Clinical Presentation of Palpable Lesions in Sarcoidosis
Lumps from sarcoidosis present in distinct patterns: highly specific skin lesions like lupus pernio (chronic violaceous plaques on the nose, cheeks, and ears), subcutaneous nodules (firm, asymptomatic nodules under normal-appearing skin), maculopapular lesions (erythematous or violaceous raised bumps), and lymphadenopathy (most characteristically bilateral hilar nodes, but also palpable peripheral nodes). 1, 2
Specific Cutaneous Lesions (Granulomatous)
Lupus Pernio
- Highly specific for sarcoidosis and represents chronic, disfiguring disease 1, 2
- Presents as chronic violaceous skin lesions, typically on the nose, cheeks, and ears 2
- Associated with more severe systemic involvement and chronic course 3
- Hallmark of chronic disease that does not respond well to conventional treatments 4, 5
Subcutaneous Nodules
- Present as firm, asymptomatic nodules covered by normal-appearing skin, most commonly on forearms and legs 1, 6
- Diagnosis requires high index of suspicion since overlying skin appears normal 6
- In the vast majority of patients (>70%), subcutaneous nodules are the manifestation that allows diagnosis of systemic sarcoidosis 6
- Strong association with bilateral hilar lymphadenopathy (72.7% of cases) 6
- More often associated with remission of systemic disease at two years compared to plaques or lupus pernio 4
Maculopapular Lesions
- Appear as maculopapular, erythematous, or violaceous skin lesions 1, 2
- Most frequent type of specific (granulomatous) skin lesions 4
- Usually transient or tend to follow the course of systemic disease 5
- Associated with better prognosis and more likely remission at two years 4
Plaques
- Present as raised, flat-topped lesions 4, 5
- Associated with chronic sarcoidosis and more severe systemic involvement 5, 3
- Hallmark of chronic disease course 4
Lymphadenopathy
Thoracic Lymph Nodes
- Bilateral hilar adenopathy is the most characteristic finding, present in approximately 90% of cases 2
- Highly probable diagnostic feature on chest X-ray, CT, and PET imaging 1
Peripheral Lymphadenopathy
- Two or more enlarged extrathoracic nodes visible on CT, MRI, or PET imaging 1
- Palpable peripheral lymph nodes may be present 7
Other Palpable Organ Involvement
- Symmetrical parotid gland enlargement presents as bilateral facial swelling 1, 2
- Lacrimal gland swelling may be visible or palpable 1, 2
- Hepatomegaly and/or splenomegaly may be detected on physical examination 1, 2
Non-Specific Lesions
Erythema Nodosum
- Presents as tender, raised nodules on the shins 2
- Highly probable indicator when part of Löfgren's syndrome (bilateral hilar adenopathy with erythema nodosum and/or periarticular arthritis) 1, 2
- Associated with excellent prognosis and spontaneous resolution 4, 3
- Does not show granulomas on biopsy, distinguishing it from specific lesions 4, 5
Critical Clinical Pearls
Prognostic significance varies dramatically by lesion type: Löfgren's syndrome and erythema nodosum indicate acute, benign disease with good prognosis, while lupus pernio and plaques signal chronic, severe disease requiring aggressive management 4, 5, 3
Skin biopsy of specific lesions reveals non-caseating granulomas, allowing early diagnosis through a minimally invasive procedure 4, 5
Cutaneous lesions occur in 9-37% of sarcoidosis patients, making skin the second most commonly involved organ after the lungs 5
Common Diagnostic Pitfalls
- Failure to biopsy subcutaneous nodules because overlying skin appears normal, leading to missed diagnosis 6
- Inadequate exclusion of infections (tuberculosis, fungal) that can mimic sarcoidosis exactly with granulomatous lymphadenopathy 2, 8
- Insufficient workup for systemic disease when cutaneous sarcoid granulomas are identified—every patient requires systemic evaluation 3
- Underestimating psychological impact of chronic disfiguring lesions like lupus pernio, which require treatment despite being minimally symptomatic physically 4, 5