Figs 1,2). No obvious clinical scarring in the areas of alopecia was noted. Several exclamation mark-like hairs and normal hairs were noted on examination in the affected areas, together with folliculocentric scaling. There was no history of infection, trauma or drug use. The physical examination of the patient was normal and he was otherwise asymptomatic on presentation. The histopathology from punch biopsies of the affected areas revealed tight, discrete, epithelioid non-caseating granulomas in the dermis and the superficial subcutaneous tissue, centred on hair follicles and sweat glands. This result is consistent with sarcoidosis.1 The histopathology from punch biopsies is shown in Figures 3 and 4. The chest X-ray revealed bilateral hilar lymphadenopathy. Routine laboratory data, including full blood count, liver function tests, electrolytes urea and creatinine, iron studies, hepatitis B and C viral serology, serum protein electrophoresis, serum protein immunofixation, anti nuclear
INTRODUCTION We present a case of non-scarring non-scalp alopecia due to sarcoidosis. Alopecia is a rare manifestation of sarcoidosis in the skin. Alopecia associated with sarcoidosis is usually scarring and affects the scalp.1 Sarcoidosis is a systemic inflammatory disorder of unknown origin that affects all
Correspondence: Dr Luke Dan, Network 6, NSW Health, 1A Curry Street, Newcastle, NSW 2291, Australia. Email: [email protected] Luke Dan, MBBS. John Relic, FACD. Conflict of interest: None Submitted 6 October 2014; accepted 16 February 2015. © 2015 The Australasian College of Dermatologists
Figure 1 left arm.
Dorsal forearm alopecia and exclamation mark hairs on
2
L Dan and J Relic
Figure 2 Mix of alopecia and some exclamation mark hairs on the right lower leg.
Figure 3 Punch biopsy from an area of alopecia revealing noncaseating granulomas that are diagnostic of sarcoidosis.
antibodies, urine analysis, antibodies to extractable nuclear antigen, cardiolipin and beta2 glycoprotein immunoglobulin G antibodies and lymphoid subsets were all normal or negative. The only remarkable laboratory finding was that the patient’s angiotensin converting enzyme (ACE) level was elevated 73 U/L. Pulmonary function testing with spirometry revealed normal lung function. An ophthalmological examination of the patient was unremarkable.
Figure 4 Punch biopsy from an area of alopecia revealing noncaseating granulomas that are diagnostic of sarcoidosis.
diagnosis of alopecia areata. However, the presence of folliculocentric scaling is not typical of alopecia areata. The patient’s elevated ACE levels, bilateral hilar lymphadenopathy and the presence of non-caseating granulomas on punch biopsy support a diagnosis of sarcoidosis in this case. With the exception of the hilar lymphadenopathy illustrated on chest X-ray there was no evidence of other organ involvement. Alopecia due to sarcoidosis usually affects the scalp and is predominantly a scarring alopecia.3 We could find only one other case of non-scarring non-scalp alopecia on a literature review. This case involved a South African patient who had non-scarring alopecia confined to his lower limbs.4 A presentation such as this could be potentially misdiagnosed as alopecia areata, mucinosis follicularis or lupus erythematosus. Our patient did not receive treatment for his pulmonary disease as he was asymptomatic at the time of diagnosis. His areas of alopecia are improving without treatment.
REFERENCES 1. 2. 3.
DISCUSSION The clinical non-scarring nature of the patient’s alopecia and the presence of exclamation-like hairs suggested a
© 2015 The Australasian College of Dermatologists
4.
House NS, Welsh JP, English JC et al. Sarcoidosis induced alopecia. Dermatol. Online J. 2012; 18: 4. Greer KE, Harman LE, Kayne AL. Unusual cutaneous manifestations of sarcoidosis. South. Med. J. 1977; 70: 666–8. Wolff K, Johnson RA. Part two dermatology and internal medicine. In: Wolff K, Johnson RA, Suurmond R. (eds.). Color Atlas and Synopsis of Clinical Dermatology, 5th edn. New York: McGraw-Hill, 2005; 428–31. Rapp SE. An unusual cause of hair loss. Arch. Dermatol. 2002; 138: 259–64.
Australasian Journal of Dermatology (2015) ••, ••–••
doi: 10.1111/ajd.12328
BRIEF REPORT
Sarcoidosis presenting as non-scarring non-scalp alopecia Luke Dan1 and John Relic2 1
Network 6 NSW Health, and 2Royal Newcastle Centre and Lake Macquarie Dermatology Private Practice, Newcastle, New South Wales, Australia
ABSTRACT In this article we describe a 39-year-old man who presented with non-scarring non-scalp alopecia of his limbs as the initial presentation of sarcoidosis. Alopecia is a rare cutaneous manifestation of sarcoidosis. A literature review has found only one other example of sarcoidosis presenting as non-scarring non-scalp alopecia in an area other than the scalp in a patient who was otherwise asymptomatic. Several reported cases have described scarring alopecia of the scalp, which is the area of skin most commonly affected by sarcoidosis. There has been one documented case of sarcoidosis manifesting as total body non-scarring alopecia in a patient who had systemic symptoms of sarcoidosis. Other cases have presented rare cutaneous manifestations of sarcoidosis but in all these cases several other organ systems have been involved, and the patient has had systemic symptoms on presentation or the cutaneous presentation did not include non-scalp non-scarring alopecia. Key words: alopecia, sarcoidosis.
