Can Sarcoidosis Cause a Rash?
Yes, sarcoidosis commonly causes skin manifestations including rashes, occurring in up to 30% of patients and often serving as the initial presentation of the disease. 1
Types of Skin Manifestations
Sarcoidosis produces two categories of skin lesions that you need to distinguish clinically:
Specific (Granulomatous) Lesions
These contain non-caseating granulomas on biopsy and include:
- Maculopapular lesions - the most common specific cutaneous manifestation, appearing as erythematous or violaceous papules and plaques 2, 1, 3
- Subcutaneous nodules - palpable nodules beneath the skin surface 2, 4, 3
- Lupus pernio - violaceous, indurated plaques typically affecting the nose, cheeks, and ears 5, 4, 6
- Plaques - larger, raised lesions that can be disfiguring 1, 3
- Scar sarcoidosis - granulomas developing in old scars 3, 6
Non-Specific Lesions
- Erythema nodosum - tender, red nodules typically on the lower legs, representing reactive inflammation without granulomas 3, 6, 7
Prognostic Significance
The type of skin lesion helps predict disease course:
- Favorable prognosis: Erythema nodosum (especially with Löfgren's syndrome), maculopapular lesions, and subcutaneous nodules typically indicate self-limited disease with potential spontaneous resolution 3, 6
- Chronic disease markers: Plaques and especially lupus pernio strongly correlate with persistent, chronic sarcoidosis requiring prolonged treatment 1, 3, 6
Diagnostic Approach
When you encounter suspected cutaneous sarcoidosis:
- Perform skin biopsy of accessible lesions to demonstrate non-caseating granulomas - this provides early diagnosis through a minimally invasive procedure 2, 4, 7
- Obtain chest imaging (CT scan) immediately to evaluate for bilateral hilar adenopathy and perilymphatic nodules, as pulmonary involvement occurs in up to 95% of cases 2, 4
- Check baseline labs: serum ACE level, calcium, alkaline phosphatase, and complete blood count 2, 4
Treatment Considerations
For localized cutaneous lesions:
- High-potency topical corticosteroids (clobetasol or halobetasol propionate) as first-line therapy 1
- Intralesional triamcinolone acetonide may be more effective than topical preparations for localized disease 1
For widespread or refractory cutaneous disease:
- Oral prednisone remains first-line systemic treatment, with response in up to two-thirds of patients 1
- Methotrexate for steroid-sparing in chronic cases 2, 1
- TNF inhibitors (infliximab, adalimumab) for refractory disease not responding to conventional immunosuppression 2, 1
Critical Pitfall
The skin is the second most commonly affected organ after the lungs in sarcoidosis 3, 7. Never assume isolated cutaneous findings - always perform systemic evaluation including chest imaging and laboratory assessment, as cutaneous manifestations frequently herald multisystem disease requiring different management strategies 2, 7, 8.