CUTANEOUS

TUBERCULOSIS
ROBBY W WIJAYA
WARREN LIE
TRI RAHAYU
NUR FADILAH
Pembimbing Residen:
dr. Nur Putri Nuzul Iryani
Pembimbing Supervisor:
Dr. dr. Khaeruddin Djawad, Sp.KK(K)

DEFINITION
Tuberculosis infection of the skin caused by the
Mycobacterium tuberculosis complex, M. bovis, or bacillus
Calmette-Guerin (BCG) where the clinical manifestations
vary depending on the patients immunity, environmental
factors, and bacterial inoculation.

EPIDEMIOLOGY
TB incidence (2014) = 9.6 million cases,
TB with HIV (2014) = 1.2 million cases,
MDR-TB (2014) = 480.000 cases,
Extrapulmonary TB = 14-20%
Cutaneous TB has a global distribution, more common in
tropical area and developing world.
Most common cutaneous TB form = scrofuloderma,
TVC
Male > female

ETIOLOGY
Mycobacterium tuberculosis complex:
M. tuberculosis (most common), M. bovis, M. caprae, M.
africanum, M. microtim, M. pinnipedii, dan M. canetti
Size = 0.5 to 3 m, bacil, non-spore forming, aerobic
Gram staining = neutral
Acid fast bacili mycolic acid, long-chained FA
Cell wall lipids bind to arabinogalactan/peptidoglycan
low permeability difficult to penetrate by
antibiotics

CLASSIFICATION

PATHOGENESIS
There are 6 ways of infections
1. Infection directly to the skin from the organ under the
skin that has been infected by tuberculosis (e.g.
scrofuloderma)
2. Inoculation directly to the skin around orificium (e.g.
orificial tuberculosis)
3. Hematogenous spreading (e.g. miliary cutaneous
tuberculosis)

PATHOGENESIS
4. Lymphogenous spreading (e.g. lupus vulgaris)
5. Direct spreading mucous membrane which have been
infected by tuberculosis (e.g. lupus vulgaris)
6. Direct innoculation to the skin when there is damage
to the skin and decreased local resistance (e.g.
tuberculosis verrucosa cutis)

CLINICAL MANIFESTATIONS

Primary Inoculation Tuberculosis

Exogenous cTB in nonimmune host
Papules, pustules, or indolent ulcer, with livid
surrounding and shallow granular base
Lymphangitis and lymphadenitis can occur several weeks
after the primary lesion
Induration of ulcer tuberculous chancre

Primary Innoculation TB

Ulcerated nodule with inguinal lymphadenopathy

Tuberculosis Veruccosa Cutis

Exogenous cTB on individual with prior TB infection
Serpiginous spreading, lenticular papules with
violaceous halo hyperkeratotic, warty, firm plaque,
irregular border, with cicatrix in the middle
Predilection: lower leg and foot, dorsolateral
hand/fingers, places which are often gets trauma, most
common on the knee

Tuberculosis Veruccosa Cutis

Hyperkeratotic, warty plaque with irregular

border on dorsum of hand

Lupus Vulgaris
Predilection: head, neck, face
Infection may be endogenous or exogenous
Ill defined soft papules which evolves into well-defines
irregular plaque
Groups of erythematous nodules which turns yellow on
diascopy (apple jelly color)
Nose/ear cartilage destruction
Scarring is prominent

Lupus Vulgaris

Reddish plaque in cheek, jaw, and ear

Scrofuloderma
Contiguous spread from affected lymph nodes or
tuberculous bones (phalanges, sternum, ribs) or joint
Predilection: parotid/submandibular region,
supraclavicular, neck, axilla, inguinal region (rare)
TB lymphadenitis: freely moveable subcutaneous nodule
softening/liquefication cold abscess fistula
ulcer with livid surrounding and irregular sinuses
crust cicatrix + skin bridge (chronic)

Scrofuloderma

Abscess formation, ulceration, and extrusion of

purulent caseous material from scrofuloderma
in the clavicular region

Miliary Cutaneous TB
Spread to the skin from a focus on the body
Tuberculin test negative (anergy)
Circumscribed erythematous rash, papules, vesicles,
pustules, scaling, or generalized purpura

Orificial Tuberculosis
= ulcerative cutaneous tuberculosis
Predilection = around orificium due to direct contact
with infected body fluid (sputum) in immunosupressed
autoinnoculation
Mucosal nodule painful circular/irregular ulcer with
undermined border and livid surrounding

Orificial Tuberculosis

Orificial tuberculosis around the mouth: painful

ulcer

Gummatous Cutaneous TB
Hematogenous spread from the lungs
Gumma subcutaneous infiltrates, circumscript and
chronic, which will then soften and become destructive

Sequelae of BCG Innoculation

In the normal course of BCG vaccination, an infiltrated
papule develops after approximately 2 weeks, attains a
size of approximately 10 mm after 612 weeks,
ulcerates, and then slowly heals, leaving a scar
Vaccination may provoke an accelerated reaction in a
previously infected person

