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research-article2015

CMSXXX10.1177/1203475415575016Journal of Cutaneous Medicine and SurgeryMorand et al

Case Report

Systemic Sarcoidosis Revealed by Axillary Electrolysis

Journal of Cutaneous Medicine and Surgery 2015, Vol. 19(4) 404­–406 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1203475415575016 jcms.sagepub.com

Meggie Morand1, Solange Beauregard2,3, and Steve Mathieu2

Abstract Background: Sarcoidosis is a noncaseating granulomatous disease that affects a large variety of organs and tissues. Skin sarcoidosis is commonly found in scar and tattooed tissues. Objective: To report this particular case of sarcoidosis following electrolysis hair removal. Method: We report the case of a woman who developed sarcoidosis years after axillary electrolysis hair removal. Results: The diagnosis of cutaneous sarcoidosis was suggested by the clinical manifestations and confirmed by histopathologic findings. Conclusion: Sarcoidosis should be considered during the investigation of skin lesions occurring in scar or traumatized tissue. Résumé Contexte : La sarcoïdose se caractérise par des granulomes non caséeux dans un ou plusieurs organes et tissus. La sarcoïdose cutanée apparaît habituellement dans le tissu cicatriciel ou sur la peau tatouée. Objectif : Rapporter ce cas particulier de sarcoïdose cutanée suite à une épilation par électrolyse. Méthodologie : Nous rapportons le cas d’une femme ayant développé une sarcoïdose cutanée des années après l’épilation des aisselles à l’électrolyse. Résultats : La sarcoïdose cutanée a été suspectée par les manifestations cliniques et confirmée par les résultats des examens histopathologiques. Conclusion : On devrait envisager le diagnostique de sarcoïdose cutanée lorsque des lésions cutanées apparaissent à l’intérieur de cicatrices ou des tissus traumatisés. Keywords dermatology, electrolysis hair removal, sarcoidosis, scar Cutaneous sarcoidosis is a skin disease that can be associated with systemic involvement. In literature, clear associations have been established between sarcoidosis and traumatized skin or scars. Around 30% of patients with cutaneous sarcoidosis mention having scar sarcoidosis.1 We report a case of cutaneous sarcoidosis that emerged on skin areas that were exposed to electrolysis hair removal treatments for several years.2

syringoma, sarcoidosis, atypical lichen sclerosis, lichen amyloidosis, follicular dyskeratosis, and postinflammatory hyperpigmentation. Two excisional 4-mm punch biopsies were taken from the lesions. The histopathology showed noncaseating granulomas without significant lymphatic invasion at the periphery (Figure 2). Grocott and Ziehl-Nielsen staining yielded negative results. Polarized light examination did not provide any

Case Report

1

A 35-year-old woman who smoked complained of axillary brownish lesions (Figure 1). She reported having electrolysis hair removal in that area for many years and developed lesions after her last treatment. She did not have a known disease and was not taking any medication. On physical examination, follicular brownish papules were noted. These lesions were distributed symmetrically bilaterally. The differential diagnosis included Fox-Fordyce disease,

Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Canada 2 Department of Medicine, Service of Dermatology, Hôpital St-Sacrement, CHU Laval, CHU Québec, Université Laval, Quebec, Canada 3 Department of Medicine, Service of Dermatology, CHU Sherbrooke, Université de Sherbrooke, Sherbrooke, Canada Corresponding Author: Meggie Morand, Faculté de Médecine et des Sciences de la Santé, CHU Sherbrooke, Clinique de Dermatologie, 3001 12e avenue Nord, J1H 5N4, Sherbrooke, QC, 25499, Canada. Email: [email protected]

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Figure 1.  Axillary follicular brownish papules.

Figure 2.  Hematoxylin and eosin–stained biopsy specimens showing naked granulomas.

supplementary clues. Results of bacterial, mycobacterial, and fungal cultures were negative. Taken together, these evidences led to the diagnosis of sarcoidosis. The pulmonary radiograph showed pulmonary interstitial infiltrate localized in the upper third portion of lungs. There were no hilar or mediastinal lymph nodes on that exam. Thoracic computer-assisted tomography demonstrated micronodular infiltration of superior lobes and few hilar lymph nodes. Those findings were compatible with a parenchymal pulmonary sarcoidosis, stage 2 or 3. The assessment of other parameters showed no abnormalities (complete blood count, c-reactive protein, liver transaminases, alkaline phosphatase, calcium, phosphorus, fasting blood glucose, thyroid stimulating hormone, angiotensin converting enzyme, urine analysis, and tuberculosis skin test). A respiratory function test was normal. Nevertheless, a treatment with oral inhalation of ciclesonide (Avesco) was initiated. An ophthalmologic examination was carried out. Dry eyes were diagnosed and treated with lubricating drops. Clobetasol propionate 0.05% (Dermovate) was used as topic treatment twice daily during 1 month and once daily for 1 other month. Papules regressed in macules.

