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Granulomatous skin disease — cutaneous sarcoidosis and granuloma annulare
Granulomatous skin diseases look like red-brown papules or plaques; in sarcoidosis the granulomas are "naked" and non-necrotising and the skin can be a window to systemic disease, while in granuloma annulare the lesions are annular, benign and usually clear on their own.
Why it matters in the exam
Exam stems show a woman with red-purple papules around the nose and on the cheeks (lupus pernio), papules within old scars and tattoos, or erythema nodosum with hilar lymph nodes and arthritis (Löfgren syndrome). The question tests which presentations indicate chronic disease (lupus pernio is linked to chronic lung disease and upper-airway involvement), the work-up needed (chest X-ray, lung function, calcium, kidney function, ECG and eye examination) and the treatment. Granuloma annulare is shown as a ring of skin-coloured papules on the back of the hand, without scale — unlike tinea. Remember also that in a sarcoidosis biopsy granulomatous infection such as tuberculosis and fungi must be excluded before starting immunosuppression. Remember that in sarcoidosis the blood ACE level may be raised but is not diagnostic, and that heart and eye involvement can be silent and is therefore checked even without symptoms. The doctor should also ask about respiratory symptoms, fatigue and visual changes.
Key points
- Cutaneous sarcoidosis presents with red-brown papules and plaques with non-necrotising granulomas.
- Lupus pernio is linked to chronic lung and upper-airway disease, whereas Löfgren syndrome resolves and has a good prognosis.
- Every patient with cutaneous sarcoidosis needs a systemic work-up of the lungs, calcium, kidneys, heart and eyes.
- Treatment ranges from topical steroids to hydroxychloroquine, methotrexate and TNF inhibitors.
- Granuloma annulare is a ring of papules without scale, benign and usually self-resolving.
Summary table
| Entity | Clinical appearance | Systemic significance | Treatment |
|---|---|---|---|
| Sarcoidosis — papules and plaques | Red-brown papules on the face, "apple-jelly" colour on glass pressure | Window to systemic disease | Topical or intralesional steroids, hydroxychloroquine |
| Lupus pernio | Purple plaques on the nose, cheeks and ears | Linked to chronic lung disease and sinus involvement | Methotrexate, TNF inhibitors (infliximab) |
| Löfgren syndrome | Erythema nodosum, hilar nodes, ankle arthritis, fever | Good prognosis; usually resolves within months | NSAIDs and rest |
| Sarcoidosis in scars and tattoos | Papules within an old scar or tattoo | May be the first sign | Full systemic work-up |
| Granuloma annulare | Ring of skin-coloured papules on the backs of the hands and feet, no scale | Usually none; the generalised form is sometimes linked to diabetes and dyslipidaemia | Reassurance, topical or intralesional steroids; usually resolves |
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Sources
- ERS clinical practice guidelines on treatment of sarcoidosis, 2021 — Extrapulmonary disease
- British Association of Dermatologists guidance on cutaneous sarcoidosis, 2022 — Assessment and treatment
- Fitzpatrick's Dermatology, 9th edition (2019) — Granuloma annulare and necrobiosis lipoidica
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.