Sequelae of BCG Innoculation

Problems include the following:
LV at or near the vaccination site (latency of months to years)
Koch phenomenon in individuals sensitive to tuberculin
Regional adenitis, sometimes severe and with systemic symptoms,
more often in children
After deep injection, local abscesses, excessive ulceration
Scrofuloderma with suppuration for 612 months
Generalized tuberculid-like reactions (rare)
Generalized adenitis, osteitis, organ tuberculosis (e.g., in the joints)
occasionally

Lichen Scrofulosorum
Hematogenous spread in individual strongly sensitive to
M. tuberculosis
Uncommon lichenoid eruption mainly found in children
Firm, follicular flat-topped yellowish/pink papules,
erythematous or skin colored, fine scaling
Predilection: chest, abdomen, back, and sacrum area

Papulonecrotic Tuberculid
Occurs in children/young adults
Symmetrical, erythematous papule papulonecrotics
or papulopustule crust, necrotic tissue with central
depression cicatrix
Predilection: face, extensor, and trunk

Papulonecrotic Tuberculid

Papulonecrotic tuberculid on the forearm

Erythema Nodosum
Indolent erythematous nodules on extensors

Erythematous nodules on extensors of lower

extremity

Erythema Induratum of Bazin

Indolent, erythematous nodules on flexors
Suppuration ulcers or hypotrophy
Chronic-recurrent course of disease

Erythema Induratum of Bazin

Erythematous nodules on flexors of lower

extremity

DIAGNOSIS

History taking : patient had contact with droplet nuclei

from those with infectious pulmonary Tb

All CTB clinical presentations have a similar histological

basis, composed of lymphocytes, epithelioid histiocytes
and giant cells

The histological differences observed for each clinical

presentation result from the variation in the hosts ability to
organize the granulomatous process

(Santos, 2014)

Black : Epithelioid histiocytes and; Blue : lymphocytes

(Santos, 2014)

Langhans giant cells are frequently found in the inflammatory

infiltrate
(Santos,

2014)

LAB EXAMINATIONS

Dermatopathology

PIT: initially nonspecific inflammation; after 36 weeks, epithelioid

cells, Langhans giant cells, lymphocytes, caseation necrosis.
AMT: nonspecific inflammation and vasculitis.
TVC : characterized by massive pseudoepitheliomatous hyperplasia
of epidermis and abscesses.

(Wolff, 2009)

Mycobacterial culture

Gold standard active TB infection, and it can also

distinguish mycobacteria subspecies and determine
antibiotic susceptibility.
Tuberculin Skin Test

Identifies individuals sensitized to Mtb. The test

becomes positive in 2 to 10 weeks after the infection.
PCR
Confirming the presence of mycobacteria

(Wolff, 2009) (Santos, 2014)

DIFFERENTIAL DIAGNOSIS

PRIMARY INOCULATION TUBERCULOSIS

Picture 9. Syphilis
(Ratini, 2016)

Picture 10. Sporotrichosis (William, 2010)

TUBERCULOSIS VERRUCOSA CUTIS

Picture 11. Keratosis

(Medscape, 2006)

Picture 12. Hyperkeratotic Lupus Vulgaris

(Singal, 2015)

SCROFULODERMA
CUTIS)

(TUBERCULOSIS

Picture 13. Hidradenitis suppurativa

(Fitzpatrick, 2012)

COLLIQUATIVA

LUPUS VULGARIS (TUBERCULOSIS LUPOSA)

Picture 14. Discoid Lupus Erythematosus

(Medscape, 2015)

ORIFICIAL TUBERCULOSIS
(TUBERCULOSIS
ULCEROSA CUTIS ET MUCOSAE, ACUTE
TUBERCULOUS ULCER)

Picture 15. Aphthous ulcers

(DermNZ, 2015)

TREATMENT
1. Supportive general status correction (nutritional support)
2. Medical treatment :
continuous treatment to prevent drug resistance
combined drug regimen : using at least 2 bactericidal drugs,
including INH
there are 2 steps in treating tuberculosis :
1.

Initial step

2.

Continued step

Special Considerations In Treating

Tuberculosis of The Skin
Tuberculosis verrucosa cutis and localised forms of LV
INH alone for up to 12 months
Scrofuloderma surgical intervention
Small lesion of LV or tuberculosis verrucosa cutis best
excised, but tuberculostatics should be given
concomitantly
Long standing LV with mutilation plastic surgery

Drugs

Dosage

Administration

Isoniazid

5-10 mg/kgBW

Per oral, single dose

Rifampicin

10 mg/kgBW

Per oral, single dose on empty

stomach

Pirazinamid

20-35 mg/kgBW

Per oral, divided dose

Ethambutol

1st and 2nd month : 25 Per oral, single dose

mg/kgBW, continued with

Streptomicin

15 mg/kgBW
25 mg/kgBW

i.m.

PROGNOSIS
In general, as long as the treatment are given as
mentioned, the prognosis is good . As long as the basic
principles of treatment are supervised, the new cases of
drug-sensitive tuberculosis are curable almost 100%