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INTRODUCTION
• Tuberculosis usually affects the lung, but virtually all other
system may be involved : intestine, kidney, lymph node,
bones, joints, epididymis, skin ( called EXTRA
PULOMONARY TUBERCULOSIS).
• Tb of the skin is a relatively rare, with a wide spectrum of
clinical finding depending on the source of infection & the
immune status of the host.
• The most prevalent in Indonesia : scrofuloderma, tb verucosa
cutis
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EPIDEMIOLOGY
• First recognized in 1826 by Laennec
• IT NOW OCCURS MOSTLY IN THE TROPICS
• IN THE TROPICS (INDONESIA), THE MOST
FREQUENT FORMS OF SKIN TB ARE
SCROFULODERMA & TB VERUCOSA CUTIS.
• IN EUROPEAN & AMERICAN COUNTRIES,
LUPUS VULGARIS & SCROFULODERMA ARE
MORE FREQUENT.
• LV IS MORE THAN TWISE IN WOMEN
• TB VERUCOSA CUTIS IS MORE COMMON IN
MEN
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CLASSIFICATION
OF SKIN TUBERCULOSIS
1. Exogenous infection :
a. Primary inoculation tuberculosis
b. Tuberculosis verucosa cutis
2. Endogenous spread :
a. Lupus vulgaris
b. Scrofuloderma
c. Acute miliary tuberculosis
d. Orificial tuberculosis
e. Tubereculous gumma (Metastatic tuberculous abs
cess.
3. Tuberculid
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ANOTHER CLASSIFICATION
PILLSBURRY CLASSIFICATION :
A. TRUE TUBERCULOSIS
1. Primary skin tuberculosis :
a. Tuberculous chancre/ Primary
inoculation tuberculosis/ Tuber-
culous primary complex.
b. Tuberculosis cutis milliaris
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Other classification:
A. Multibacillary form:
1. Direct inculation:
- Primary inoculation tuberculosis (chancre)
- Skrofuloderma
- Perioral tuberculosis
2. Hematogenous spread:
- Acute milliary tuberculosis
- Metastatic abscess (gumma)
B. Paucibacillary form:
1. Direct inoculation:
- Tuberculosis verrucosa cutis (warty tuberculosis)
- Lupus vulgaris
2. Hematogenous spread:
- Lupus vulgaris
- Tuberculid papulonecrotic, erythema induratum, lichen scrofulosorum
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ETIOLOGY
All forms of skin tuberculosis are caused by
• M. tuberculosis
• M. bovis
• The attenuated BCG organism
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PATHOGENESIS
THERE ARE 5 ROUTES OF SKIN TB :
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TUBERCULIN REACTION
• This reaction is a delayed type, induced by
mycobacteria during primary infection.
• The “old tuberculin” has now been
replaced by PPD (Purified Protein
Derivative)
• The method most widely used is ID
injection --- > leads to local tuberculin
reaction --- > erytheme & induration > 10
mm (+).
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SCROFULODERMA
(tuberculosis colliquativa cutis)
• Scrofuloderma is subcutaneous tb leading to
cold abscess formation & a secondary
breakdown of the overlying skin.
• The underlying infections could be : lymph node,
bones, joints, testis or epididymis.
• The infections on lymph nodes, bones, joints,
testis and epididymis could be caused by
hematogenous spreads of tb infection from the
lung, kidney or other tb process in the body.
• The most common of skin tb in Indonesia & India
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Scrofuloderma (continued)
• It first presents as a firm, sc nodule, usually well
defined, freely movable, and asymptomatic.
• As the lesion enlarges it softens.
• After months, liquefaction with perforation
occurs, causing ulcers and sinuses.
• The ulcers are linear, undermined, bluish edges
and soft (livide), granulating floors, without
indurations, and no painful.
• Skin bridge developed.
• Tuberculin sensitivity is usually pronounced.
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Scrofuloderma (continued)
Hitopathology :
- Massive necrosis & abscess formation in
the centre of lesion are non spesific.
- The periphery of the abscesses or margins
of the sinuses contain tuberculoid
granuloma.
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Scrofuloderma (continued)
Diagnosis :
- Clinical manifestation (anamnesis, physical
examination). If there is an underlying tuberculous
lymphadenitis/ bones/ joints disease/testis, the diagnosis
usually presents no difficulty.
- Tb process in another site of the body (e.g. pulmonary/
kidney tb or others)
- PPD test is strongly positive.
- Laboratoric examinations (Ziehl Neelsen), culture on
Lowenstein media. Positive results on culture confirm the
diagnosis.
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Differential dignosis of
scrofuloderma
• Syphilitic gumma
• Sporotrichosis
• Actinomycosis
• Hydradenitis suppurativa
• Atypical mycobacterial infections
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TUBERCULOSIS VERRUCOSA
CUTIS (warty tuberculosis)
Pathogenesis :
- Tb verrucosa cutis caused by exogenous
re-infection (inoculation) in previously
sensitized individuals with high immunity.
- Inoculation occurs at sites of minor
wounds or rarely from own patient sputum.
- Children may become infected playing on
contaminated ground.
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Tb verrucosa cutis (continued)
Epidemiology :
- The second most frequent form of skin tb
in Indonesia.
- More often found in men.
- In adults, these tend to be occupational
lesions of pathologists: prosectors warts or
butcher’s warts.
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Clinical manifestations :
- Lesions usually occur on the hands or in children on the lower
extremities as a small asymptomatic papule or papulo- pustule with
a purple inflammatory halo.
