Dermatology Online Journal

Scar sarcoidosis sparing a surgical scar
Vandana Mehta MD DNB¹, C Balachandran MD¹, Mary Mathew MD²
Dermatology Online Journal 13 (3): 37

1. Department of Skin and STD, Kasturba Medical College, Manipal, India
2. Department of Pathology, Kasturba Medical College, Manipal

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Sarcoidosis is a chronic multisystem granulomatous disorder of unknown etiology. The development of sarcoidal granulomas in preexisting scars as a manifestation of cutaneous sarcoidosis is uncommon and clinicians unaware of the significance of this sign may dismiss it lightly. We describe a rare case of sarcoidal reactivation in a traffic accident scar with sparing of a post surgical scar and discuss its significance in the pathogenesis of this enigmatic disease.

A 43-year-old policeman presented to us with an increase in size of a scar on his right forehead of 4 months duration. He had sustained the original injury during a road traffic accident 12 years prior. The lesion was asymptomatic and the patient denied any history of fever, weight loss, exertional dyspnea, cough, or eye complaints. Cutaneous examination revealed a 7X4 cm hyperpigmented indurated plaque on the right side of the forehead extending beyond the dimensions of the original scar (Fig. 1). His 6-year old surgical scar on the right knee following an arthroscopic surgery was not affected. All the routine hematological and biochemical investigations such as hemogram, urinalysis, liver and renal function tests, serum calcium levels, and chest x-ray were normal. The ACE levels were elevated and the Mantoux test was positive. Biopsy for histopathology and reticulin stains showed features suggestive of sarcoidosis (Figs. 2-4).

Figure 1	Figure 2
Figure 1: Scar on the forehead Figure 2. Reticulin stains

Figure 3	Figure 4
Figure 3. Granulomas in the dermis (5 X) Figure 4. Close-up view of the granuloma (10 X)

Scar sarcoidosis, a common presentation among West Africans, was first described by Caesar Boec in 1899 [1]. It may either precede or accompany systemic sarcoidosis or may be a manifestation of a relapse [2]. It is especially uncommon in the absence of other cutaneous manifestations of sarcoidosis and takes the form of redness or reactivation of old cutaneous scars after a latent period of 6 months to 59 years. In our patient the scar was involved after a latent period of 12 years, well within the range described. Scars may be involved early in the course of the disease, long before lung parenchymal involvement occurs. However, isolated scar sarcoidosis is a benign disorder with a good prognosis. In addition to reactivation of scars from previous wounds, scar sarcoidosis has been reported at sites of healed herpes zoster [3], tattoos [4], venipuncture sites [5], ritual scarification [6], desensitization injections[7] and following cutaneous laser surgery [8]. The pathogenesis may be a hypersensitivity reaction similar to erythema nodosum[9]. Foreign body reaction is an important entity in the differential diagnosis. Although no foreign body was seen in the histopathology specimens, because this scar was the site of an injury in a road accident, a foreign body reaction cannot be completely ruled out.

The development of new nodules or plaques in a traumatic scar or venipuncture site may be an important clue to the diagnosis of sarcoidosis. In patients already suspected of having the disease these areas should not be overlooked as they could serve as an easy source of tissue for histopathological confirmation of the disease.

References

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2. Chudomirova K, Velichkova L, Anavi B. Recurrent sarcoidosis in skin scars accompanying systemic sarcoidosis. J Eur Acad Dermatol Venereol 2003;17:360-1.

3. Corazza M, Bacilieri S, Stuma R. post herpes zoster scar sarcoidosis. Acta Dermatol Venereol 1999;79:95.

4. Yesudian P, Azurdia RM. Scar sarcoidosis following tattooing of the lips successfully treated with mepacrine. Clin Exp Dermatol 2004;29:552-4.

5. Burgdorf WH, Hoxtell EO, Bart BJ. Sarcoid granulomas in venipuncture sites. Cutis 1979;24:52- 3.

6. Nayar M. Sarcoidosis on ritual scarification. Int J Dermatol 1993;32:116-118.

7. Healsmith MF, Hutchimson PE. The development of sarcoidosis at sites of desensitisation injections. Clin Exp Dermatol 1992; 17:367-9.

8. Kormeili T. Cutaneous sarcoidosis at sites of previous laser surgery. Cutis 2004;73:53-5.

9. Millet MS, Ziv R, Trau H. Sarcoidosis versus foreign body granulomas. Int J Dermatol 1987;26:582-5.

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