Clinicopathologic challenge Lichenoid papules in the periorbital area Galal El-Enany, MD, Marwa M. Fawzy, MD Dip Dermpath (ICDP-UEMS), Mona R.E. Abdel-Halim, MD, Dip Dermpath (ICDP-UEMS), Eman El-Nabarawy, MD, Dip Dermpath (ICDP-UEMS), Amira El-Tawdy, MD, Dip Dermpath (ICDP-UEMS), Mostafa Abdel-Latif, MD, Heba A. Abdelkader, MD, Sally Doss, MD, and Hagar El-Sayed, MSc Dermatopathology Unit, Dermatology Department, Kasr Al Aini Hospital, Cairo University, Cairo, Egypt Correspondence Mona R.E. Abdel-Halim, MD Dermatology Department Kasr Al Aini Hospital Cairo University Kasr Al Aini Street, 11562 Cairo, Egypt E-mail: abdelhalimmona@gmail.com Conflicts of interest: The authors declare no conflicts of interest, and no funding was received. doi: 10.1111/ijd.14427 What is your diagnosis? Clinical Findings A 50-year-old female with a 4-year history of pulmonary and cutaneous sarcoidosis presented with a recent onset of liche- noid, pruritic, slightly scaly papules on both upper lids and infraorbital skin with progressive course (Figs. 1a,b). She reported only partial improvement of the chest symptoms and original cutaneous lesions on systemic steroids with few resid- ual erythematous papules on the nose (Fig. 1c). However, she reported being noncompliant on treatment during the last 2 years. A new chest CT scan was ordered. It revealed multiple enlarged mediastinal lymph nodes with a pattern of affection suggesting sarcoidosis (Fig. 1d). Serum calcium and 24-hour urinary calcium were normal as well as ANA and ENA panel. The patient gave no history of use of any topical agents on her eyelids and was not on any other systemic medication around the time of onset of the eruption. Histopathologic Findings A 4 mm punch biopsy was taken from one of the eyelid lesions, and histopathological examination revealed orthokeratotic stratum corneum with keratin-filled dilated follicular infundibulae. Interface reaction pattern was seen in the dermis with vacuolar degeneration, necrotic keratinocytes, and lymphocytes along the DEJ. Many necrotic keratinocytes were seen also in follicu- lar structures. The dermis showed a superficial and mid-dermal perivascular lymphohistiocytic infiltrate with minimal perifollicular extension. In addition, a discrete granuloma composed of col- lections of epithelioid cells surrounded by minimal lymphocytes was detected (Fig. 2). Stains for fungi, bacteria, and mycobac- teria were negative, and examination by polarized light revealed no foreign material. Figure 1 Affection of the right (a) and left (b) eyelids and infraorbital regions with lichenoid papules. Residual lesions on the nose (c). CT chest demonstrating enlarged mediastinal lymph nodes (d) ª 2019 The International Society of Dermatology International Journal of Dermatology 2019 1