Cutaneous Tuberculosis

17
Cutaneous tuberculosis has recorded an inc- – Hematogenous, resulting in miliary tuber-
rease in its incidence recently. This has largely culosis in an immunocompromised host,
coincided with the general decline in pulmo- especially, in children.
nary tuberculosis in developed countries. The
current situation in the Indian subcontinent &ODVVL¿FDWLRQ
seems to approximate that of developed coun- Cutaneous tuberculosis is a manifestation of
tries of the temperate regions of the globe. cell-mediated immunity. It is divided into the
Hence, it is imperative to study the pattern of following:
cutaneous tuberculosis in the tropics, which Primary tuberculosis: It manifests in an indi-
PD\QRWRQO\KHOSLQGHÀQLQJLWVVWDWXVEXWDOVR vidual not previously infected or who has
enrich teaching. QRW DFTXLUHG D QDWXUDO RU DUWLÀFLDO LPPXQLW\
to the tubercle bacillus. It may present either
Causative Microorganisms as:
Mycobacterium tuberculosis, Mycobacterium bovis, ‡ 3ULPDU\ LQRFXODWLRQ WXEHUFXORVLV WXEHUFX
and Bacillius Calmette Guerin occasionally are lous chancre), or
responsible for cutaneous tuberculosis. ‡ $FXWHPLOLDU\WXEHUFXORVLVRIWKHVNLQ
Secondary tuberculosis: It develops in an indi-
Route of Infection vidual who has either been previously infected
It may either be the result of the following: RUKDVDFTXLUHGDQDWXUDORUDUWLÀFLDOLPPXQLW\
‡ ([RJHQRXVLQRFXODWLRQ to the tubercle bacillus. It is perceived as
– Primary chancre, in the absence of hyper- forming a continuous spectrum with lupus
sensitivity to tubercle bacillus vulgaris and tuberculosis verrucosa cutis at one
– Lupus vulgaris (LV) and tuberculosis end and scrofuloderma and tuberculosis cutis
verrucosa cutis (TBVC) in a presensitized RULÀFLDOLVDWWKHRWKHU7KLVVSHFWUXPWDNHVLQWR
host. account the gradation of cell-mediated immu-
‡ (QGRJHQRXVVSUHDGWKURXJK nity of the host from high to low across the
– Contiguous extension (autoinoculation) spectrum. Secondary cutaneous tuberculosis is
resulting either in scrofuloderma or tuber- conceived either as the reinfection (lupus vulga-
FXORVLVFXWLVRULÀFLDOLV7%&2 ris and tuberculosis verrucosa cutis) or reacti-
– Lymphatics, resulting in lupus vulgaris vation (scrofuloderma and tuberculosis cutis
in previously sensitized individual RULÀFLDOLV
 76 Textbook of Clinical Dermatology

Clinical Features with the lymphadenitis. The primary lesion

Tuberculous Chancre usually heals with scarring, but may persist
or terminate in lupus vulgaris or tuberculosis
It results from the inoculation of Mycobacteria YHUUXFRVDFXWLV7KHUHJLRQDOQRGHVPD\EUHDN
LQWRWKHVNLQRUPXFRVDRIDQRQVHQVLWL]HGLQGL GRZQ SURGXFLQJ VFURIXORGHUPD 2FFDVLRQDOO\
YLGXDO 7UDXPD RU DQ\ EUHDN LQ WKH FRQWLQXLW\ erythema nodosum may develop.
RIVNLQVHUYHVDVDSRUWDORIHQWU\7KHVLWHVRI
predilection are those amenable to trauma. Face Acute Miliary Tuberculosis of the Skin
and the extremities are commonly affected. It is an uncommon expression of cutaneous
7ZRWRIRXUZHHNVDIWHUWKHLQLWLDOLQWURGXFWLRQ tuberculosis that occurs primarily in infants
of the bacilli, forms a nodule that evolves into and children, resulting from the hematogenous
DQLQGROHQWÀUPQRQWHQGHUVKDUSO\GHOLPLWHG dissemination of the tubercle bacilli. The initial
ulcer (Fig. 17.1). The bacilli reach the regional focus of infection is either pulmonary or menin-
lymph nodes and produce a painless tuber- geal and it may follow exanthems especially
FXORXV O\PSKDGHQRSDWK\ DERXW  WR  ZHHNV measles or severe infections, that lower the
after the initial infection. Tuberculous chancre, immunologic defence mechanisms. Dissemina-
lymphangitis, and regional lymphadenopathy, ted lesions occur on all parts of the body, but
a prototype of primary inoculation tuberculosis, PRVWIUHTXHQWO\RQWKHWUXQNWKLJKVEXWWRFNV
DNLQ WR WKH *KRQ·V FRPSOH[ LV SURGXFHG 7KH and genitalia. They begin as discrete, pin-head
seroconversion to the intradermal PPD coincides sized, bluish-red to brown papules capped by
minute vesicles. These vesicles dry up to form
crust. Removal of the crust reveals a small
umbilication. The lesions heal with the forma-
tion of a white depressed scar with a brownish
halo. Tuberculin sensitivity is absent because
of the overwhelming infection. The disease is
usually fatal.

