International Journal of Research in Dermatology

Jayanthi NS et al. Int J Res Dermatol. 2018 Nov;4(4):559-562

http://www.ijord.com

DOI: http://dx.doi.org/10.18203/issn.2455-4529.IntJResDermatol20184461
Original Research Article

Various presentations of cutaneous tuberculosis at a tertiary care

centre: a one year prospective study
N. S. Jayanthi, V. Anandan*, S. Kopika

Department of Dermatology, Stanley Medical College, Chennai, Tamil Nadu, India

Received: 29 May 2018

Revised: 12 July 2018
Accepted: 19 July 2018

*Correspondence:
Dr. V. Anandan,
E-mail: dermanandan@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Cutaneous tuberculosis is a rare manifestation of tuberculosis accounting for about 1.5% of all the extra
pulmonary manifestations, though the prevalence of pulmonary tuberculosis is high in India. The aim of the study was
to prospectively analyze the various clinical presentations of cutaneous TB and their age and sex distribution among
the OPD attending patients over a period of one year.
Methods: Prospective study, conducted during July 2016 to June 2017. Clinically suspected cases of cutaneous
tuberculosis were subjected to lesional biopsy and the results obtained were analyzed.
Results: Out of 36 clinically suspected cases, 24 turned out to be cutaneous tuberculosis and apart from these, 5 cases
were referred from other departments as cutaneous tuberculosis. The predominant presentation was lupus vulgaris in
12 patients, followed by tuberculous verrucosa cutis in 8 cases, tuberculous ulcers in 3 cases and the remaining 2
cases were erythema induratum of Bazin. Among them, 13 were men accounting to about 52% and 7 were children
which accounted for 28% and the remaining 5 were women which added to 20%.
Conclusions: Though the cutaneous manifestations of tuberculosis is very rare, the recent years have shown a rising
incidence especially among children and therefore requires a high index of suspicion in them since India has very
high prevalence of tuberculosis as such.

Keywords: Cutaneous tuberculosis, Lupus vulgaris, Children

INTRODUCTION patient and whether or not there has been previous

sensitization with tuberculosis. Endogenous infection is
Cutaneous tuberculosis is a relatively rare presentation of the most common route and exogenous is very rare. M.
tuberculosis with varied manifestations.1 In developing tuberculosis is the main organism responsible for
countries like India since the incidence of tuberculosis is cutaneous tuberculosis. Occasionally M. bovis and,
very high, the number of cutaneous tuberculosis cases are rarely, Bacille Calmette–Guérin (BCG), an attenuated
significant. It accounts for about 1.5% of all the extra form of M. bovis, are implicated. There has been a recent
pulmonary manifestations. It can occur via direct surge in the incidence of cutaneous tuberculosis which
inoculation of the bacteria into skin or through can be attributed to the early, better and accurate
contiguous spread, autoinoculation and haematogenous diagnosis of cutaneous tuberculosis.2 In urban areas, the
spread. The wide clinical spectrum of cutaneous increased co infection with HIV and social risk factors
tuberculosis is dependent on the route of infection seem to have a role in this rise.3,4 A current problem is
(endogenous or exogenous), the immune status of the that even standard presentations may be overlooked

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 Jayanthi NS et al. Int J Res Dermatol. 2018 Nov;4(4):559-562

through lack of familiarity with the various patterns that

may occur. Hence a proper knowledge about the various
manifestations of tuberculosis and a degree of suspicion
14 Lupus Vulgaris
is always needed for early diagnosis of cutaneous
tuberculosis.
41 TBVC
14
Aims
Tuberculous ulcer

The aim of the study was to prospectively analyze the,

Erythema Induratum
31 of Basin
 Various presentations of cutaneous tuberculosis
which have been proved by histopathology.
 Age and sex distribution of those proven cutaneous
TB cases.
Figure 1: Incidence of various clinical types of
METHODS cutaneous tuberculosis.

Among the patients who attended the Dermatology 60

outpatient department, Stanley Medical College, Chennai, 52
patients who were clinically suspected to have cutaneous 50
tuberculosis were subjected to lesional biopsy and the
results were obtained during a period of one year from 40
July 2016 to June 2017. From these biopsy proven cases,
28
the various clinical presentations of cutaneous 30
tuberculosis and their age and sex distribution were 20
analyzed. 20

Inclusion criteria 10

0
Inclusion criteria were patients with clinical suspicion of
cutaneous TB; patients willing for biopsy; both sex; age men children women
<70 years.

Exclusion criteria Figure 2: Gender distribution of cutaneous

tuberculosis in our study.
Exclusion criteria were patients not willing for biopsy;
patients >70 years. Among these 29 cases, 15 were men accounting to 52%
and 6 were women who accounted for 20% and the
Statistical analysis remaining 8 were children which added to 28% (Figure
2).
Data were analyzed using SPSS and for count data
frequencies were calculated.

RESULTS

Among the patients attending outpatient Department of

Dermatology, 36 were clinically suspected to have
cutaneous tuberculosis, out of which 24 turned out to be
cutaneous tuberculosis histopathologically. Apart from
these, 5 cases proven by histopathology as cutaneous
tuberculosis were referred from other departments to
Department of Dermatology.

Among these 29 biopsy proven cases, the predominant

one was lupus vulgaris, found in 12 patients accounting
to 41% of the cases, followed by tuberculous verrucosa
cutis occurring in 9 patients (31%) and tuberculous ulcers
occurring in 4 cases (14%) and the remaining 4 cases Figure 3: Lupus vulgaris in a child.
were erythema induratum of Bazin (14%) (Figure 1).

