Cutaneous Tuberculosis

CUTANEOUS
TUBERCULOSIS
Neirita Hazarika
ETIOLOGY- Mycobacterium Tuberculosis
PATHOGENESIS- manifestations of lesions depend on
1.Immunity of the host
 Specific immunity to M. Tuberculosis – depending
on whether exposure to the bacteria is primary or
secondary
 General immunity of the host
2. Route of entry
3. Bacterial load
CLASSIFICATION
1.Exogeneous source
Tuberculous chancre
Warty tuberculosis/ TVC
Lupus vulgaris
2.Endogenous source
a. contiguous source – Scrofuloderma
b. auto-inoculation – Oroficial T.B.
c. hematogenous - Lupus vulgaris,
Tuberculous gumma
3.Tuberculides –
a. Micropapular – Lichen scrofulosorum
b. Papular, Papulo-necrotic
c. Nodular– Erythema nodosum
Erythema induratum(Bazin)
Tuberculous Chancre
No prior immunity to M. tuberculosis
( Primary complex in the skin)
Entry–cuts, abrasion, insect bites, wounds
Site- exposed areas of limbs, face
Age - children
Clinicalfeature
Nodule → ulcerates
producing tuberculous
chancre
Crusts form and edges
become indurated
Regional
lymphadenopathy in
few weeks
Dev. Of immunity →
lesion heal to produce
a scar
Warty Tuberculosis/ Tuberculosis Verrucosa
Cutis
Exogenous source
Moderate to high immunity to M.
tuberculosis
Occupational- who handle tuberculous
tissue eg. butcher, pathologist,
veterinarians (anatomist wart)
Site – hands, feet
Single indolent
verrucous nodule or
plaque with a
serpenginous border,
indurated base, centre
may show scarring.
Heals in several
months leaving thin
atrophic scar
Lymphadenopathy rare
Scrofuloderma/ Tuberculosis Cutis
Colliquativa
Develops as an extension of an underlying

focus – lymph node or bone
Site – cervical region common with

infected cervical lymph nodes breaking
down into the skin
Infected lymph nodes
become inflamed,
swollen, get fixed to
overlying bluish skin
Breakdown of lymph
nodes → formation of
ulcers with undermined
edge
AFB can be
demonstrated
Orificial Tuberculosis/ Tuberculosis Cutis
Orificialis
Develops from auto inoculation around the
muco cutaneous junctions in patients with
internal tuberculosis
Site-lips, mouth in pulmonary T.B.

anal region in intestinal T.B
external genitalia in genitourinary T.B
Host immunity poor with active internal

disease.
Small erythematous
nodules break
down, form round,
shallow, granulating
ulcers covered by
thin crust.
Painful
No tendency to heal
without effective
treatment
Tuberculin test may
be -ve
Lupus Vulgaris
most common form of cut. TB
Usually acquired from an external source;
rarely from haematogenous dissemination
Site – around nose (nasal mucosa and

lips) and face in western countries
buttocks, thighs, legs in India
Initial lesion is a soft erythematous nodule
Slowly several such nodules coaslesce to

form a soft plaque which slowly extends
Presence of APPLE JELLY nodules at edge

of plaques- in diascopy( uncommon in
Indian skin)
MATCH STICK sign – soft nodules can be

probed or pierced with a match skick
Diseases relentlessly progresses with
irregular extension of the plaque
Healing occurs with SCARRING
Occasional ulceration, crusting and

scarring with destruction of underlying
tissues and cartilage- ULCERATIVE and
MUTILATING form
Tuberculous Gumma
Results hematogenous dissemination from
a tubercular focus
Usual in malnourished children
The lesion is initially a subcutaneous

nodule which breaks into the skin to form
an ulcer with an undermined edges.
TUBERCULIDES
Symmetrical eruptions
Result of internal focus of tuberculosis, though

internal disease may not be active. Patient
health is good.
Prob. Cause hematogenous dissemination of

bacilli in a person with high degree of immunity
Tuberculin test always +ve
Cured by ATT
Lichen Scrofulosorum
Tiny<5mm, perifollicular,
lichenoid papules
Asymptomatic
Site – trunk
Involute
after many
months without scars
Tuberculintest –
strongly +ve
Papulonecrotic Tuberculides
Crops of deep seated papules and nodules
Lesions are capped by pustules; ulcerate
forming crusts
Healin a few months with scar

New crops keep developing
Asymptomatic
Tuberculin test strongly +ve
Erythema Nodosum
Crops of indurated very tender,
erythematous deep seated nodules,
which evolve from red to violaceous to
yellow
Inspection – bruise, palpation nodule
Never ulcerates; heal without scarring
Site– bilateral shins
Constitutional- fever, malaise
Tuberculin test
+ve
Course-
spontaneous
resolution in 6
weeks
Histology – septal
pannicullitis no
vasculitis
Erythema Induratum
Site- calves in young adult females

Bilaterally symmetrical
Initial develop in cold weather
Subcutaneous nodules and plaques
with gradually involve the overlying
skin with ulceration
Tuberculin test
+ve
Ulcers heal
leaving atrophic
scars
Chronic ,
recurrrent
Histological –
nodular vasculitis
Investigations
To confirm tuberculosis
A. Biopsy – caseating granuloma
B. Isolation of M.tuberculosis –
1.culture of AFB from pus, skin
biopsy specimen
2. PCR
C. Mantoux test
To rule out concomittant tuberculosis
in other organs
1. CXR
2. X-ray joint, bones
3. FNAC – of enlarged lymph nodes
Differential diagnosis
lupus vulgaris- leishmaniasis, sarcoidosis,

systemic fungal infection, SCC
tuberculosis verrucosa cutis - warts

TREATMENT
Standard ATT
Intensivephase – isoniazid 5mg/kg
For 2 months rifampicin 10mg/ kg
ethambutol 15mg/ kg
pyrazinamide 20mg/kg
Continuous phase - isoniazid 5mg/kg
For 4 months rifampicin 10mg/ kg
Extension – max. 8 months

THANK YOU

Cutaneous Tuberculosis

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Cutaneous Tuberculosis

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CUTANEOUS

Develops as an extension of an underlying

Site – cervical region common with

Site-lips, mouth in pulmonary T.B.

Host immunity poor with active internal

Site – around nose (nasal mucosa and

Slowly several such nodules coaslesce to

Presence of APPLE JELLY nodules at edge

MATCH STICK sign – soft nodules can be

Healing occurs with SCARRING

Occasional ulceration, crusting and

Usual in malnourished children

The lesion is initially a subcutaneous

Result of internal focus of tuberculosis, though

Prob. Cause hematogenous dissemination of

Tuberculin test always +ve

Healin a few months with scar

Site- calves in young adult females

lupus vulgaris- leishmaniasis, sarcoidosis,

tuberculosis verrucosa cutis - warts

Extension – max. 8 months

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