Systemic sarcoidosis presenting with alopecia of the scalp

A 39-year-old African-American woman was referred to the department of dermatology, Mount Sinal Hospital, New York for evaluation of a skin lesion on her scalp which had been present for 3 years and had recently changed in appearance. On examination, she was found to have erythematous plaques with hair loss extending from the frontal hairline on the right side in a "C-shaped" distribution, terminating behind the left ear. Two years later the lesion had rapidly extended to the vertex of the scalp and left temporal area (Fig. 1). There was a 10 cm × 12 cm area of alopecia at the vertex with slight erythema, but there was no evidence of scarring, inflammation or nodularity of the scalp (Fig. 2). A skin biopsy taken from the forehead revealed granulomatous dermatitis showing noncaseating granuloma with negative acid fast bacilli (AFBC) and ammonical-silverstain for fungus (GMS) (Fig. 3). She complained of chronic nasal congestion for 8 months. Nasal cavity examination and laryngeal endoscopy showed multiple nodules on the nasal septum and vocal cord. At that time, a presumptive diagnosis of sarcoidal nodule of the nasal septum and vocal cord was made and corticosteroids were administered orally. A chest X-ray demonstrated prominence of the right peritracheal and perihilar regions consistent with sarcoid. A 67 Gallium scan disclosed increased uptake in the lung and perihilar lymph nodes. A skull X-ray showed soft tissue density of the skull, probably indicating a subcutaneous sarcoidal nodule. Computed tomography (CT) scanning of her brain and skull base showed a soft tissue mass along the outer table of the calvarium within the frontal region. Six years ago, she experienced visual changes: blurred vision, tearing, floaters on both eyes and a 1 cm × 1 cm subcutaneous, painful, firm mass on the lateral side of her left upper eyelid. A skin biopsy was performed in another hospital and revealed noncaseating granuloma.