Papers from ILDS
Dermatology 2008;217:89–93
DOI: 10.1159/000128284
Clinical and Epidemiological Study of
Cutaneous Tuberculosis in Northern
Ethiopia
Margherita Terranova a Valeska Padovese a Ugo Fornari b Aldo Morrone b
a
Italian Dermatological Centre, Ayder Hospital, Mekele, Ethiopia; b San Gallicano Institute, Preventive Medicine of
Migration, Tourism and Tropical Dermatology, Rome, Italy
Key Words
Cutaneous tuberculosis, Ethiopia ⴢ Developing countries ⴢ
HIV infection ⴢ Scrofuloderma ⴢ Gumma tubercularis ⴢ
Lupus vulgaris
Abstract
Background: Tuberculosis is a major public health problem
in Ethiopia but cutaneous tuberculosis (CT) has not been
documented. Objective: This study was conducted to deter-
mine its existence and its clinical pattern in Tigray, a north-
ern region of Ethiopia. Methods: We report 202 cases of CT
who attended the Italian Dermatological Centre in the 34-
month period between January 2005 and October 2007. The
diagnosis was made on a clinical, cytological and histologi-
cal basis. Results: Clinically, 143 cases of scrofuloderma, 22
of lupus vulgaris, 18 of gumma, 11 of lichen scrofulosorum,
6 of tuberculosis verrucosa cutis and 2 of erythema indura-
tum of Bazin were observed in our department. All patients
were aged between 18 months and 69 years, and 49 were
paediatric cases. Forty-five were HIV positive. Conclusion:
The number of CT cases observed in the period of 34 months
indicates a high incidence of the disease in the region also in
the paediatric age. CT is still underdiagnosed due to the low
number of dermatologists as well as the poor life conditions
of the population and the traditional belief in magic medi-
cine. The current study may therefore provide some indica-
tion about the epidemiology of CT in Ethiopia.
Copyright © 2008 S. Karger AG, Basel
© 2008 S. Karger AG, Basel
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Received: August 23, 2007
Accepted: December 5, 2007
Published online: April 29, 2008
Introduction
Tuberculosis (TB) is a major public health problem
worldwide and especially in the developing countries [1,
2]. Cutaneous tuberculosis (CT) comprises only a small
proportion (1–2%) of all cases of TB [3]; nevertheless, in
consideration of the high prevalence of TB in many de-
veloping countries, these numbers become significant.
The World Health Organization estimates that the TB
prevalence is 533/100,000 population for Ethiopia [4]. In
this country, nearly 52% of the population lives below the
national poverty line, and about 86% of the economically
active population works in agriculture [5]. In this study,
we present our clinical experience with 202 cases as first
report regarding CT in Ethiopia.
Materials and Methods
This study was conducted in the Italian Dermatological Cen-
tre (IDC) of Mekele, placed in the northern region of Ethiopia.
This hospital caters for the skin and venereal diseases of approxi-
mately 4 million people who are economically very poor.
During the period of intake, from January 2005 to October
2007, all cases of CT seen in the IDC were included in this study.
A diagnosis of CT was based upon a combination of clinical fea-
tures, fine-needle aspiration cytology (FNAC) and Ziehl-Neelsen
(ZN) staining and/or biopsy for histopathological evidence; cuta-
neous biopsy was performed from the most active part of the le-
sions. We used cytology as first line of investigation for the diag-
nosis of CT and biopsy for histological examination as second.
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Margherita Terranova, MD
San Gallicano Institute
Preventive Medicine of Migration, Tourism and Tropical Dermatology
Via di San Gallicano, 25A, IT–00153 Rome (Italy)
Tel. +39 32 8461 2574, Fax +39 06 5854 3786, E-Mail margheritaterranova@hotmail.com
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Table 1. Main features of patients

Type of CT Number of Males Females Mean Adult Paediatric Paediatric History of Lung Bone
patients age HIV+ cases HIV+ previous and involve- involve-
years (≤15 years) treated TB ment ment

Scrofuloderma 143 (70.8%) 70 73 27 28 46 12 32 10 14

Lupus vulgaris 22 (10.9%) 10 12 31 0 0 0 1 0 0
Gumma 18 (8.9%) 8 10 22 5 2 0 2 2 0
Lichen scrofulosorum 11 (5.4%) 4 7 27 0 1 0 1 7 0
Tuberculosis verrucosa cutis 6 (3%) 4 2 33 0 0 0 0 0 0
Erythema induratum of Bazin 2 (1%) 0 2 37 0 0 0 1 1 0
Total 202 96 106 27 33 49 12 37 20 14

Response to antituberculous therapy was an additional confirma-
tion. X-rays of the chest and/or of bones were performed in sus-
pect cases.
