Elsevier

Clinics in Dermatology

Volume 25, Issue 2, March–April 2007, Pages 173-180
Clinics in Dermatology

Cutaneous tuberculosis

https://doi.org/10.1016/j.clindermatol.2006.05.005Get rights and content

Abstract

Cutaneous tuberculosis continues to be one of the most elusive and more difficult diagnoses to make for dermatologists practicing in developing countries. Not only because they have to consider a wider differential diagnosis (leishmaniasis, leprosy, actinomycosis, deep fungal infections, etc) but also because of the difficulty in obtaining a microbiological confirmation. Despite all the advances in microbiology, including sophisticated techniques such as polymerase chain reaction, the sensitivity of new methods are no better than the gold standard, that is, the isolation of Mycobacterium tuberculosum in culture. Even now, in the 21st century, we rely on methods as old as the intradermal reaction purified protein derivative (PPD) standard test and therapeutic trials, as diagnostic tools. In this situation, it is important to recognize the many clinical faces of cutaneous tuberculosis to prevent missed or delayed diagnoses.

Section snippets

Historical aspects

Scrofuloderma and lupus vulgaris are the oldest forms of cutaneous tuberculosis (TB) described in the medical literature and were known as the king's evil.1 Lupus, meaning wolflike, initially referred to any ulcerative lesion, reminiscent of a wolf bite. In 1803, Robert Willand used the word lupus as a reference to the latter stages of facial cutaneous TB. This clinical description of facial lupus was the origin of similar terms such as lupus erythematosus and lupus pernio (a variant of

Epidemiology

Worldwide, there are more cases of TB now than at any other time in the history of humankind. The World Health Organization estimates that between 1.5 and 2 million people die each year from TB. Indeed, estimates are that there is a TB-related death every minute. In 1999, the World Health Organization estimated that there were a staggering 8,417,000 new cases of TB globally, representing a reverse of the steady decline in incidence that had been seen during the latter half of the 20th century.

Classification

The most widely accepted classification system for cutaneous TB is based of the mechanism of propagation by (i) direct inoculation (ii) through contiguous infection, or (iii) hematogenous dissemination.6 One useful additional concept that has been introduced is the bacterial load,3 analogous to that described by Ridley and Jopling in reference to M leprae in Hanson's disease. Thus, cutaneous TB is classified into multibacillary and paucibacillary forms (Table 1).

The multibacillary forms include

Clinical forms

When considering cutaneous TB, one must be mindful that although the morphology of the lesions may vary greatly, certain findings may be very indicative of cutaneous TB: the scrofuloform picture, the annular plaque with verrucose border of lupus vulgaris, or the frankly hypertrophic plaque on acral locations of TVC. A positive contact history with persons having old or active TB would support the diagnosis.

The following is a description of the clinical forms common in developing countries:

Primary-inoculation TB (tuberculous chancre)

In cases of primary-inoculation TB, the social history is often helpful because the patient is usually a health care or laboratory worker that has acquired TB through accidental inoculation of contaminated material. Another common presentation is seen in children (often with no previous bacillus of Calmette-Guérin (BCG) immunization) that are exposed to Mycobacterium tuberculosis through a household member of caregiver with pulmonary TB. Lesions are usually located on the face, hands, and feet.

Tuberculosis verrucosa cutis

Tuberculosis verrucosa cutis is characterized by the presence of a solitary, verrucose plaque, usually on an extremity such as the hand or the foot (Fig. 7). It is usually painless and occurs as a consequence of reexposure (reinoculation) to the mycobacterium in an individual with previous exposure. It affects adults and children.

In children, lesions are usually seen on the feet. It has been reported as a common form of presentation in Asia, although a recent series from Japan showed a

Diagnosis and therapy

A clinical diagnosis is dependant upon a careful evaluation of the clinical presentation. Does the patient fit any of the clinical categories described above? Supporting evidence includes epidemiological data, contact history or previous tuberculous disease, and the result of the tuberculin reaction.

A skin biopsy should be performed in all cases and specimens stained and cultured for acid-fast bacilli. Too strict diagnostic microbiological criteria, however, may result in missed diagnosis. If

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