Lupus Vulgaris
,WLVDUHLQIHFWLRQWXEHUFXORVLVRIWKHVNLQRFFXU
ring in previously sensitized host with a high
degree of tuberculin sensitivity. Immunity is
moderate, and hypersensitivity to PPD is high.
It may appear following exogenous inocula-
tion or occasionally, may be the result of either
direct extension or lymphatic spread. It may
appear over the primary inoculation site, but it
usually follows tuberculosis at other site. It may
appear over the scar of scrofuloderma or after
Figure 17.1: Tuberculous chancre on the cheek %&* YDFFLQDWLRQ +LJK GHJUHH RI LPPXQLW\ WR
 Cutaneous Tuberculosis 77
the tubercle bacilli in lupus vulgaris results in
slower evolution of the disease.
The lesion is usually solitary. The initial le-
sion is a small, brownish red papule of soft
FRQVLVWHQF\¶$SSOHMHOO\QRGXOHV·WKRXJKFRQ-
sidered as pathognomonic of the disease are in-
frequently demonstrated. It gradually becomes
HOHYDWHG LQÀOWUDWHG DQG EURZQ LQ FRORU ,W
shows gradual peripheral extension and central
atrophic areas. The diverse clinical variants of
lupus vulgaris are as follows:
Plaque form: It PDQLIHVWV DV ÁDW SODTXHV ZLWK
SRO\F\FOLF RU VHUSLJLQRXV FRQÀJXUDWLRQ 7KH
Figure 17.3: Lupus vulgaris affecting the lips
surface may be smooth or covered with scales.
The plaque may show scarring with islands of
active lupoid lesion (Fig. 17.2). tissues and cartilage are destroyed producing
Hypertrophic form: It may present either as soft contractures and deformities.
tumorous growths with a nodular surface or Vegetating form: ,WLVFKDUDFWHUL]HGE\PDUNHG
DV K\SHUNHUDWRWLF PDVVHV (GHPD O\PSKDWLF LQÀOWUDWLRQQHFURVLVDQGXOFHUDWLRQZLWKPLQL
stasis, vascular dilatation, and elephantiasis mal scarring.
may be present. Papular and nodular forms: It has also a special
Ulcerative form: Necrosis, ulceration, and scar- character.
ring predominate in this form. The deeper Lupus vulgaris may affect buccal, nasal, and
FRQMXQFWLYDO PXFRVDH )LJ  HLWKHU SULPD
rily or by extension of the cutaneous lesion. The
nose is frequently affected with the destruction
of its cartilage. Direct extension or lymphatic
spread from nasal focus may result in the
involvement of the palate, gingiva, larynx, and
pharynx.
Scarring is a cardinal feature of healing
lupus vulgaris. It may be extensive resulting in
the destruction of the underlying tissues and
cartilage and subsequent cicatricial changes.
This is responsible for the deformities and
mutilations such as ectropion, microstomia,
FRQWUDFWXUHVNHORLGVGHIRUPLWLHVRIVRIWSDODWH
and laryngeal stenosis. Squamous cell carci-
noma and rarely basal cell carcinoma, and
Figure 17.2: /XSXVYXOJDULV$ÀDWSODTXHGHSLFWLQJ sarcoma may complicate.
