9/18/2019 Cutaneous Tuberculosis - StatPearls - NCBI Bookshelf

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Cutaneous Tuberculosis
Authors

Ahmad Charifa1; Amanda M. Oakley2.

Affiliations
1 Yale School of Medicine
2 University of Auckland

Last Update: February 22, 2019.

Introduction
Tuberculosis is an infection caused by Mycobacteria, most commonly Mycobacterium tuberculosis. This infection
most commonly involves the lungs. When it involves the skin, it is called cutaneous tuberculosis. It is a rare disease.

The history of cutaneous tuberculosis dates back to 1826 when it was first reported by Laennec. He reported a lesion
on his hand that was caused by entry of the causative organism into his skin. However, the causative organism was not
known until 1882 when Robert Koch first discovered M. tuberculosis. Later, it was isolated from a cutaneous lesion
of an affected person.[1][2][3]

Classification

Although there are various classification systems, the most universally used classification of cutaneous tuberculosis
variants is based on the following:

Exogenous cutaneous tuberculosis: Tuberculous chancre and tuberculosis verrucosa cutis

Endogenous cutaneous tuberculosis: Contiguity or autoinoculation (scrofuloderma, orificial tuberculosis and

some cases of lupus vulgaris); hematogenic dissemination (lupus vulgaris, tuberculous gumma, and acute
miliary tuberculosis)

Tuberculids: Papulonecrotic tuberculid; Lichen scrofulosorum

Cutaneous tuberculosis: Secondary to Bacillus Calmette–Guerin vaccine (BCG) vaccination

Etiology
Infection with M. tuberculosis causes cutaneous tuberculosis. It is a transmittable disease that spreads from one
affected person to another. It can also be caused by Mycobacterium bovis and BCG vaccine, less commonly.[4][5][6]

Epidemiology
Unlike pulmonary tuberculosis, cutaneous tuberculosis is not common. Of all the patients that present with extra-
pulmonary manifestations of tuberculosis, 1% to 2% suffer from cutaneous tuberculosis. It is more prevalent in parts
of the world where infection with human immunodeficiency virus (HIV) is common, or where people are
immunodeficient for other reasons.

Pathophysiology
Cutaneous invasion of M. tuberculosis causes the disease. This invasion can be exogenous or endogenous.
Endogenous invasion is usually due to spread of pulmonary tuberculosis by hematogenous or lymphatic
dissemination. Exogenous invasion is due to direct inoculation of bacteria. This leads to an immune cascade within

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cutaneous cells that leads to the formation of granulomas, the hallmark of tuberculosis. These present with a variety
of clinical lesions.

Histopathology
Early lesions may show surface ulceration, epidermal hyperplasia, and a dense dermal infiltrate of neutrophils,
lymphocytes and plasma cells. Over time, chronic inflammatory cells and granulomatous inflammation replace the
neutrophils, with variable caseation necrosis. Acid-fast bacilli are usually easy to find in early lesions but are rare
once granulomas develop.

History and Physical

The history of the patient may describe a variety of symptoms. A patient may have pulmonary tuberculosis along with
cutaneous tuberculosis and may give a history of cough, sputum, night sweats, fever, weight loss, hemoptysis, chest
pain, and fatigue, among others, along with cutaneous symptoms. In disseminated cutaneous tuberculosis, abdominal
pain and diarrhea may suggest abdominal tuberculosis. A headache may indicate tubercular meningitis. Direct
inoculation of bacteria presents with cutaneous symptoms alone.

History may also reveal immune deficiency due to underlying diseases like AIDS, uncontrolled diabetes, malignancy,
and end-stage renal disease (ESRD). Other causes of immunodeficiency include intravenous drug abuse and
immunosuppressive therapy.

On examination, physical findings may include various kinds of cutaneous lesions. There can be inflammatory
papules, ulcers, nodules, pustules, verrucous plaques, or any other type of lesion.

Evaluation
Evaluation of suspected cutaneous tuberculosis requires history and examination along with a full workup. The
workup may include the tuberculosis skin test (TST) or Mantoux test, Serum QuantiFERON-TB Gold (QFT-
G) levels, PCR, and skin biopsy.[7][8][9]

Tuberculosis skin test (TST) involves inoculation with 0.1 mL of liquid that contains purified protein derivative
(PPD) into the skin. The site for the injection is the superficial skin of the volar wrist or forearm. The test is
interpreted after a wait of 48 to 72 hours. The diameter of the skin induration is measured and recorded.

The serum QFT-G test is an alternative to tuberculin skin test (TST). It is a blood test that detects both active and
latent tuberculosis by gamma interferon release assay.

Skin biopsy is a reliable test for the diagnosis of cutaneous tuberculosis. A skin biopsy is evaluated in 2 ways. First,
slides are prepared and examined under a microscope to detect acid-fast bacilli. Second, the skin tissue is cultured at
low temperature to detect growth of M. tuberculosis. Culture is the gold standard for diagnosis of tuberculosis.

Other tests that can help with diagnosis include a chest x-ray and sputum examination. Sputum examination involves
microscopy for AfB and culture.

Treatment / Management
Treatment of cutaneous tuberculosis is the same as treatment of systemic tuberculosis. It also involves multidrug
treatment. The drugs that are most commonly used are isoniazid, rifampicin, pyrazinamide, and ethambutol or
streptomycin. The treatment consists of 2 phases.

An intensive phase that involves rapidly decreasing the burden of M. tuberculosis

A continuation phase that is also called the sterilizing phase

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The intensive phase of therapy lasts about 8 weeks. After this phase, the patient no longer remains infectious, but he
or she still requires more treatment to eradicate the infection. The continuation phase is designed to eradicate
remaining bacteria and lasts for 9 to 12 months. Cure of tuberculosis requires the patient to adhere to treatment
strictly.

