Cutaneous tuberculosis can present in different clinical forms as a result of Mycobacterium tuberculosis, M. bovis, or BCG vaccine infection of the skin. Lupus vulgaris is the most common form, appearing as painless reddish-brown nodules on the face that slowly enlarge. Scrofuloderma typically affects the neck and chest as an asymptomatic swelling that breaks down into sinuses or ulcers. Diagnosis involves skin biopsy demonstrating tuberculoid granulomas and potentially identifying acid-fast bacilli, along with a positive tuberculin test. Treatment consists of a multi-drug regimen in two phases to reduce the bacterial burden and ensure sterilization.

1. DEPARTMENT Of Dermatology, venereology
Name : Mohamed Mahmoud Abbass
Group : 7th
Course : 4th
Topic : CUTANEOUS TUBERCULOSIS

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. Immunopathology
• Skin biopsy specimens examined with monoclonal
antibodies
– intense expression of HLA-DR on keratinocytes
– moderate to high Langerhans cell hyperplasia
– infiltration by CD3+ pan-T cells as well as CD8+
and CD4+ T cells(CD4 > CD8)
• Predominant lymphocyte in dermal granulomas
– activated CD3+ T cell
– expressing MHC class II antigens & interleukin 2
receptor

4. Classification

5. 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

7. Verrucosa cutis (prosector’s wart)
• 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 Purified protein derivative (PPD) test may also result positive

9. 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

11. 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

13. 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

15. 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

17. 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

19. 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

22. THANKS