Scarring alopecia of the scalp from sarcoidosis: A case report

Laura F. Sandoval1, D.O., Jonathan S. Crane2,3, D.O. 1Sampson Regional Medical Center, Dermatology Resident, PGY-3, Clinton, NC, 2Sampson Regional Medical Center, Dermatology Residency Program Director, Clinton, NC, 3DermOne, Wilmington, NC

Disclosures: Drs. Sandoval and Crane have no conflicts to disclose. D E Introduction Discussion

 Sarcoidosis is a systemic disease that can involve the skin in 25% of  We report a case of sarcoidosis presenting as severe scarring alopecia. patients, however, cutaneous sarcoidosis of the scalp is uncommon.1  Scarring alopecia of the scalp from sarcoidosis is rare and usually  A 2012 review of literature identified 39 cases of sarcoidosis presents as a few patches of hair loss resembling discoid lupus . induced alopecia, which included both scarring and non-scarring erythematosus, however, rarely is diffuse scarring alopecia reported.3,6 cases.2  A review of literature showed that sarcoidosis of the scalp is  Cutaneous sarcoidosis has been referred to as the great imitator of predominately in females and African Americans and is often associated other skin diseases and is often a diagnosis of exclusion. Sarcoidosis with systemic involvement.2,7 Therefore, a diagnosis of cutaneous alopecia similarly has been mistaken for discoid lupus erythematosus or sarcoidosis of the scalp alone warrants a work-up for systemic disease. other scarring alopecia, as well as, necrobiosis lipoidica.3-5 Infectious Patients should also have a full skin exam since involvement of other causes of granulomas on histopathology must also be ruled out. skin sites are usually present with sarcoidosis of the scalp.2,7 In our patient cutaneous sarcoidosis was limited to the scalp. Figures D, E, and F: F Histopathology: punch biopsy Case  Sarcoidosis of the scalp can be difficult to treatment. Treatment options include: topical, oral, and intralesional corticosteroids, of the scalp, (D) on low power  A 51 year-old African American female presented for evaluation of immunosuppressive agents such as azathioprine and methotrexate, and showing complete loss of hair “infection of the scalp”. She had previously been treated with cephalexin hydroxychloroquine, with oral prednisone most frequently providing follicles, replaced by dermal and topical mupirocin without significant improvement. 2,6-9 improvement. While treatment may successfully halt progression of fibrosis and the presence of  On physical exam, there was alopecia of the entire scalp, except for a disease, if may not result in hair regrowth. multiple epithelioid few areas of thin patchy hair, and loss of follicular openings.(Figure A) There were large hypertrophic plaques and areas of superficial erosions granulomas in the superficial overlying a smooth, shiny, hypopigmented patch covering the left side of and deep dermis. (E) Giant the scalp.(Figures B & C) There were also scattered small cell within a naked granuloma. hyperpigmented papules and plaques on the remainder of the scalp. (F) Granuloma adjacent to an  On further history, patient stated she had a long history of hair loss, not A B uninvolved nerve, previously worked-up. The current lesions (“infection”) had been present differentiating sarcoidosis for approximately 2 years, gradually worsening. She also had a past from tuberculoid leprosy. diagnosis of systemic sarcoidosis with pulmonary involvement, but she . had not received medical care for many years. In addition, she had a recent diagnosis of breast carcinoma. References  A 4-mm punch biopsy was obtained from the left parietal scalp. Differential diagnosis included: discoid lupus erythematosus, 1. Newman LS, Rose CS, Maier LA. Sarcoidosis. N Engl J Med sarcoidosis, lichen planopilaris, however a secondary infection (fungal 1997;336:1224-1234. or bacterial) or malignancy such as squamous cell carcinoma were also 2. House NS, Welsh JP, English JC, III. Sarcoidosis-induced considered. alopecia. Dermatol Online J 2012;18:4. 3. Henderson CL, Lafleur L, Sontheimer RD. Sarcoidal alopecia  Histopathology showed no hair follicles, the dermis replaced by fibrosis, as a mimic of discoid lupus erythematosus. J Am Acad Dermatol and the presence of multiple epithelioid granulomas.(Figures D & E) C 2008;59:143-145. The findings were consistent with a scarring alopecia due to 4. Harman KE, Calonje E, Robson A, Black MM. Case 1. granulomatous inflammation consistent with sarcoidosis. Sarcoidosis presenting as a scarring alopecia resembling  Pending pathology results, the patient was started on topical clobetasol Figures A, B, and C: Clinical presentation necrosis lipoidica. Clin Exp Dermatol 2003;28:565-566. ointment, with significant improvement after one month. Given the of scarring alopecia of the scalp from 5. Andersen KE. Systemic sarcoidosis with necrobiosis lipoidica- like scalp lesions. Acta Derm Venereol 1977;57:367-369. severity of disease, systemic treatment was recommended. After sarcoidosis. discussion with the patients’ oncologist, it was decided that prednisone 6. La PM, Vincenzi C, Misciali C, Tosti A. Scalp sarcoidosis with would be initiated. Once her cancer treatment was complete, the plan systemic involvement. J Am Acad Dermatol 2008;59:S126-S127. was to switch to hydroxychloroquine or methotrexate, however patient 7. Katta R, Nelson B, Chen D, Roenigk H. Sarcoidosis of the was lost to follow-up. scalp: a case series and review of the literature. J Am Acad Dermatol 2000;42:690-692. 8. Golitz LE, Shapiro L, Hurwitz E, Stritzler R. Cicatricial alopecia of sarcoidosis. Arch Dermatol 1973;107:758-760. 9. Smith SR, Kendall MJ, Kondratowicz GM. Sarcoidosis--a cause of steroid responsive total alopecia. Postgrad Med J 1986;62:205-207.