S126 Letters J AM ACAD DERMATOL

NOVEMBER 2008

Scalp sarcoidosis with systemic involvement

To the Editor: Cutaneous sarcoidosis is not uncom-
mon, and the skin can be the first and only area
affected.1-5 On the other hand, permanent alopecia
caused by sarcoidosis is rare and is usually charac-
terized by a few patches of cicatricial alopecia
resembling discoid lupus erythematosus.1
We report a case of extensive cicatricial alopecia
with systemic involvement caused by sarcoidosis in a
45-year-old Italian female.
Alopecia involved the scalp almost entirely,
extending from the frontal hairline to the vertex Fig 1. Red scaly patches of the forehead, left temple, and
and both parietal areas. The scalp was diffusely auricle.
shiny and atrophic, with areas of hyper- and
hypopigmentation. No signs of active inflammation
were present. A few tufted hairs were irregularly
distributed on the frontal and occipital hairline. The
patient revealed that she had been affected by
hair loss for more than 15 years, but she had never
previously received any specific treatment.
Moreover, a few slightly atrophic, scaly red-brown
papules and plaques had recently appeared on the
forehead, temples, and ears, and this finally promp-
ted her to seek medical advice.
Her medical history revealed that the patient had
been under treatment with systemic steroids for
pulmonary sarcoidosis for 5 years. Her therapy at
the time was deltacortene 5 mg every other day. Fig 2. Horizontal sections. Nodular, granulomatous der-
A 4-mm punch biopsy and a 0.6 3 0.4 cm matitis. Collections of epithelioid histiocytes, some multi-
longitudinal biopsy from an involved area of the nucleate, aligned in a palisade around foci of degenerated
scalp, for vertical and horizontal sections, respec- collagen and necrosis of inflammatory cells, surrounded
tively, led to the diagnosis of sarcoidosis (Figs by numerous lymphocytes at infundibular, isthmus level
of hair follicle in the dermis. (Hematoxylin-eosin stain;
1 and 2).
original magnification: 310.)
Therapy with hydroxychloroquine (200 mg twice
a day) and clobetasol ointment was started and the
patient was followed every 6 weeks for 12 months. involved most of the scalp with a clinical picture
After 1 year, the alopecia was without signs of that closely resembled lichen planopilaris.
progression, and the facial lesions had considerably A review of the literature also reveals that scalp
improved. sarcoidosis is quite often associated with systemic
The scalp is rarely affected in sarcoidosis and the involvement.2 Despite limited clinical data, this in-
diagnosis may be very difficult if other cutaneous or dicates that a careful work-up is needed when scalp
extracutaneous sites are not involved. Alopecia may sarcoidosis is diagnosed. Our case demonstrates that
start with an atrophic patch, sometimes with redness a very long period of time may elapse between the
and scaling, usually within a localized area. It often cutaneous and extracutaneous symptoms. It is likely
presents as a scarring alopecia that clinically resem- that a prompt initiation of therapy may have led to a
bles discoid lupus erythematosus or lichen different disease course.
planopilaris. Histologically, tubercoloid granulomas, charac-
Reviewing the English language literature, fewer terized by collections of epithelioid histiocytes
than 30 cases of scalp sarcoidosis have been surrounded by a moderately dense infı̀ltrate of
reported, mostly involving African American female lymphocytes, may be seen in not only lupus vulgaris
patients with systemic involvement.1,2 and tubercoloid leprosy, but also in sarcoidosis.6
Our case is unusual because the patient had been Therapeutic options for scalp sarcoidosis are
suffering from hair loss for more than 10 years before not satisfactory.1-3 Steroids, both systemic and intra-
the systemic disease and the cicatricial alopecia lesional, other immunosuppressive drugs, and
J AM ACAD DERMATOL Letters S127
VOLUME 59, NUMBER 5