VFDUZLWKLVODQGVRIDFWLYHSRO\F\FOLFFRQ¿JXUDWLRQ
 78 Textbook of Clinical Dermatology

Tuberculosis Verrucosa Cutis (TBVC) SODTXH LV XVXDOO\ ÀUP EXW DUHDV RI VRIWHQLQJ
It is a verrucous form of reinfection tuberculo- PD\EHSUHVHQWLQWKHFHQWHU3XVDQGNHUDWLQRXV
VLVUHVXOWLQJIURPH[RJHQRXVUHLQIHFWLRQRIVNLQ PDWHULDO PD\ EH H[SUHVVHG IURP WKH ÀVVXUHV
with tubercle bacilli in a previously infected The lesion progresses centrifugally resulting in
and/or sensitized individual possessing a mod- an annular or serpiginous pattern. Spontaneous
erate to high degree of immunity. resolution may occur at the center. Lymph node
Inoculation occurs at the site of minor abra- enlargement, if associated with TBVC is the
sion or wounds and areas amenable to trauma result of secondary infection and is not due to
DUH WKH XVXDO VLWHV RI DIÁLFWLRQ QDPHO\ WKH the tuberculous process. Classically the lesions
KDQGV ÀQJHUV DQG ORZHU H[WUHPLWLHV ,W LV DQ of TBVC is solitary, however, multiple lesions
occupational hazard for the physicians, patho- have also been recorded.
logists, forensic experts conducting autopsy,
farmers, and butchers. Scrofuloderma
It starts as an asymptomatic, small papule or It is reactivation tuberculosis occurring as a result
D SDSXORSXVWXOH ZLWK DQ LQÁDPPDWRU\ DUHROD of reactivation of the tubercle bacilli introduced
developing at the site of inoculation. It soon during a prior episode of the disease and lying
EHFRPHVK\SHUNHUDWRWLFDQGZDUW\%\JUDGXDO dormant since then. They are reactivated at an
irregular peripheral extension, it develops into a opportune time when the cell-mediated immu-
verrucous plaque with horny surface traversed nity of the individual is lowered. Such patients
E\ GHHS FOHIWV DQG ÀVVXUHV )LJ  7KH are sensitized to the tubercle bacilli, but possess
low cell-mediated immunity to it.
It originates as a tuberculous process of the
subcutaneous tissue which subsequently turns
LQWRDFROGDEVFHVV7KHUHLVDVHFRQGDU\EUHDN
GRZQRIWKHVNLQRYHUO\LQJVXFKDWXEHUFXORVLV
focus (Fig. 17.5). The tuberculosis of the lymph
QRGHVERQHVMRLQWVDQGHSLGLG\PLVLVXVXDOO\
responsible for scrofuloderma. Cervical group
of lymphnodes are most often involved. How-
HYHUDIÁLFWLRQRID[LOODU\LQJXLQDOSDUDVWHUQDO
and epitrochlear lymph nodes are also common.
,QWKHQHFNWKHWRQVLOODUVXEPDQGLEXODUSUHDX
ricular, postauricular, occipital, and supraclavi-
cular lymph nodes are usually implicated.
 7KHLQLWLDOOHVLRQSUHVHQWVDVDÀUPVXEFXWD
neous or deep cutaneous swelling or nodule,
which is freely movable. It later becomes atta-
FKHGWRWKHVNLQ,WWKHQVXSSXUDWHVVRIWHQVDQG
Figure 17.4: Tuberculosis verrucosa cutis: Verrucous LQYROYHVWKHRYHUO\LQJVNLQZLWKUHVXOWDQWXOFH
SODTXH ZLWK KRUQ\ VXUIDFH WUDYHUVHG E\ GHHS FOHIWV
ration and sinus formation. Multiple ulcers may
¿VVXUHV
 Cutaneous Tuberculosis 79
to tuberculin in these patients is controver-
sial, however, such patients ultimately develop
anergy.
The underlying disease is a far advanced
pulmonary, intestinal, or genitourinary tubercu-
losis. Bacilli shed from these foci become inocu-
lated into the mucocutaneous areas of the
RULÀFHVDWDWUDXPDWL]HGVLWH8OFHUDWLYHOHVLRQV
occur in the oral cavity, perineal, or perirectal
areas. The tongue is the most common affected
site in the mouth, particularly its tip and the
lateral margins. Soft and hard palate, lips, and
WRRWKVRFNHWPD\DOVREHLQYROYHG,QLQWHVWLQDO
tuberculosis the area on and around the anus
and in genitourinary tuberculosis vulva, glans
penis, and the urinary meatus are involved.