infiltrated plaques, nodules, and scars. The cutaneous sarcoidosis has a tropism for scar tissue, tattoos, permanent makeup, and sites formerly or chronically traumatized.1,2,6 Follicular sarcoidosis has been described in a generalised distribution.7 Electrolysis involves the deliverance of an electric current to hair bulbs, which are subsequently destroyed. The process usually leaves a microscar. Some infections can be transmitted in such treatments, including impetigo, molluscum contagiosum, and herpes simplex virus.8 Our hypothesis is that our patient probably developed a follicular scar sarcoidosis due to electrolysis. Several cases of scar sarcoidosis have been reported in old sites of venipuncture, acne, skin piercings, surgical scars, pseudofolliculitis, herpes, shingles, and hyaluronic acid injection. The knees are a common location due to frequent trauma. Old scars often become purplish and infiltrated. Lesions may be asymptomatic, sensitive, or itchy.1,9-12 Patients with scar sarcoidosis have more often associated systemic manifestations. Skin lesions can be correlated with disease progression.13

Discussion Sarcoidosis is a noncaseating granulomatous disease also known as the “great imitator” due to its multiple clinical manifestations.2,3 The etiology of sarcoidosis remains unclear. Microbiologic, genetic, and environmental factors seem to be involved in the pathogenesis. Genetic predispositions appear to activate immune reactions directed toward antigens.4 Further studies are needed to clarify the pathogenesis of sarcoidosis.2,5

Clinical Features Specific lesions commonly found in sarcoidosis include sarcoidal granulomas, lupus pernio, macules, papules, ­

Diagnosis Diagnostic is suggested by the histopathologic examination of skin biopsies. According to Haimovic et al, a thorough workup is recommended in patients with suspected or diagnosed cutaneous sarcoidosis and should include the following: detailed history of symptoms and environmental exposure, complete physical examination, chest radiography, pulmonary function tests, electrocardiogram, cardiac ultrasound, renal and liver function tests, complete blood count, calcium, urine analysis for nephrolithiasis, ophthalmic examination, and tuberculin skin test or interferon release assay.14

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Management

References

Cutaneous sarcoidosis should be treated when it is symptomatic or cosmetically unacceptable for the patient. Indeed, lesions may undergo spontaneous regression or remain stable. Topical or intralesional corticosteroids are considered first-line treatment for mild disease. Oral corticosteroids can be used in refractory cases. Systemic anti-inflammatory or immunosuppressive agents may be administered alone or in combination with the topic treatment. Tumor necrosis factor inhibitors can be useful in some cases.1,2

1. Marchell RM, Judson MA. Chronic cutaneous lesions of sarcoidosis. Clin Dermatol. 2007;25:295-302. 2. Haimovic A, Sanchez M, Judson MA, Prystowsky S. Sarcoidosis: a comprehensive review and update for the dermatologist. Part I: cutaneous disease. J Am Acad Dermatol. 2012;66:699. 3. English JC 3rd, Patel PJ, Greer KE. Sarcoidosis. J Am Acad Dermatol. 2001;44:725-743. 4. Newman LS, Rose CS, Bresnitz EA, et al. A case control etiologic study of sarcoidosis: environmental and occupational risk factors. Am J Respir Crit Care Med. 2004;170:1324-1330. 5. Lodha S, Sanchez M, Prystowsky S. Sarcoidosis of the skin: a review for the pulmonologist. Chest. 2009;136:583-96. 6. Yanardag H, Pamuk ON, Karayel T. Cutaneous involvement in sarcoidosis: analysis of the features in 170 patients. Respir Med. 2003;97:978-982. 7. Fujii K, Okamoto H, Onuki M, Horio T. Recurrent follicular and lichenoid papules of sarcoidosis. Eur J Dermatol. 2000;10:303-305. 8. Wanitphakdeedecha R, Alster TS. Physical means of treating unwanted hair. Dermatol Ther. 2008;21:392-401. 9. Singal A, Thami GP. Localization of cutaneous sarcoidosis: from trauma to scars. J Am Acad Dermatol. 2004;51:841-842. 10. Sorabjee JS, Garje R. Reactivation of old scars: inevitably sarcoid. Postgrad Med J. 2005;81:60-61. 11. Cecchi R, Giomi A. Scar sarcoidosis following herpes zoster. J Eur Acad Dermatol Venereol. 1999;12:280-282. 12. Dai Sacco D, Cozzani E, Parodi A, Rebora A. Scar sarcoidosis after hyaluronic acid injection. Int J Dermatol. 2005;44: 411-412. 13. Chudomirova K, Velichkova L, Anavi B, Arnaudova M. Recurrent sarcoidosis in skin scars accompanying systemic sarcoidosis. J Eur Acad Dermatol Venereol. 2003;17:360-361. 14. Haimovic A, Sanchez M, Judson MA, Prystowsky S. Sarcoidosis: a comprehensive review and update for the dermatologist. Part II: extracutaneous disease. J Am Acad Dermatol. 2012;66:719.

Conclusion This case brought out the importance of including sarcoidosis in the differential diagnosis of skin lesions emerging in areas that have been exposed to various insults. This case report suggests that this disease can arise from skin that has received electrolysis hair removal treatments, which could also be called Koebner or pathergy phenomenon. Sarcoidosis is a great imitator that gives a huge variety of skin manifestations; therefore, it remains a disease challenging to diagnose. Its early diagnosis is particularly important since it may unravel systemic involvement that needs specific treatments. In about one-third of cases of sarcoidosis, skin lesions are the first manifestation.14 Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.