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 Jayanthi NS et al. Int J Res Dermatol. 2018 Nov;4(4):559-562

was seen in 81.8% and 55% of the cases respectively,

which was higher compared to our study and also TBVC
was found only in 9.1% and 5% respectively of cases
which was very less compared to our study.6,7 Similarly,
in studies by Singh Gurmohan and Varadaraj et al lupus
vulgaris was the most common presentation.8,9 The
incidence of scrofuloderma was 0% in our study whereas
in Kumar et al and Neeraj et al study, it was 21.2% and
25% respectively.6,7

The tuberculids are thought to be the result of

immunological reactions to hematogenously spread
antigenic components of M. tuberculosis, usually
occurring in individuals with high levels of immunity,
with an extracutaneous source of M. tuberculosis. The
Figure 4: Tuberculous verrucosa cutis. three forms of tuberculids are lichen scrofulosorum,
papulonecrotic tuberculid and erythema induratum of
DISCUSSION bazin.10 Among tuberculids, erythema induratum of basin
was seen in four cases and no cases of papulonecrotic
The incidence of the different forms of cutaneous tuberculid and lichen scrofulosorum were reported
tuberculosis varies globally. Primary inoculation of the whereas in Kumar Bhushan study among the 6 tuberculid
skin, usually following trauma, produces a tuberculous cases, 3 were erythema induratum of basin, 2 were
chancre in the non-immune host, whereas the so-called papulonecrotic tuberculid and one was lichen
‘prosector’s wart’, or tuberculosis verrucosa cutis, occurs scrofulosorum.
in primary infection in the immune host. 3 Lupus vulgaris
occurs mainly through haematogenous, lymphatic or The predominant sex affected by cutaneous tuberculosis
contiguous spread but can occur following inoculation. is men which may be attributed to their frequent outdoor
Scrofuloderma results from contiguous involvement of exposures and other environmental and social factors but
the skin overlying tuberculosis in a deeper structure, most in recent times the increasing incidence in women and
commonly lymphadenitis, bone or joint disease, or children is also being emphasized greatly.8 Among the
epididymitis. Metastatic tuberculous abscesses total cases, 52% were men and 20% were women and
(tuberculous gumma) can occur due to haematogenous 28% were children below 14 years of age (Figure 2).
spread from a primary focus. This usually occurs when Similar male predominance was noted in studies by
host resistance is suppressed, can be part of miliary Kumar et al and Pai et al.6,9 Among children the
tuberculosis, and results in single or multiple lesions. predominant presentation was lupus vulgaris in our study
Orificial, perioral or perianal tuberculosis can occur which varies from the study by Singal et al where
following ingestion of mycobacteria from either scrofuloderma was the predominant presentation.11
swallowed respiratory secretions or from milk Children may acquire tuberculosis accidentally by
contaminated with M. bovis.4 playing or sitting on the ground contaminated by
tuberculous sputum or other discharges and living in
However, with increasing number of cases in overcrowded dwellings.12 Children are also more likely to
immunocompromised individuals and improved have an underlying systemic involvement compared to
diagnostic tools, many uncharacteristic manifestations adults.
have been discovered recently. Though it is generally
considered that the incidence of cutaneous tuberculosis is Clinical assessment of lymph nodes, pulmonary and
very less, in tropical countries like India it is found in gastrointestinal system, nervous system, eyes and
significant numbers.5 musculoskeletal system should be performed to rule out
any systemic involvement. So a multispecialty approach
In our study there were totally 29 cases of biopsy proven is needed once a case of tuberculosis is diagnosed. All
tuberculosis over a period of one year which was higher newly diagnosed cases of cutaneous tuberculosis must be
than in the study conducted by Kumar Bhushan, were a treated as extrapulmonary tuberculosis and started on
total of 66 cases in a period of four years were category - 1 anti tuberculosis therapy and followed up
diagnosed.6 regularly.

Among the various presentations of cutaneous CONCLUSION

tuberculosis the most common one in our study was lupus
vulgaris accounting to 41% of the total cases and TBVC Though the cutaneous manifestations of tuberculosis is
was seen in 31% of the cases (Figure 3 and 4). Whereas very rare, the recent years have shown a rising incidence
in the study conducted by Kumar et al and Neeraj et al, especially among children and therefore requires a high
the commonest presentation was lupus vulgaris, which index of suspicion in them since India has a very high

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 Jayanthi NS et al. Int J Res Dermatol. 2018 Nov;4(4):559-562

prevalence of tuberculosis as such. A proper diagnostic Tropical dermatology, Editor, Canizares O,

approach along with timely starting of anti- tuberculous Blackwell publication, London; 1975: 134-152.
therapy can help in bringing down the burden of this 6. Kumar B, Kaur S. Pattern of cutaneous tuberculosis
disease in resource poor countries where tuberculosis is in North India. Indian J Dermatol Venereol Leprol.
found to have a heavy toll on life. 1986;52(4):203-7.
7. Puri N. Clinical and Histopathological profile of
Funding: No funding sources patients with Cutaneous Tuberculosis. Indian J
Conflict of interest: None declared Dermatol. 2011;56(5):550-2.
Ethical approval: The study was approved by the 8. Singh G. Lupus vulgaris in India. Indian J Dermatol
institutional ethics committee Venereol Leprol. 1974;40(6):257-60.
9. Pai VV, Naveen KN, Athanikar SB, Dinesh US,
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