The lesion consists of a small, yellowish or
UHGGLVK QRGXOH WKDW UDSLGO\ EUHDNVGRZQ WR
form an exquisitely painful, shallow ulcer with
Figure 17.5: 6FURIXORGHUPD$QXOFHUZLWKEOXLVKXQGHU bluish undermined edges. The surrounding
PLQHGHGJHVDQGVRIWJUDQXODWLQJVXUIDFH
mucosa is swollen, and the ulcer is covered with
form which are arranged linearly. These ulcers pseudomembranous material.
have bluish undermined edges and soft granu-
ODWLQJÁRRUV7KHUHLVRIWHQDZDWHU\SXUXOHQW Histopathology
or gaseous discharge from the sinuses. The histopathologic reactions to M. tuberculosis
 6SRQWDQHRXVKHDOLQJRFFXUVEXWLWWDNHV\HDUV can be organized along an immunopathologic
EHIRUHLWLVFRPSOHWH&RUGOLNHNHORLGVFDUVDQG VSHFWUXPDVLQOHSURV\$VHTXHQFHIURPQRQ
localized recurrences are characteristic. necrotic epithelioid cell granulomas with no
Scrofuloderma is usually associated with acid-fast bacilli (high immune) through necrotic
manifest tuberculosis elsewhere in the body, epithelioid granulomas with some acid-fast
usually in the lungs. bacilli to the position of necrosis with abundant
acid-fast bacilli (low immune) can be arranged.
7XEHUFXORVLV&XWLV2UL¿FLDOLV /XSXVYXOJDULVW\SLÀHVWKHKLJKLPPXQHSROH
It is the tuberculosis of the mucous memb- DQGWKHSDWLHQWVZLWK7%&2DQGDFXWHPLOLDU\
UDQHV DQG WKH VNLQ RI WKH RULÀFHV UHVXOWLQJ tuberculosis form the low immune pole. The
from autoinoculation of tubercle bacilli in KDOOPDUN RI WKH KLVWRSDWKRORJLF GLDJQRVLV RI
patients with advanced visceral tuberculosis. cutaneous tuberculosis is the presence of tub-
It affects men more often than the women and erculous/tuberculoid granuloma.
is most often prevalent in the middle-aged or Primary tuberculous chancre: The early histo-
older individuals. Cutaneous hypersensitivity logic picture is an acute neutrophilic reaction
 80 Textbook of Clinical Dermatology

punctuated by areas of necrosis and associated PLQLPDODQGWKHWXEHUFOHEDFLOOLDUHGLIÀFXOWWR

with numerous tubercle bacilli. Three to 6 demonstrate. Secondary epidermal changes in
ZHHNV ODWHU FRLQFLGLQJ ZLWK WKH FRQYHUVLRQ RI the form of atrophy, ulceration, acanthosis, or an
WKHWXEHUFXOLQVHQVLWLYLW\WKHLQÀOWUDWHEHFRPHV occasional pseudoepitheliomatous hyperplasia
granulomatous and epithelioid cells, giant cells, PD\EHSUHVHQW$VTXDPRXVFHOOFDUFLQRPDLV
and lymphocytes appear. Caseation necrosis an uncommon outcome.
becomes evident, and the tubercle bacilli Tuberculosis verrucosa cutis: The histologic
become sparse. SLFWXUHFRQVLVWVRIK\SHUNHUDWRVLVK\SHUJUDQX
Acute miliary tuberculosis: Histologic examin- losis, acanthosis, and papillomatosis overlying
ation reveals focal areas of necrosis and abscess DQ DFXWH LQÁDPPDWRU\ LQÀOWUDWH LQ WKH HSLGHU
formation, surrounded by a zone of macro- mis and microabscesses in the upper der-
phages, containing numerous tubercle bacilli. mis. Tuberculoid granulomas with moderate
