This document discusses cutaneous tuberculosis, which occurs when Mycobacterium tuberculosis infects the skin. Cutaneous TB can develop from either external or internal sources and presents with various clinical features. The most common forms are lupus vulgaris, scrofuloderma, and lichen scrofulosorum. Diagnosis involves skin biopsies and tests to identify acid-fast bacilli. Treatment consists of long-term multidrug therapy following standard protocols for tuberculosis. Proper diagnosis of cutaneous TB is important to prevent missed or delayed treatment.

1. CUTANEOUS
TUBERCULOSIS
Sattar kamali

2. INTRODUCTION
• Cutaneous tuberculosis occurs rarely, despite a high and increasing
prevalence of tuberculosis worldwide. Mycobacterium tuberculosis,
Mycobacterrium bovis, and the Bacille Calmette-Guérin vaccine can
cause tuberculosis involving the skin
• Cutaneous tuberculosis can be acquired exogenously or
endogenously and present as a multitude of differing clinical
morphologies
• Cutaneous TB- 1.5% of extrapulmonary TB
• Diagnosis of these lesions can be difficult, as they resemble many
other dermatological conditions that are often primarily considered.
• Commonest form
in adults: Lupus Vulgaris
in childhood: Scrofuloderma and Lichen scrofulosorum

3. • Skin manifestations present as a result of hematogenous spread or
direct extension from a latent or active foci of infection
• Cutaneous tuberculosis (CTB) is frequently elusive as it mimics a
wide differential diagnosis and also evades microbiological
confirmation despite recent advances in sophisticated techniques
• Although rare, given its worldwide prevalence, it is important to
recognize the many clinical variants of CTB to prevent missed or
delayed diagnoses

4. CLASSIFICATION
Not previously exposed:Tuberculosis chancre, Milliary tuberculosis
of the skin
Previously sensitized hosts:Lupus vulgaris ,Scrofuloderma
,Tuberculosis verrucosa cutis
Multibacillary:Primary inoculation TB, scrofuloderma, tuberculosis
periorificialis, acute military tuberculosis, gumma
 Paucibacillary:Tuberculosis verrucosa cutis, lupus vulgaris

5. Route of
infection
Clinical type histology course
Inoculation
tuberculosis
(exogenous
source)
Tuberculosis
chancre
Tuberculosis
verrucosa cutis
Lupus vulgaris
(occasionally)
Non specific TB
specific TB
specific
Localized
Localized
Localized
Secondary
tuberculosis (
endogenous
source)
Contiguous
spread Auto-
inoculation
Scrofuloderma
Orificial
tuberculosis
TB specific TB
specific
Localized
Progressive
Haematogenous
tuberculosis
Acute military
tuberculosis
Lupus vulgaris
Tuberculous
gumma
TB specific TB
specific TB
specific
Generalized
Localized
Localized
Eruptive
tuberculosis
Lichen
scrofulosorum
Variable variable
variable
Localized
Scattered Crops

6. LUPUS VULGARIS
• The most common form of skin tuberculosis
• Painful cutaneous tuberculosis skin lesions with nodular appearance, most
often on the face around the nose, eyelids, lips, cheeks, ears and neck
• Often develops due to inadequately treated pre-existing tuberculosis, it
may also develop at site of BCG vaccination
• It begins as painless reddish-brown nodules which slowly enlarge to form
irregularly shaped red plaque
• Diagnosis-
• On diascopy, it shows characteristic "apple-jelly" color
• Biopsy will reveal tuberculoid granuloma with few bacilli
• Mantoux test is positive

8. DIASCOPY TEST:
If lesion is pressed by a glass slide to diminish vascular
component of inflammation, individual nodules appear as
yellow brown spots (apple jelly color), so nodules are named
“apple jelly nodules”.