In Ethiopia, the current national guidelines drug regimen for
extrapulmonary TB consists of ethambutol, rifampicin and pyra-
zinamide for 8 weeks of the intensive phase and then ethambutol
and isoniazid for 6 months of the continuation phase.
Patients affected by extensive CT and gumma were admitted
to our department for daily dressing together with oral multi-
drug treatment (MDT).
Results
During the study period, 202 cases of CT were identi-
fied representing 0.7% of the outpatients attending the
IDC. Table 1 shows the mean features of the reported se-
ries. Patient ages ranged from 19 months to 69 years with
a mean of 27 years. Forty-nine were !15 years old (24.3%).
Thirty-seven subjects (18.3%) had a history of TB with a
complete 8-month cycle of treatment, and 36 (18%) had a
family history of TB. There were 106 female cases (52.4%),
so we did not observe the male predominance noted by
some previous studies [3, 6–9].
Scrofuloderma (SFD) was the commonest form seen in
143 patients (70.8%), followed by lupus vulgaris (LV) in 22
(10.9%), gumma in 18 (8.9%), lichen scrofulosorum (LS)
in 11 (5.4%), tuberculosis verrucosa cutis (TBVC) in 6 (3%)
and erythema induratum of Bazin in 2 (1%; table 1).
The lesions of SFD were ulcerated and mostly located
over the lymph nodes (120 cases), bones (14 cases), breast
(4 cases) and testicle (2 cases); suppuration and sinus were
visible in most patients. The affected sites originating
from lymph nodes were mainly the cervical areas (fig. 1)
and the axilla, but also the groins and chest. Superficial
colliquation was visible over osteomyelitis of the scalp,
ribs and limbs.
All cases of SFD were confirmed by FNAC and ZN
staining where acid-fast bacilli (AFB) were identified. The
FNAC confirmation of all cases of SFD permitted to ex-
clude any clinical suspicion of lymphogranuloma venere-
um, granuloma inguinale and hydroadenitis suppurativa
that represented the differential diagnosis in some pa-
tients. FNAC permitted also to include 4 cases of granulo-
matous mastitis (fig. 2) and 2 of monolateral orchitis with
superficial ulcerations as further manifestation of TB.
LV was the next most prevalent type of CT; affected
areas were the face and limbs. In our cases, LV consists of
a low number of total cases if compared with the report-
ed series of other countries [3, 9, 10]. Cutaneous leish-
maniasis represents the most important simulator of LV
and, among 199 of suspect cases, 175 consisted of leish-
maniasis confirmed by fine-needle aspiration and/or bi-
opsy and 2 of histologically proven actinomycosis.
LS was present in 11 patients as a non-itchy eruption
of multiple miniature follicular papules clustered on the
trunk resembling lichen spinulosus and pityriasis rubra
pilaris.
TBVC was seen in 3% of the series; all affected patients
were adults. It was characterized by asymptomatic, ver-
rucous plaques located on the limbs. Lichen planus ver-
rucosum and deep fungal infections as chromoblastomy-
cosis represented the main differential diagnosis.
Erythema induratum, consisting of firm, erythemato-
sus subcutaneous nodules of the legs, was seen in only 2
patients, both HIV-negative adult women. Relapse of
similar cutaneous lesions was seen after almost 1 year of
completed anti-TB treatment in one of them.
HIV-positive patients numbered 45 (22%); lung in-
volvement was present in 20 over 45 (44.4%). Among 49
paediatric patients, 12 (24.5%) had the HIV-TB co-infec-
tion. All HIV patients clinically presented SFD and 5 of

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Fig. 1. Multiple SFD of 8 months’ dura-
tion in an immunocompetent 57-year-old
woman.
them gumma. Three patients affected by HIV and in
MDT for pulmonary TB developed SFD of the axilla or
of the submandibular area during the continuation phase
of treatment.