Results of treatment depend on the immunity of a patient, their overall health, the stage of the disease, the type of
cutaneous lesions, the patient’s compliance, duration of treatment, and any side effects experienced.

Differential Diagnosis
Differential diagnosis of cutaneous tuberculosis includes:

Chronic vegetative pyoderma

Blastomycosis

Chromoblastomycosis

Drug reactions

Granulomatosis with polyangiitis (Wegener granulomatosis)

Granulomatous rosacea

Syphilitic gumma

Keratosis spinulosa

Papular eczema

Coccidioidomycosis

Glossitis

Atypical mycobacterial infection

Chronic granulomatous disease

Lupoid rosacea

Nodular vasculitis (Weber-Christian disease)

Nodular pernio

Many different diseases can be included in differential diagnosis depending on the presentation of cutaneous
tuberculosis. It is difficult to make a diagnosis of this disease because of its resemblance with many other cutaneous
lesions.

Prognosis
Prognosis of cutaneous tuberculosis is good in patients who are not immunocompromised. However, even aggressive
treatment may not be effective in patients who are immunocompromised and where the organisms are multidrug
resistant.

Pearls and Other Issues

Prevention

Prevention of cutaneous tuberculosis involves BCG vaccination; identification, separation, and treatment of the
person who is a source of infection; and use of sterilized instruments, along with other steps. As immunodeficiency is

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the biggest cause of skin tuberculosis, one should try to avoid it by controlling diabetes and other diseases. In cases
where drug therapy is the cause of immunodeficiency, pretesting and treating latent tuberculosis with antibiotics are
indicated.

Compliance

Compliance with treatment recommendations is essential when it comes to treating tuberculosis. A patient who is not
compliant may cause the organisms to be drug resistant. Multiple therapies may be needed, and in such patients,
directly observed treatment (DOT) is recommended.

Enhancing Healthcare Team Outcomes

Cutaneous tuberculosis may present to the nurse practitioner or primary care provider. Since the skin features are not
always obvious, the patient should be referred to an infectious disease consult, dermatologist or an internist. The
management of cutaneous tuberculosis is the same as treatment of systemic tuberculosis. It also involves multidrug
treatment. The drugs that are most commonly used are isoniazid, rifampicin, pyrazinamide, and ethambutol or
streptomycin. The treatment consists of 2 phases.

An intensive phase that involves rapidly decreasing the burden of M. tuberculosis

A continuation phase that is also called the sterilizing phase

Results of treatment depend on the immunity of a patient, their overall health, the stage of the disease, the type of
cutaneous lesions, the patient’s compliance, duration of treatment, and any side effects experienced.[10][11]

Questions
To access free multiple choice questions on this topic, click here.

References
1. Haitz K, Ly A, Smith G. Idiopathic granulomatous mastitis. Cutis. 2019 Jan;103(1):38-42. [PubMed: 30758334]
2. Mello RB, Vale ECSD, Baeta IGR. Scrofuloderma: a diagnostic challenge. An Bras Dermatol. 2019 Jan-
Feb;94(1):102-104. [PMC free article: PMC6360976] [PubMed: 30726475]
3. Chen ST, Cahalane AM, Ryan ET, Foreman RK. Case 2-2019: A 36-Year-Old Man with Rash, Abdominal Pain,
and Lymphadenopathy. N. Engl. J. Med. 2019 Jan 17;380(3):275-283. [PubMed: 30650323]
4. Hirt P, Price A, Alwunais K, Schachner L. An interesting case of coincidental epidermolytic hyperkeratosis and
erythema annulare centrifugum in the setting of latent tuberculosis in a 12-year-old female. Int. J. Dermatol. 2019
Jan 08; [PubMed: 30623423]
5. Yeo PM, Lee SX, Tan YE, Sng LH, Ang CC. Epidemiology, risk factors, and outcomes of adult cutaneous non-
tuberculous mycobacterial infection over a 10-year period in Singapore. Int. J. Dermatol. 2018 Dec 25; [PubMed:
30585309]
6. Khan A, Singaraddi R, Shetty D, Rodrigues G. Primary cutaneous 'ulcerative' tuberculosis of the scrotum: a rare
occurrence. BMJ Case Rep. 2018 Dec 19;11(1) [PMC free article: PMC6303554] [PubMed: 30573537]
7. Franco-Paredes C, Marcos LA, Henao-Martínez AF, Rodríguez-Morales AJ, Villamil-Gómez WE, Gotuzzo E,
Bonifaz A. Cutaneous Mycobacterial Infections. Clin. Microbiol. Rev. 2018 Jan;32(1) [PMC free article:
PMC6302357] [PubMed: 30429139]
8. Errichetti E, Stinco G. Dermatoscopy of Granulomatous Disorders. Dermatol Clin. 2018 Oct;36(4):369-375.
[PubMed: 30201146]
9. Khadka P, Koirala S, Thapaliya J. Cutaneous Tuberculosis: Clinicopathologic Arrays and Diagnostic Challenges.
Dermatol Res Pract. 2018;2018:7201973. [PMC free article: PMC6077618] [PubMed: 30111996]
10. van Zyl L, du Plessis J, Viljoen J. Cutaneous tuberculosis overview and current treatment regimens. Tuberculosis
(Edinb). 2015 Dec;95(6):629-638. [PubMed: 26616847]
11. Bellet JS, Prose NS. Skin complications of Bacillus Calmette-Guérin immunization. Curr. Opin. Infect. Dis.
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9/18/2019 Cutaneous Tuberculosis - StatPearls - NCBI Bookshelf

2005 Apr;18(2):97-100. [PubMed: 15735410]

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