This patient has sarcoidosis. Sarcoidosis is a granulomatous, infiltrating disease that is more common in black persons and may be incidentally discovered by detection of lymphadenopathy, often in the chest. A chronic, nonproductive cough is the most common pulmonary symptom of sarcoidosis, as occurs in this patient. The cutaneous manifestations of sarcoidosis result from granulomatous infiltration in the skin with papule formation at the site of disease. Lesions tend to be grouped around the nose and are sometimes seen around the eyes or mouth. Sarcoidal involvement of tattoos and scars is not uncommon. Smoking may alter the pulmonary immune milieu, and smokers tend to have a lower incidence of sarcoidosis, with some patients occasionally developing sarcoidosis after smoking cessation. However, smoking is not recommended as a preventive or therapeutic measure. Medium-potency topical glucocorticoids are the usual first-line therapy for cutaneous sarcoidosis on the face, with high-potency agents used in other lower risk sites. Intralesional glucocorticoids are also a treatment option.

Dermatomyositis presents with cutaneous findings of erythema over skin folds or flexures, such as the metacarpal and proximal and distal interphalangeal joints, the elbows, the shoulders and back (“shawl sign”), posterior neck, the upper chest (“V sign”), lateral hips, and around the eyes. Patients may have an interstitial lung disease; however, the skin lesions described in this patient are not characteristic of dermatomyositis.

Hodgkin lymphoma can cause hilar lymphadenopathy and may cause severe pruritus. The resulting pruritus can lead to extensive skin excoriations; these lesions are usually elongated, jagged, angled erosions and scars due to self-induced scratching. The pruritus from Hodgkin lymphoma may be striking and severe, and lymphoma is one of the potential culprits to consider as an internal source of pruritus in select patients.

Limited systemic sclerosis, or CREST syndrome, is characterized by cutaneous calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly or tapering of the digits, and telangiectasias. None of these features are present in this patient.

Systemic lupus erythematosus often presents with skin findings. The classic acute rash of systemic lupus is a bright red symmetric patch over the cheeks and central face, the “butterfly” malar rash. Subacute cutaneous lupus presents with annular red scaly patches in photodistributed areas, especially prominent on the upper back, chest, and arms. Chronic cutaneous lupus lesions are generally the characteristic “discoid lupus” lesions with pink-to-violaceous erythema, scaling, and dyspigmentation and atrophic scarring. While pleuritis can occur with lupus, the combination of papular skin lesions and dry cough is characteristic of sarcoidosis.