Histological examination showed chronic granuloma-
tous changes with epithelioid cells, Langhans giant cells
and plasma cells in all different clinical types of CT ex-
amined. Caseating necrosis was visible in some cases of
SFD and LV. AFB was not detected on histology. Epider-
mal changes like ulceration, hyperkeratosis, acanthosis
or atrophy were observed according to diverse clinical
types of CT.
The duration of disease was very variable, ranging
from 2 weeks to 20 years. Only for 131 patients (64.8%)
was this period ^1 year. Before coming to the IDC, 133
patients (65.8%) had undergone medical examination in
another hospital or health centre, and among these, 41
(30.8%) were diagnosed as having CT (SFD in all cases).
A 106 patients (52.4%) chose the traditional healer as first
approach to the skin lesions; local remedies reported in-
clude herbal treatment, applications of unspecified ani-
mal fat and a compress or bath with holy water.
MDT performed in our patients led to complete heal-
ing of skin lesions at the end of the 8-month cycle with
the exception of 4 cases; 2 of the resistant cases consisted
of ulcerative lesions of the back or abdomen and 2 cases
were SFD over bone involvement.
Cutaneous Tuberculosis in Ethiopia
Fig. 2. Granulomatous mastitis with SFD of 8 months’ duration
in an immunocompetent 27-year-old woman. FNAC and ZN
staining showed AFB.
Discussion
CT is a topical, very common disease in Ethiopia. The
reported proportion of CT amongst the outpatients at-
tending dermatological departments in the international
literature is between 0.12 and 0.5% [3, 8, 9, 11, 12]; in our
series reflecting the situation of northern Ethiopia, it ap-
pears to be 0.7%. These data probably reflect the general
situation of TB infection in this country where the noti-
fication rate of cases is still increasing and the proportion
of new extrapulmonary cases is high (35% in 2004) [4].
The different clinical types of CT are reported in the
literature with very variable incidence from different
countries [2, 3, 9, 10, 12, 13]. In our cases, SFD represents
the commonest manifestation, followed by LV, and these
data are similar to other series reported from Morocco [2]
or India [13] and opposite to other reports from India
with a high incidence of TBVC [3] or from Hong Kong
where no cases of SFD were registered among 147 cases
of CT [9]. It is difficult to find a satisfactory explanation
for these differences. Dissimilar data reported may re-
flect dissimilar immunological conditions like preva-
lence of cellular or humoral immune status of the host
based on genetic ethnical factors or on immunization sta-
tus secondary to bacillus Calmette-Guérin vaccination
campaigns performed or not in the different countries.
Other additional factors may be related to cultural or eco-
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Fig. 3. Ulcerative TB of the back and right shoulder of 15 months’
duration in an 18-year-old boy. No improvement was evident af-
ter an 8-month cycle of MDT alone.
nomic factors of populations; for example, the use or not
of shoes, as well as different rates of risk for work-related
injuries, may lead to different incidences of TBVC and
LV. Moreover, similarly to Indian reports, the prevailing
habit of drinking unpasteurized milk and yogurt in many
parts of the country could lead to subsequent infection of
cervical lymph nodes (which were the commonest site in
our series) by mycobacteria [13]. Finally, the underre-
porting of CT may be due to the presence or not of der-
matologists in the territory because skin involvement is
less common than pulmonary TB and therefore non-der-
matologists may be less familiar with the entity.
CT is a challenge for physicians because of the lack of
rapid diagnostic procedures. In a recent study, FNAC and
ZN staining are indicated as simple, rapid and effective
alternatives to histological examination for the diagnosis
of CT [14]. Also in our series, cytology represented an
easy, cost-effective and useful procedure, especially in
cases of SFD where AFB were always identified in 1 or 2
samples. FNAC showed also AFB in 4 cases of granuloma-
tous mastitis and in 2 of monolateral orchitis with super-
ficial ulcerations as further manifestation of SFD. In the
literature, the association between granulomatous masti-
tis and TB infection has been discussed [1] but in our se-
ries we got confirmation of the aetiological relationship.
