What are the bumps around this man’s mouth?

30 year old man develops a rather sudden onset of papules around his mouth.  No prior history of any such eruption. He  reports that the lesions have remain static for the past several weeks.  No medication use before or after the onset of the flesh colored papules. No pustules or comedones present. The patient reports the lesions are only very mildly pruritic, at times. He is very concerned about “having to go through acne all over again”.

Diagnosis:

Papular Sarcoid (biopsy confirmed)

Discussion
No other cutaneous lesions. Papular sarcoid is the most common cutaneous manifestation of systemic sarcoidosis.  In addition to a general medical exam (his Internist found bilateral hilar adenopathy on x-ray) and is continuing to follow.  We initiated topical class V corticosteroid treatments with mild to moderate success. The doses of oral steroid to gain acceptable cutaneous control for him caused significant weight gain and mood irritability. The patient wished additional cutaneous control and we initiated up methotrexate 15 mg weekly with folic acid. He did well on this for several months however despite the folic acid, developed significant G.I. upset. We then went to SQ methotrexate and the patient continued to experience G.I. upset.  At this point initiated thalidomide treatment with appropriate laboratory monitoring a dosage of 100 alternating with 200 mg every other day. Three months into therapy the papules have resolved and we will continue to follow with his Internist.

For additional information please see:
http://www.dermnetnz.org/dermal-infiltrative/sarcoidosis.html

Ref. Dermatology. G. Levene and S. Goolamali p. 82.

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