Dermatology Online Journal

Scar sarcoidosis with a 50-year interval between an accident and onset of lesions
Hiram Larangeira de Almeida Jr^1,2, Roberto Coswig Fiss¹
Dermatology Online Journal 14 (11): 18

1. Federal University of Pelotas
2. Catholic University of Pelotas. hiramalmeidajr@hotmail.com

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Abstract

Cutaneous sarcoidosis has been reported to develop in scars. We report an unusual case of sarcoidal granuloma formation in scars that had been present for 50 years.

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Introduction

The onset of sarcoidosis in old scars is a well-known isotopic phenomenon; it can be restricted to the skin [1, 2] or be a manifestation of systemic sarcoidosis [3]. Scar sarcoidosis has been described in many countries and was reported in scars of accidents [2], herpes zoster [1], desensitization injections [4], and pseudofolliculitis barbae [5], among many others; pediatric cases are also reported [6].

Case Report

An otherwise healthy 75-year-old woman, claimed that several old scars had changed their appearance in the last two years. On her face old scars became infiltrated and she noted also that some scratches on her buttocks had become raised. These scars were produced after a fall from a horse at the age of 23. Some of the prior injuries on her face were sutured, but the scratches on her buttocks were superficial and sutures were not necessary. The new lesions were treated with topical steroids without response.

Figure 1	Figure 2
Figure 1. Infiltration of scars on the face Figure 2. Apple-jelly appearance of old scratches on the buttocks

Figure 3
Figure 3. Nude granuloma in the dermis (H&E x400)

Skin examination showed elevated linear scars on the face (Fig. 1). On the gluteal region linear lesions could be observed, which had the typical apple jelly color (Fig. 2). Light microscopy of a skin lesion showed non-caseating epithelioid granulomas without lymphocytic infiltration at the margins, the so-called naked granuloma (Fig. 3). Radiographic examination of thorax, eye examination, serum calcium, 24-hour urine calcium and serum angiotensin-converting enzyme testing gave normal results. She was treated with oral prednisolone (40 mg per day) and chloroquine diphosphate (250 mg per day) for 4 weeks with marked improvement of the lesions.

Discussion

The real mechanism of the infiltration of old scars with sarcoidal granulomas is not fully understood, a foreign body reaction has been suggested by some authors. As this form of sarcoidosis may be associated with extracutaneous involvement, systemic disease should be ruled out.

In our patient, there was a very long interval, 50 years, between the event causing the scars and the onset of granulomas. A foreign body reaction is very unlikely with this interval. Another interesting point is the fact that some lesions were not sutured (Fig. 2) and this precludes the possibility that the surgical procedure triggered the granulomas in the skin. A case with sarcoidal involvement of a traumatic scar that spared a surgical scar was also reported [7]. In such cases a foreign body reaction cannot be completely excluded.

Associated therapy with systemic steroids and antimalarials was effective.

References

1. Cecchi R, Giomi A. Scar sarcoidosis following herpes zoster. J Eur Acad Dermatol Venereol. 1999 May;12(3):280-2. PubMed

2. Almeida Jr HL , Jannke HA. Sarcoidose em cicatrizes prévias. An Bras Dermatol 2004; 79: 79-82.

3. Souza PRM, Duquia RP, Vetoratto G, Almeida Jr HL. Infiltration of old scars: a manifestation of sarcoidosis. J Bras Pneumol 2004; 30:585-587.

4. Healsmith MF, Hutchinson PE. The development of scar sarcoidosis at the site of desensitization injections. Clin Exp Dermatol. 1992 Sep;17(5):369-70. PubMed

5. Norton SA, Chesser RS, Fitzpatrick JE. Scar sarcoidosis in pseudofolliculitis barbae. Mil Med. 1991 Jul;156(7):369-71. PubMed

6. Singal A, Thami GP, Goraya JS. Scar sarcoidosis in childhood: case report and review of the literature. Clin Exp Dermatol 2005 May;30(3):244-6. PubMed

7. Mehta V, Balachandran C, Mathew M. Scar sarcoidosis sparing a surgical scar. Dermatol Online J. 2007 Jul 13;13(3):37. PubMed

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