(BMJ)—A 91-year-old woman with HTN treated with ramipril presented with a 4-month hx of a non-itchy rash on her face, forearms, and hands. Review of sx: no cough, fever, night sweats, or weight loss. Exam: violaceous papules and plaques on forearms; orange-red plaques on L temple, nose, and R forearm. No lymphadenopathy. CXR: multiple miliary opacities. Bronchial lavage: negative for TB and CA. What’s the dx?
Lichenoid sarcoidosis
Subacute cutaneous lupus erythematosus
Lichen planus
Cutaneous tuberculosis
Cutaneous leishmaniasis
You are correct. Skin bx showed multiple noncaseating granulomas, and stains for bacteria, mycobacteria, and fungi were negative, which was suggestive of cutaneous lichenoid sarcoidosis. Lichenoid sarcoidosis accounts for approximately 1% to 2% of cases of cutaneous sarcoidosis and may be a marker of systemic dz. It often presents as crops or single 1- to 3-mm dome-shaped erythematous or skin-colored papules on the trunk, limbs, and face. It’s a dx of exclusion; therefore, a comprehensive hx (including travel and systemic sx) and skin bx and tests to exclude infection are required. The patient had little improvement after 8 weeks of topical steroids; however, after daily topical 0.1% tacrolimus for 3 months, substantial flattening of the lesions occurred. Oral steroid was not initiated, given the asymptomatic lung dz.

BMJ 2019;364:l2