Scar sarcoidosis with a 50-year interval between an accident and onset of lesions
1. Federal University of Pelotas
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.
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 . Scar sarcoidosis has been described in many countries and was reported in scars of accidents , herpes zoster , desensitization injections , and pseudofolliculitis barbae , among many others; pediatric cases are also reported .
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.
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.
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 . In such cases a foreign body reaction cannot be completely excluded.
Associated therapy with systemic steroids and antimalarials was effective.
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