Lupus vulgaris: Tuberculoid structures com- amount of caseation necrosis and few tubercle
posed of epithelioid cells, occasional Langhans EDFLOOLDUHVHHQLQWKHPLGGHUPLV$WWLPHVWKH
giant cell, and mononuclear cells are present, GHUPDOLQÀOWUDWHPD\EHQRQVSHFLÀFDOWRJHWKHU
XVXDOO\ LQ WKH XSSHU GHUPLV 2I WKH PRQR 0DUNHGÀEURVLVKRZHYHURFFXUVFRQVLVWHQWO\
nuclear cells, monocytes lie in the immediate Scrofuloderma: Histopathologic examination of
periphery of the tubercles, while lymphocytes the center of the lesion reveals ulceration and
DUH ORFDWHG IDUWKHU DZD\ 2FFDVLRQDO IRUHLJQ abscess formation. Tuberculoid structures with
ERG\JLDQWFHOOPD\EHSUHVHQW)LJV$DQG PDUNHG FDVHDWLRQ QHFURVLV DUH SUHVHQW LQ WKH
B). Caseation necrosis when present is usually ORZHUGHUPLVDQGDWWKHSHULSKHU\(SLWKHOLRLG
FHOOV IRUP WKH PDMRU FRPSRQHQW ZLWK D ODUJH
number of giant cells. Tubercle bacilli are easily
LGHQWLÀHG$VWKHOHVLRQJHWVROGHUDQGFDVHDWLRQ
necrosis sets in, however, it becomes relatively
PRUHGLIÀFXOWWRGHPRQVWUDWHWKHEDFLOOL*UDQX
loma formation may not be appreciated and the
VHFWLRQV PD\ RQO\ VKRZ D QRQVSHFLÀF FKURQLF
LQÁDPPDWRU\LQÀOWUDWH
7XEHUFXORVLVFXWLVRUL¿FLDOLV The histologic pic-
WXUHLVXVXDOO\QRQVSHFLÀFVKRZLQJXOFHUDWLRQ
and lymph edema. Yet, in most cases, tuber-
FXORLGLQÀOWUDWHVZLWKSURQRXQFHGQHFURVLVDUH
found deep in the dermis. Tubercle bacilli are
A B easy to demonstrate.
Figure 17.6A: 7XEHUFXORLG JUDQXORPD GLVSOD\LQJ O\P Diagnosis
SKRF\WHV KLVWLRF\WHVJLDQW FHOOV + DQG ( î   %
7XEHUFXORVLV YHUUXFRVD FXWLV 7%9&+ DQG ( î   The diagnosis of secondary cutaneous tuber-
Courtesy: %ODFNZHOO 6FLHQFH ,1& 6HKJDO 91 et al. culosis is made on the basis of relevant posi-
5HLQIHFWLRQVHFRQGDU\LQRFXODWLRQFXWDQHRXVWXEHUFX-
ORVLV,QW-'HUPDWRO tive history. In reinfection tuberculosis, it is
 Cutaneous Tuberculosis 81
imperative to form a history of primary infection very strong evidence against any but the miliary
RU %&* YDFFLQDWLRQ 7KH ODWWHU LQ SDUWLFXODU WXEHUFXORVLV$WXEHUFXORXVJUDQXORPDFKDUDF
VKRXOG EH JLYHQ GXH FRQVLGHUDWLRQ IRU %&* terized by an accumulation of epithelioid cells
vaccination forms an important component of surrounded by a wall of mononuclear cells,
LPPXQL]DWLRQ SURJUDP ,W PD\ EH LGHQWLÀHG presence of giant cells and caseation necrosis,
WKURXJK %&* VFDU 3ULPDU\ LQIHFWLRQ DQGRU is diagnostic of tuberculosis. It is also possible
%&* YDFFLQDWLRQ LV UHVSRQVLEOH IRU WKH FHOOXODU to demonstrate acid-fast bacilli in such a granu-
immunity and sensitization to the tubercle ORPD+RZHYHUWKHVLJQLÀFDQFHRIWXEHUFXORLG
bacillus. Subsequently, infection by another JUDQXORPDPDUNHGE\DFFXPXODWLRQRIHSLWKH
strain of M. tuberculosis in such an individual lioid cells surrounded by mononuclear cells
is responsible for reinfection tuberculosis. The and conspicuous absence of caseation necrosis
evolution of the disease is slow. is relative.