9. DIFFRENTIAL DX
 Basal cell carcinoma
 Sarcoidosis
 Discoid lupus erythomatosus
 Leprosy
 Deep fungal infection

10. WARTY TB
Synonyms:
Tuberculosis verrucosa cutis
Anatomist’s warts
Prosector’s warts
Verruca necrogenica

11. INTRODUCTION
• Rash of small, red papular nodules in the skin that may appear
2–4 weeks after inoculation by Mycobacterium tuberculosis in a
previously infected and immunocompetent individual.
• Entry point usually is the site of a trauma, wound or puncture
in the skin (eg- during an autopsy), the most frequent site for
the wart are the hands
• The diagnosis is confirmed by a skin biopsy and a positive
culture for acid-fast bacilli
• A PPD test may also result positive

12. • Small, asymptomatic,
firm , red or brown warty
papule with slight
inflammatory areola
• Extends to form
verrucous plaque
• Irregular extension at
edges leads to
serpiginous outline
• Fissure discharging pus
can be seen
• Spontaneous involution
forming white atrophic
scar

13. DDX
•wart
•blastomycosis
•chromoblastomycosis
•sporotrichosis
•hypertrophic lupus vulgaris
•hypertrophic lichen planus
•squamous cell carcinoma

14. SCROFULODERMA
•Condition caused by tuberculous involvement of the skin by
direct extension, usually from underlying tuberculous
lymphadenitis.
•An asymptomatic reddish swelling which breaks down to form
sinuses, fistulate or tuberculous ulcers
• Characteristic caseous material discharges from lesions
• Most common sites – neck, chest

15. • Involvement of skin
overlying contiguous
tuberculosis focus usually
in lymph gland, bone, joint,
lacrymal gland or duct.
• Asymptomatic, well defined
,firm, freely movable,
bluish-red nodule breaks
down to form undermined
ulceration with granulating
tissue at base.

16. PRIMARY INOCULATION TB
•Earliest lesions:
– 2–4 weeks after inoculation
– brownish papule, nodule, or ulcer with an undermined edge
and granular haemorrhagic base
•Induration with adherent crust
•Painless, non-healing ulcer with unilateral regional
lymphadenopathy, especially in child, should arouse suspicion

18. MILIARY TUBERCULOSIS
• It is a rare haematogenous dissemination of tuberculosis
• Usually affects:
– Young children
– Immunosuppressed patients
– Concurrent HIV infection
– Following viral infections
• Patient develops:
– Crops of minute bluish papules, vesicles, pustules
– Erythematous nodules
– Haemorrhagic lesions

20. TUBERCULID
• Hypersensitivity reaction to M. tuberculosis or its products in
patient with significant immunity
• Following criteria must be fulfilled to designate a condition as
tuberculid:
– Skin lesion must show tuberculoid histopathology
– Mycobacterium tuberculosis must not be demonstrated in
the lesion
– Tuberculin test must be strongly positive
– Treatment of underlying TB focus must lead to resolution of
skin lesion

22. LICHEN SCROFULOSORUM
•Second most common pattern of cutaneous TB in children
•Rare tuberculid that presents as a lichenoid eruption of minute
papules in children and adolescents with tuberculosis
•The lesions are usually asymptomatic, closely grouped, skin-
colored to reddish-brown papules, often perifollicular
•Mainly found on the abdomen, chest, back, and proximal parts
of the limbs

24. DIAGNOSIS
• The diagnosis is usually on skin biopsy. Typical tubercles are
caseating epithelioid granulomas that contain acid-fast bacilli. These
are detected by tissue staining, culture and polymerase chain reaction
(PCR).
• Tuberculin skin test
• QFT-G
• X-ray
• Sputum culture

26. TREATMENT
• CTB treatment is the same as that for systemic TB and
consists of long, multidrug therapy
• The chemotherapeutic treatment of TB is divided into two
phases:
-an intensive or bactericidal phase, designed to rapidly reduce
the total body burden of Mycobacterium tuberculosis
-a continuation or sterilizing phase
• The most commonly used drugs are isoniazid, rifampin,
pyrazinamide, and either ethambutol or streptomycin

27. THANKS FOR YOUR
ATTENTION