January/February 2012 • Volume 10 • Issue 1 - SKINmed Journal

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PAUCIBACILLARY CTB January/February 2012 TB VERRUCOSA CUTIS TBVC occurs after direct inoculation of M tuberculosis into the skin of previously infected individuals. It manifests as a painless, solitary, purplish or brownish red warty plaque that may extend peripherally, causing central atrophy, or form fissures that exude pus or keratinous material (Figure 2). It is often accompanied by lymphadenopathy. Skin lesions may evolve and persist for years, although spontaneous resolution may also occur. Response to treatment is favorable. 6,19 LUPUS VULGARIS LV is a chronic and progressive form of CTB that is widely described as the most common form. Lesions occur on normal skin as a result of direct extension from underlying deeper TB focus, by lymphatic or hematogenous spread, after primary inoculation or BCG vaccination, or in scars of old scrofuloderma. 20 Lesions are typically small, solitary, nodular, sharply defined, and reddish brown with a gelatinous consistency. “Apple-jelly” nodules present on the head and neck of individuals in Western Figure 2. Tuberculosis verrucosa cutis illustrating verrucous, hyperkeratotic fissured lesions. CORE CURRICULUM Figure 3. Lupus vulgaris: well-circumscribed plaque, displaying coalesce of discrete, red-brown papules, elevated verrucous border, and central atrophy. countries, while lesions on the lower extremities or buttocks are present in individuals in tropical and subtropical areas. It has several clinical variations such as classic plaque or keratotic hypertrophic, ulcerative, and vegetating. The plaque type begins as discrete, red-brown papules that coalesce and form plaques with a slightly elevated verrucous border and central atrophy (Figure 3). Persistent lesions may damage underlying tissue and ulcerate, causing severe disfigurement and an increased risk of skin cancer. 21 TUBERCULIDS The relationship between tuberculids and TB is a subject of continuing debate. They are generalized exanthems with a moderate to high degree of host immunity to TB. Patients are usually in good health and show (1) positive tuberculin skin test results; (2) inactive tuberculous involvement of viscera or lymph nodes; (3) negative staining and culture for pathogenic mycobacteria in affected tissue; and (4) skin lesions that heal with remission or treatment of TB. Its morphological variations include lichen scrofulosorum (LS), 22 erythema induratum of Bazin (EIB), and PNT. Tuberculids may be classified into 2 groups: (1) true tuberculids, and (2) facultative tuberculids. M tuberculosis plays a major etiologic role in the former, while it is one of several possible etiologic agents in the latter. Tuberculids were once believed to be a result of hypersensitivity to the presence of mycobacterial antigens within a host of previously acquired immunity to TB; however, most are now known not to be uniquely caused by M tuberculosis. PNT and LS are still widely accepted as true tuberculids and EIB as a facultative tuberculid. 22 SKINmed. 2012;10:28–33 30 Cutaneous Tuberculosis
January/February 2012 Figure 4. Lichen scrofulosorum: multiple, small, grouped, firm, perifollicular, lichenoid papules and/or plaques. LICHEN SCROFULOSORUM LS is an eruption of multiple, small, grouped, asymptomatic, firm, perifollicular, lichenoid papules and/or plaques (Figure 4), most often affecting children or young adults, that progresses and subsides within weeks to months without scarring. 4,23 An association between LV, caries of the spine, LS, 24 and its unusual occurrence in pulmonary TB25 has been described in the past. ERYTHEMA INDURATUM OF BAZIN EIB is a TB-associated panniculitis that presents with multiple, painful, recurring, ulcerated nodules that affect the legs of women. 4,6 Pre-existing vascular disease may predispose patients SKINmed. 2012;10:28–33 31 CORE CURRICULUM to lesions during exposure to cold weather. Lesions are chronic, slow to resolve (if at all), and result in atrophic hyperpigmented scarring after several months (Figure 5). Although patients show TB skin hypersensitivity, acid-fast bacilli (AFB) are rarely identified. A study from Spain demonstrated that about 10% of cases were positive for M tuberculosis using polymerase chain reaction (PCR). 26 A case series and literature review revealed that organisms, such as Mycobacterium bovis and Mycobacterium marinum, may also be involved in the etiology of EIB, although no evidence of such was found during the investigation. It was suggested that EIB has diverse etiologies with varying pathogenesis, leading to similar histological changes, and the cases analyzed may not have had an infectious etiology (suggesting a facultative tuberculid picture). 27 PAPULONECROTIC TUBERCULID Papulonecrotic tuberculid occurs as a chronic and recurrent symmetric eruption of necrotizing skin papules appearing in clusters and healing with varioliform scars (Figure 6). Tubercle bacilli are difficult to demonstrate, but patients typically have an internal focus of TB and are tuberculin sensitive, and skin lesions resolve after anti-TB therapy. TB DNA has been detected in these lesions using PCR amplification reactions. 28 Lesions appear on the exterior aspects of extremities, knees, elbows, buttocks, and lower trunk in a symmetric distribution, often in clusters. Individual lesions are asymptomatic, small, dusky red papules with a central punctum or crust. Involution is common after 6 to 8 weeks. 29 DIAGNOSIS Diagnosis of CTB is based on relative and absolute criteria, in addition to supportive immunologic evidence. 30 Figure 5. Erythema induratum occupying the lower leg. Figure 6. Papulonecrotic tuberculid. Cutaneous Tuberculosis
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January/February 2012 • Volume 10 • Issue 1 - SKINmed Journal

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