INTRODUCTION Sarcoidosis is a noncaseating granulomatous multi-system disease of unknown etiology that most commonly affects young adults. It affects males and females equally, but females are more likely to show ocular involvement. There is a greater prevalence of sarcoidosis in the southeastern United States, and it is believed to occur more commonly among blacks. A bimodal incidence has been reported. A sub-acute presentation in patients less than 30 years of age is more likely to be self-limited, subsiding within two years. This transient variety is seldom associated with skin lesions. A more chronic form of the disease occurs in older age groups and skin lesions occur in up to 30% of patients. This form is believed to be due to a defect in T-lymphocyte suppressor function, and it frequently presents with hilar adenopathy, lung infiltrations, and more rarely with skin or eye lesions. The incidence of ocular involvement in patients with sarcoidosis is estimated to be 22% and eyelid lesions may be seen in 11%.
CLINICAL PRESENTATION Eyelid lesions most commonly take the form of unilateral or bilateral slightly elevated, discrete, yellow-to-brown or purplish papules and plaques that eventually demonstrate central clearing. They usually evolve into annular or circinate lesions with or without central ulceration. "Millet-seed" subcutaneous nodules or confluent violaceous nodules may also occur. Associated eyelid edema and erythema is common. Occasionally sarcoid lesions can result in full-thickness destruction of eyelid tissues. Associated ocular involvement may include acute anterior uveitis, keratitis sicca, conjunctival granulomas, lacrimal gland infiltration, orbital inflammation, chorioditis, optic neuritis, and retinal vasculitis. Candle wax exudates along the retinal veins are thought to be virtually pathognomonic, but they seldom occur. Constitutional symptoms of fever and malaise are common, as is hilar adenopathy, lung infiltrations, and arthralgias. Rarely, eyelid sarcoid can be seen in the absence of any systemic manifestations. Central nervous system abnormalities occur in fewer than 10% of cases, however, this incidence doubles if there is involvement of the optic nerve or ocular fundus.
HISTOPATHOLOGY The hallmark of sarcoidosis is the noncaseating granuloma. The granulomas have sharp borders and are formed of tightly clustered epithelioid cells, usually with Langhans or foreign body-type giant cells. Epithelioid cells are activated macrophages with oval to elongate nuclei, pale pink granular cytoplasm, and indistinct cell borders. A variable number of lymphocytes rim the granulomas. Older granulomas become surrounded by fibrous connective tissue.
DIFFERENTIAL DIAGNOSIS The differential diagnosis includes discoid lupus erythematosus, chalazia, hordeola, epidermal inclusion cyst, xanthelasma, lipoid proteinosis, amyloidosis, sebaceous cyst, lichen planus, erythema nodosum, tuberculosis, leprosy, syphilis and parasitic, fungal, viral (molluscum contagiosum, herpes simples and herpes zoster), or bacterial infections.
TREATMENT Diagnosis is supported by chest X-ray (positive in 80%), tuberculin skin test anergy, increased angiotensin-converting enzyme, positive gallium scan, elevated serum protein level with elevated alph-2globulin fraction, and elevated serum calcium level. Treatment revolves around systemic steroids. The most favorable prognosis is seen in younger patients with the more acute self-limited form of sarcoidosis. Associated intraocular inflammation is controlled with topical steroids and cycloplegics. Eyelid lesions often respond to systemic corticosteroid therapy, however, they often recur when treatment is stopped. Intralesional triamcinolone for cutaneous palpebral sarcoidosis can be effective for localized eyelid disease.
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Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.