A Solitary Papule on the Eyelid as the First Manifestation of Systemic Sarcoidosis

Sarocoidosis can affect several organs, including the skin, and demonstrates a broad range of clinical manifestations. The first manifestation of sarcoidosis may sometimes be difficult to recognize. Herein, we report a case of a patient who had a solitary papule on her eyelid as the first and only manifestation of sarcoidosis that caused a diagnostic challenge. A 54-year-old woman visited our clinic with a solitary well demarcated ovoid erythematous papule on her right upper eyelid (Fig. 1). The lesion developed about 6 months prior to her visit and she denied any symptoms. She had no particular medical history. Under the impression of a common benign cutaneous condition, such as a syringoma, wart, xanthoma or irritated seborrheic keratosis, skin biopsy was performed. Histologic findings revealed non-caseating granuloma in the dermis, which was consistent with sarcoidosis (Fig. 2). Multiple enlarged hilar and mediastinal lymph nodes were noted on computed tomography, which were suggestive of pulmonary sarcoidosis. Ophthalmologic examination found no evidence of ocular involvement of sarcoidosis. For further evaluation and treatment, she was referred to the Department of Pulmonology. After administration of oral hydroxychloroquine at a dose of 400 mg/day for 7 months, she is currently under regular follow up with no signs of relapse. Cutaneous involvement in cases of sarcoidosis occurs in 20∼35% of cases and may present in various forms, including as macule, papule, nodules, plaques, or single or multiple erythematous and brownish lesions. Lupus pernio is characterized by the presence of mid-face erythematous and infiltrated lesions, which may lead to disfigurement. Darier- Roussy nodules are thought to be associated with systemic diseases and are subcutaneous lesions where epithelioid gra-nulomas are observed1-3. Other unusual forms include ul-cerated, psoriasiform, verrucous, rosaceiform, sclerodermiform, mimicking lipodermatosclerosis, lichenoid and erythrodermic lesions as well as alopecia that may present with cica- tricial3,4. A solitary papule on the upper eyelid rarely requires a biopsy to confirm the diagnosis. Clinically, rather benign lesions, such as syringoma, verruca plana, xanthelasma or lupus lupus miliaris disseminatus faciei, are suspected, with little urge for the clinician to perform a histologic diagnosis. Routine treatment with ablative lasers could have led to negligence of systemic sarcoidosis. This case depicts the uncommonness of a solitary inflammatory papule being the sole clinical manifestation of multisystemic sarcoidosis. Even though histologic examinations for every single skin lesion on the eyelid seem virtually impossible, papules with atypical features on the eyelid, like the one described in this case, should be given special attention.