races and all ages, but is most common in those aged 20–40 years, and it affects both men and women.2
CASE REPORT A 39-year-old man presented with a 12-month history of isolated areas of localised alopecia involving the dorsal surfaces of all four limbs (Figs 1,2). No obvious clinical scarring in the areas of alopecia was noted. Several exclamation mark-like hairs and normal hairs were noted on examination in the affected areas, together with folliculocentric scaling. There was no history of infection, trauma or drug use. The physical examination of the patient was normal and he was otherwise asymptomatic on presentation. The histopathology from punch biopsies of the affected areas revealed tight, discrete, epithelioid non-caseating granulomas in the dermis and the superficial subcutaneous tissue, centred on hair follicles and sweat glands. This result is consistent with sarcoidosis.1 The histopathology from punch biopsies is shown in Figures 3 and 4. The chest X-ray revealed bilateral hilar lymphadenopathy. Routine laboratory data, including full blood count, liver function tests, electrolytes urea and creatinine, iron studies, hepatitis B and C viral serology, serum protein electrophoresis, serum protein immunofixation, anti nuclear
INTRODUCTION We present a case of non-scarring non-scalp alopecia due to sarcoidosis. Alopecia is a rare manifestation of sarcoidosis in the skin. Alopecia associated with sarcoidosis is usually scarring and affects the scalp.1 Sarcoidosis is a systemic inflammatory disorder of unknown origin that affects all
Correspondence: Dr Luke Dan, Network 6, NSW Health, 1A Curry Street, Newcastle, NSW 2291, Australia. Email: [email protected] Luke Dan, MBBS. John Relic, FACD. Conflict of interest: None Submitted 6 October 2014; accepted 16 February 2015. © 2015 The Australasian College of Dermatologists
Figure 1 left arm.
Dorsal forearm alopecia and exclamation mark hairs on
2
L Dan and J Relic
Figure 2 Mix of alopecia and some exclamation mark hairs on the right lower leg.
Figure 3 Punch biopsy from an area of alopecia revealing noncaseating granulomas that are diagnostic of sarcoidosis.
antibodies, urine analysis, antibodies to extractable nuclear antigen, cardiolipin and beta2 glycoprotein immunoglobulin G antibodies and lymphoid subsets were all normal or negative. The only remarkable laboratory finding was that the patient’s angiotensin converting enzyme (ACE) level was elevated 73 U/L. Pulmonary function testing with spirometry revealed normal lung function. An ophthalmological examination of the patient was unremarkable.
Figure 4 Punch biopsy from an area of alopecia revealing noncaseating granulomas that are diagnostic of sarcoidosis.
diagnosis of alopecia areata. However, the presence of folliculocentric scaling is not typical of alopecia areata. The patient’s elevated ACE levels, bilateral hilar lymphadenopathy and the presence of non-caseating granulomas on punch biopsy support a diagnosis of sarcoidosis in this case. With the exception of the hilar lymphadenopathy illustrated on chest X-ray there was no evidence of other organ involvement. Alopecia due to sarcoidosis usually affects the scalp and is predominantly a scarring alopecia.3 We could find only one other case of non-scarring non-scalp alopecia on a literature review. This case involved a South African patient who had non-scarring alopecia confined to his lower limbs.4 A presentation such as this could be potentially misdiagnosed as alopecia areata, mucinosis follicularis or lupus erythematosus. Our patient did not receive treatment for his pulmonary disease as he was asymptomatic at the time of diagnosis. His areas of alopecia are improving without treatment.
REFERENCES 1. 2. 3.
DISCUSSION The clinical non-scarring nature of the patient’s alopecia and the presence of exclamation-like hairs suggested a
© 2015 The Australasian College of Dermatologists
4.
House NS, Welsh JP, English JC et al. Sarcoidosis induced alopecia. Dermatol. Online J. 2012; 18: 4. Greer KE, Harman LE, Kayne AL. Unusual cutaneous manifestations of sarcoidosis. South. Med. J. 1977; 70: 666–8. Wolff K, Johnson RA. Part two dermatology and internal medicine. In: Wolff K, Johnson RA, Suurmond R. (eds.). Color Atlas and Synopsis of Clinical Dermatology, 5th edn. New York: McGraw-Hill, 2005; 428–31. Rapp SE. An unusual cause of hair loss. Arch. Dermatol. 2002; 138: 259–64.
