A Persistent Scalp Plaque Resistant to Conventional Therapies

Document Type

Conference Proceeding

Publication Date

7-21-2025

Publication Title

J Invest Dermatol

Keywords

Dermatology

Abstract

Sarcoidosis is a systemic disease characterized by non-caseating granulomas, with cutaneous involvement in ∼25% of patients. Scalp involvement in cutaneous sarcoidosis is rare and often misdiagnosed as common inflammatory conditions such as lichen simplex chronicus and scalp psoriasis. This case illustrates the diagnostic challenge and necessity of considering sarcoidosis in the differential diagnosis of persistent scalp plaques resistant to therapies. Only a handful of cases describing scalp involvement in sarcoidosis have been reported, magnifying a gap in clinical awareness that deserves greater attention. A 58-year-old Black female with chronic uveitis presented with a 6-month history of an intermittently pruritic occipital scalp plaque. She was initially treated for presumed tinea capitis with a 4-week course of terbinafine, showing mild improvement. Exam revealed a thick, scaly plaque with whitish-brown crust and no lymphadenopathy. A KOH exam was inconclusive, so a fungal culture was obtained, and she was started on another 4-week course of oral terbinafine and ketoconazole 2% shampoo, with minimal improvement. The culture was negative and she was transitioned to topical fluocinolone 0.1% oil, but at her 3-month follow-up, the disease had progressed, with new violaceous, scaly lesions at the left medial canthus and frontal scalp. A scalp biopsy showed granulomatous dermatitis favoring sarcoidosis. AFB, Fite, and Grocott stains were negative. Elevated ACE levels and imaging revealed hilar/paratracheal lymphadenopathy and breast and axillary lymph node biopsies showed noncaseating granulomas, further supporting systemic involvement. She was diagnosed with systemic sarcoidosis and treated with topical clobetasol, tacrolimus, intralesional Kenalog, minocycline, and methotrexate, resulting in significant improvement. The various clinical morphologies of scalp sarcoidosis make prompt diagnosis difficult and, thus, appropriate treatment is often delayed. This case contributes to clinical practice by highlighting that clinical findings alone are insufficient for diagnosis and the value of early biopsy in persistent scalp plaques of ambiguous etiology.

Volume

145

Issue

11

First Page

1

Find It @ Sladen

Share

COinS