Concomitant extracutaneous tuberculosis has been
reported in between 9 and 38% of patients with CT [9, 13].
In our study, we found a higher rate of extracutaneous
involvement (80.7%), which may be explained by the pre-
92 Dermatology 2008;217:89–93
Fig. 4. Complete healing of the skin lesions in the same patient as
in figure 3 after a repeated 8-month cycle of MDT associated with
daily dressing of the wounds.
dominance of SFD resulting from lymph node and bone
TB.
Regarding the duration of disease, only for 64.8% of
cases was this period ^1 year. Reporting of an 8- to 20-
year-long history of CT without any medical consultation
was not uncommon. Before coming to the IDC, 133 pa-
tients (65.8%) had undergone a medical examination in
another hospital or health centre, and among these, 41
were diagnosed as having CT. All cases of CT previously
diagnosed in non-dermatological centres were SFD. Oth-
er clinical types of CT are probably not diagnosed in this
region where human resources in the medical sector are
poor and there are no other dermatologists. A high index
of awareness is needed for the diagnosis of CT, especially
in cases of small and asymptomatic lesions of LS. Glob-
ally, all these data are very significant as indicators of the
situation of the country. The poor population of northern
Ethiopia does not turn to the medical centre for a long
time after the appearance of persistent skin lesions. The
low numbers of TBVC and LS are probably underdiag-
nosed in this region because they do not represent ‘trou-
blesome’ lesions for affected people because they are si-
lent and without any discharge, and patients, mostly busy
in their daily agricultural work, do not consult a physi-
cian for asymptomatic lesions.
In many areas of Africa, traditional medicine is wide-
ly practised [15]; 52.4% of our Ethiopian series chose the
traditional healer as first approach for their skin lesions;
so, the culture of medicine is still not completely affirmed
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in this country, where belief and trust in traditional and
magic practices are quite common. Local applications of
mixed herbal leaves represented the commonest reported
remedy.
We stress that, in cases of extensive cutaneous involve-
ment, oral MDT with anti-TB therapy is not enough to
heal the lesions and that local treatment with daily dress-
ing is necessary. This concept is different from drug re-
sistance; some of our patients with extensive ulcerative
CT (fig. 3) got complete healing of the lesions (fig. 4) at
the second cycle of MDT associated with daily dressing
whereas no improvement was seen with the first cycle of
the same MDT alone.
Drug-resistant TB, both initial and acquired, was re-
ported from different regions of the country [16–18].
Eighteen percent of our series had a history of TB with a
complete 8-month cycle of treatment. Also in our cases
with cutaneous involvement, we observed 4 resistant
cases (1.9%), 2 of them affected by wide, ulcerative lesions
of the back or abdomen and 2 cases of SFD over bone in-
volvement. Moreover, relapses of cutaneous lesions of er-
ythema induratum were seen after almost 1 year of com-
pleted anti-TB treatment in 1 immunocompetent patient.
With the advent of HIV infection, the problem of MDT-
resistant TB has increased; in our series, 1 of the resistant
cases was in stage III of HIV infection.
HIV has played a key role in TB, modifying its inci-
dence and clinical presentation [19]. The Ethiopian coun-
try profile estimates 21% of TB-patients to be co-infected
by HIV. In our case, there were 45 HIV-positive patients,
consisting of 22% of adult series and 24.5% of paediatric
patients. Three patients affected by HIV infection and in
MDT for pulmonary TB developed SFD from the cervical
lymph nodes during the continuation phase of treatment.
These data can be considered as sign of drug resistance
but could also be due to poor compliance of the pa-
tients.
WHO global programmes help patients of Ethiopia, as
well as people of other poor countries, by offering free
treatment for tuberculosis; anyway, other factors such as
non-compliance, drug resistance, the HIV epidemic, tra-
ditional culture and beliefs and lack of dermatologists
may lead to unsatisfactory results.
To our knowledge, this is the first report providing
data on CT in Ethiopia and reflects its existence, clinical
pattern and practical problems faced in its management
in the country.

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