In reactivation tuberculosis, a history of acute The recovery of M. tuberculosis on culture
V\VWHPLFWXEHUFXORVLVLQWKHSDVWLVXVXDOO\DIÀU- LQ/RZHQVWHLQ-HQVHQPHGLDWRZHHNVDIWHU
mative which was diagnosed by clinical and in- LQRFXODWLRQ FRQÀUPV WKH GLDJQRVLV +RZHYHU
vestigative procedures, namely lymphocytosis, an effort should be made to exclude atypical
UDLVHGEORRGVHGLPHQWDWLRQUDWHVNLDJUDPRIWKH Mycobacteria by performing niacin test and
FKHVW UHYHDOLQJ LQÀOWUDWLRQ RI WKH SDUHQFK\PD ORRNLQJ IRU WKH IRUPDWLRQ RI SLJPHQW RQ
producing mottling, or cavitation, or pleural ef- H[SRVXUH WR VXQOLJKW *XLQHD SLJ LQRFXODWLRQ
fusion, or enlargement of hilar lymph nodes, provides absolute, though delayed proof of
positive reaction to Mantoux test, demonstration SDWKRJHQHFLW\ &RQÀUPDWLRQ KRZHYHU LV QRW
of the acid-fast bacilli in the smear and its recov- DOZD\V SRVVLEOH HYHQ E\ WDNLQJ LQWR DFFRXQW
ery in culture. Futhermore, there is a history of WKHVHUHODWLYHDQGDEVROXWHFULWHULD$WKUHDSHX
administration of antitubercular drugs in ade- WLF WULDO LV WKHQ MXVWLÀHG LI FOLQLFDO VXVSLFLRQ LV
quate dosage for a requisite period. Subsequent VWURQJ $ VKRUWWHUP LQWHQVLYH FKHPRWKHUDS\
to that the patient recovered and was declared results in amelioration of the signs and symp-
cured. The only evidence of such active systemic toms and appreciable clinical improvement in
GLVHDVH PD\ EH SXOPRQDU\ VFDUULQJ ÀEURVLV DVVKRUWSHULRGDVWRZHHNV
DQGRU FDOFLÀFDWLRQ DV UHYHDOHG RQ VNLDJUDP
However, some of the tubercle bacilli escape the Treatment
action of antitubercular drugs and lie in a dor- The treatment of cutaneous tuberculosis is
PDQW VWDWH DV ¶SHUVLVWHUV· DQG DUH UHDFWLYDWHG DW similar to that of systemic tuberculosis. The
an opportune time. REMHFWLYHVRIWUHDWPHQWDUHLWRSURPSWO\FXUH
Besides the history, the other relative criteria the disease, thus reducing its morbidity, (ii) to
are the morphology of the lesion, and the prevent the emergence of resistant strains and
Mantoux test. The diagnostic value of positive LLLWRSUHYHQWWKHHPHUJHQFHRI¶SHUVLVWHUV·DQG
WXEHUFXOLQ WHVW LV EOXUUHG E\ %&* YDFFLQDWLRQ hence reduce the possible relapses. In order to
in early life and by exposure to related Myco- DFKLHYHWKHSUHFHGLQJREMHFWLYHVLWLVLPSHUDWLYH
bacteria. However, a very strongly positive to administer antitubercular drugs, the details
Mantoux test is a strong suspicion of active RI ZKLFK DUH JLYHQ LQ 7DEOH  $Q LQWHQVLYH
WXEHUFXORXV LQIHFWLRQ $ QHJDWLYH UHDFWLRQ LV D short course regimen comprising isonicotinic
 82 Textbook of Clinical Dermatology

Table 17.1: Antitubercular drugs

Dosage
Drugs Adults Children Side effects/interactions with other drugs
5LIDPSLFLQ WRPJ WRPJNJ Intermittent dosing RQFHZHHN
   ,QÀXHQ]DOLNHV\QGURPHZLWKPDODLVHDQGKHDGDFKH