- They become hyperkeratotic and are often mistaken for a common
wart.
- Slow growth and peripheral expansion lead to the development of a
verrucous plaque with an irregular border.
- The lesion usually is solitary, but multiple lesions may occur.
- Regional lymphnodes are rarely affected.
- Spontaneous involution eventually occurs, leaving an atrophic scar.
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Differential diagnosis :
- Wart or keratosis
- Chromomycosis
- Hypertrophic lichen planus
- Squamous cell carcinoma
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ORIFICIAL TUBERCULOSIS
(tb ulcerosa cutis et mucosae)
Pathogenesis :
- Orificial tb is a rare form of tb of the mucous
membranes and orifices that is caused by auto-
inoculation of mycobacteria from progressive tb
of internal organs (e.g pulmonary tb/ intestine tb/
kidney tb and others).
- Mycobacteria shed from these foci in large
numbers are inoculated into the mucous
membranes.
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Clinical manifestations :
- In patient with pulmonary tb, the lesion can develop
around the anus or lip.
- A small yellowish/ reddish nodule appears on the
mucosa and breaks down to form a soft ulcer with a
typical punched-out appearance, undermined edges,
and circular, irregular border.
- The ulcer floor bleed easily.
- The surrounding mucosa is edematous and inflamed.
- Lesion may be single/ mutiple, extremely painful
resulting dysphagia.
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• The tongue is most frequently affected,
particularly the tip and the lateral margins.
• Soft and hard palate are also common site
• In advanced cases the lip are involved and oral
condition often represents an extension of
ulcerative tb of the pharynx and larynx.
• In patients with intestinal tb, lesion develop
around the anus, and in females with active
genitourinary disease, the vulva is involved.
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• Histopathology
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• Course :
30
• Inoculation of punture wounds may result in
subcutaneous abscesses.
• Slowly progressive regional lymphadenopathy
develops 3-4 weeks after the infection.
• After weeks or months, cold abscess may
develop that perforate to the surface of the skin
and form sinuses.
• The regional lymphnode may also be involved.
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• Body temperature may be slightly elevated
• In half the patients, fever, pain and swelling
simulate a pyogenic infection.
Histopathology :
- Early, there is an acute non spesific inflam
matory reaction.
- Mycobacteria are easily detected
- After 3-6 weeks the infiltrate and regional
lymphnodes acquire a tuberculoid appearance
and caseation may occur.
32
• Course :
33
• Differential diagnosis :
- Syphilis
- Sporotrichosis
- Pyogenic infection
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• Diagnosis
35
LUPUS VULGARIS
• LV is an extremely chronic progressive
form of cutaneous tb.
• It occur on individuals with moderate
immunity & a high degree of tuberculin
sensitivity.
• Females appear to affected 2-3 than
males.
• All age groups are affected equally.
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LUPUS VULGARIS (continued)
PATHOGENESIS
• LV IS A POSTPRIMARY TB
• THE ROUTE OF INFECTIONS COULD BE
HAEMATOGENOUS (from pulmonary tb or others),
LYMPHATIC, OR CONTIGUOUS SPREAD FROM
ELSEWHERE IN THE BODY
• SPONTANEOUS INVOLUTION MAY OCCUR & NEW
LESIONS MAY ARISE WITHIN OLD SCAR.
• COMPLETE HEALING RARELY OCCURS WITHOUT
THERAPY.
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• Clinical manifestation
41
• Diagnosis
43
• Course
45
Treatment of skin tuberculosis
• In general, the management of skin tb is
similar to that of tb of other organs.
• Chemotherapy is the treatment of choice.
• Rifampicin 10 mg/kg ---- bactericidal
• Isoniazid 5 mg/kg ---- bactericidal
• Pyrazinamide 30 mg/kg ---- bactericidal
• Ethambutol 15 mg/kg ---- bacteriostatic
• Streptomycin 15 mg/kg ---- bacteriostatic
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TUBERCULID
• TUBERCULIDS : condition in which M. tb/ M.
bovis appears to playa significant role 9lichen
scrofulosorum, papulonecrotic tuberculid.
• FACULTATIVE TUBERCULIDS : condition in
which M. tb/ M. bovis may be one of several
pathogenic factors (erythema induratum of
Bazin, EN).
• NON-TUBERCULIDS : condition formerly
designated as tuberculids, there is no
relationship to tb (lupus miliaris disseminata
fasciei, Rosacea-like tuberculid, lichenoid
tuberculid).
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Lichen scrofulosorum
• Is an uncommon lichenoid eruption
ascribed to hematogenous spread of
mycobacteria in an individual strongly
sensitive to M. tb
• Usually associated with chronic tb of the
lymph nodes, bones, or pleura.
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• Clinical manifestation
50
Papulonecrotic tuberculid
• PT is a symmetric eruption of necrotizing
papules
• Appearing in crops & healing with scar
formation
• It preferentially in children or young adults
• It is rare, but not uncommon in populations
with a high prevalence of tb.
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• Pathogenesis
- Associated pulmonary or extrapulmonary tb is
common.
- Lesions are reported to respond promptly to anti
tb drugs, wether or not a tb focus is identified.
- In studies of skin lesions , M. tb DNA was
detected in approximately 50 % of patients.
- Some cases of PT have been associated with
DLE, arthritis, or EN and may therefore be
trigerred by antigen unrelated to M. tb
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• Clinical manifestation
53
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• Differential diagnosis
1. Prurigo
2. Pleva (pityriasis lichenoides et variolifor
mis acuta.
3. Secondary syphilis
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