antimalarials must be considered. We used hydroxy-

chloroquine and obtained relatively good results in
terms of remission of the facial lesions.
Michelangelo La Placa, MD, Colombina Vincenzi,
MD, Cosimo Misciali, MD, and Antonella Tosti,
MD
Department of Clinical and Experimental Medi-
cine, Dermatology Section, University of Bolo-
gna, Bologna, Italy
Funding sources: None.
Fig 1. Multiple discrete erythematous macules and
Conflicts of interest: None declared. papules, some with central vesicles, on the palmar creases
Correspondence to: Michelangelo La Placa, MD, and insteps.
Department of Clinical and Experimental Med-
icine, Dermatology Section, University of Bolo-
gna, Via Massarenti 1, 40138 Bologna, Italy
E-mail: michelangelo.laplaca@unibo.it

REFERENCES
1. Henderson CL, Lafleur L, Sontheimer RD. Sarcoidal alopecia as a
mimic of discoid lupus erythematosus. J Am Acad Dermatol
2008;59:143-5.
2. Katta R, Nelson B, Chen D, Roenigk H. Sarcoidosis of the scalp: a
case series and review of the literature. J Am Acad Dermatol
2000;42:690-2.
3. Harman KE, Calonje E, Robson A, Black MM. Sarcoidosis
presenting as a scarring alopecia resembling necrobiosis lip-
oidica. Clin Exp Dermatol 2003;28:565-6.
4. Akhdari N, Skalli HD, Lakhdar H. Erythematous lesions on the
scalp. Sarcoidosis. Arch Dermatol 2004;140:1003-8.
5. Cho HR, Shah A, Hadi S. Systemic sarcoidosis presenting with
alopecia of the scalp. Int J Dermatol 2004;43:520-2.
6. Ball NJ, Kho GT, Martinka M. The histologic spectrum of
cutaneous sarcoidosis: a study of twenty-eight cases. J Cutan
Pathol 2004;31:160-8.
doi:10.1016/j.jaad.2008.07.041
Erythema multiformeelike presentation of
chronic graft versus host disease
To the Editor: A 53-year-old male with a history of
multiple myeloma presented 6 months after an
autologous stem cell transplant followed by an
human leukocyte antigenematched allogeneic stem
cell transplant with small, diffuse, erythematous
confluent papules on his arms, legs, and trunk in
addition to several oral mucosal erosions. The diag-
nosis of chronic graft versus host disease (GVHD)
was made, and the patient was started on a slow
prednisone taper, which led to complete resolution.
One year later, he presented with a 4-month history of
acute onset tender, erythematous papules and vesi-
cles localized to the palmar creases and insteps. The
lesions had remained unchanged in number and size
Fig 2. Biopsy specimen from a representative papule
shows vacuolization of the basal layer, scant papillary
dermal lymphocytic infiltrate, and individual necrotic
keratinocytes with apposition of lymphocytes. (Hematox-
ylineeosin stain; original magnification: 340.)
but were becoming increasingly painful. Physical
examination revealed numerous 2- to 6-mm discrete
erythematous macules and papules, many of which
had a central vesicle and variable scale. They were
confined to the palmar creases and insteps, with only
a few random vesicles present on the fingertips. Many
appeared targetoid because of an erythematous halo
surrounding a central vesicle (Fig 1). Inspection of
the mouth revealed several palatal erosions. Punch
biopsy specimens were obtained from the patient’s
right hand and left foot. Histopathologic analysis
revealed individual necrotic keratinocytes with ap-
position of lymphocytes (‘‘satellite cell necrosis’’) in
the basal and mid spinous layers of the epidermis and
basal cell vacuolization and a scant papillary dermal
lymphocytic infiltrate (Fig 2).
A diagnosis of chronic GVHD was made, and the
patient was started on a slow prednisone taper and
tacrolimus ointment with some improvement. Later,
narrow band ultraviolet B light phototherapy fol-
lowed by 3 months of extracorporeal photophoresis