   $FXWHKHPRO\WLFDQHPLDZLWKLQWRKURIGRVLQJ
   $FXWHUHQDOIDLOXUHZLWKZLWKRXWKHPRO\VLV
   )HYHUUDVKO\PSKDGHQLWLV
Daily dosing
   +HSDWLWLV HSHFLDOO\ LQ DOFRKROLFV HOGHUO\ DQG WKRVH
ZLWKOLYHUGLVHDVHDVZHOO
,VRQLFRWLQLFDFLG PJ WRPJNJ 6HQVRU\DQGPRWRUSHULSKHUDOQHXURSDWK\GXHWR
K\GUD]LGH,1$+   S\ULGR[LQHGH¿FLHQF\
   0HQWDO GLVWXUEDQFHV LQFRRUGLQDWLRQ RSWLF QHXULWLV
convulsions
   /LYHUGDPDJH
Precipitation of epilepsy
   ,QKLELWLRQRISKHQ\WRLQPHWDEROLVP
(WKDPEXWRO WRPJ PJNJ 2SWLFQHXULWLVGRVHUHODWHGSDUWO\UHYHUVLEOHDIIHFWLQJ
one or both eyes
Rarely peripheral scotoma
   5HGJUHHQFRORUEOLQGQHVV
   'HFUHDVHGXUDWHFOHDUDQFH
6WUHSWRP\FLQ WRJP PJNJ ,QFUHDVHVSODVPDXULQHDFLGE\GHFUHDVHRIUHQDO
 ,QWUDPXVFXODU  WXEXODUFOHDUDQFHPD\FDXVHDUWKUDOJLDRIODUJHDQG
small joints
   1HXURPXVFXODUEORFN
   'RVHUHODWHGUHQDOWXEXODUWR[LFLW\
3\UD]LQDPLGH WRJP WRPJNJ 1HSKURWR[LF
   +HSDWLWLVZLWKKLJKGRVHVWRPJNJRQO\
Local injection in pleural or peritoneum may cause
UHVSLUDWRU\ SDUDO\VLV GXH WR FXUDUHOLNH FRPSHWLWLYH
inhibition
Different types of skin rashes
Drug fever with eosinophilia
   &RQWUDLQGLFDWHGLQOLYHUDQGNLGQH\GLVHDVH
3DUDPLQR WRJP PJNJ 8QSOHDVDQWWDVWHJDVWURLQWHVWLQDOLUULWDWLRQDQG
VDOLF\FOLFDFLG  &U\VWDOOXULD QDXVHDYRPLWLQJDQGGLDUUKHD
   $JUDQXORF\WRVLVDQGWKURPERF\WRSHQLD
   +HPRO\WLFDQHPLD
   +\SRWK\URLGLVPJRLWHUGLDEHWHVPHOOLWXV
   +HSDWLWLV
7KLDFHWD]RQH PJ PJNJ *DVWURLQWHVWLQDOV\PSWRPVVXFKDVQDXVHDYRPLWLQJ
GLDUUKHD
   (U\WKPDPXOWLIRUPH
Agranulocytosis
(WKLRQDPLGH PJ  *DVWURLQWHVWLQDOV\PSWRPV
3URWKLRQDPLGH
&DSUHRP\FLQ JP,QWUDPXVFXODU  9HVWLEXODUWR[LFLW\
&\FORVHULQH JP,QWUDPXVFXODU  &16WR[LFLW\
.DQDP\FLQ JP,QWUDPXVFXODU  0RUHVHYHUHVLGHHIIHFWVWKDQVWUHSWRP\FLQ
 Cutaneous Tuberculosis 83
Table 17.2: Treatment regimens for tuberculosis*
6-month regimens
Drugs Phase 1:2 months Phase 2:4 months
,VRQLD]LG PJNJGDLO\ PJNJGDLO\
5LIDPSLFLQ PJNJGDLO\ PJNJGDLO\
3\UD]LQDPLGH PJNJGDLO\
6XSSOHPHQWHGLQDUHDVZKHUHUHVLVWDQFHWRRQHRIWKHVHGUXJVLVGHPRQVWUDWHGE\
6WUHSWRP\FLQ PJNJGDLO\
or
(WKDPEXWRO PJNJGDLO\

8-month regimens
Drugs Phase 1:2 months Phase 2:4 months
,VRQLD]LG PJNJGDLO\ PJNJGDLO\
5LIDPSLFLQ PJNJGDLO\
3\UD]LQDPLGH PJNJGDLO\
7KLRDFHWD]ROH  PJNJGDLO\
together with
6WUHSWRP\FLQ PJNJGDLO\
or
(WKDPEXWRO PJNJGDLO\
8QOHVVRWKHUZLVHLQGLFDWHGGRVHVDUHVXLWDEOHIRUERWKDGXOWVDQGFKLOGUHQ
PJNJIRUFKLOGUHQ

DFLG K\GUD]LGH ,1$+ ULIDPSLFLQ HWKDPEX scarred areas may be conveniently destroyed
tol, and pyrazinamide are given together for by cryotherapy or electrocautery.
an initial intensive phase lasting 2 months. This
LV IROORZHG E\ DGPLQLVWUDWLRQ RI ,1$+ DQG RECOMMENDED READING
ULIDPSLFLQ RQO\ IRU DQRWKHU  PRQWKV LQ FRQWL   $QRQ\PRXV :+2 0HGLFDO 3UHVFULELQJ ,QIRU
mation. Drugs used in mycobacterial disease.
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