Cutaneous Tuberculosis Images: 12 Diagnostic Photos
Visual guide to cutaneous tuberculosis: Explore images, clinical features, diagnosis, and management of skin TB manifestations.
Cutaneous tuberculosis (CTB), also known as skin tuberculosis, encompasses a spectrum of skin manifestations caused by Mycobacterium tuberculosis infection. It accounts for 1–2% of all tuberculosis cases and presents diverse clinical forms depending on the patient’s immune status, mode of inoculation, and presence of underlying pulmonary or extracutaneous TB. This image gallery illustrates key variants, aiding dermatologists in recognition and diagnosis. CTB arises from direct inoculation, contiguous spread, haematogenous dissemination, or hypersensitivity reactions (tuberculids). Early identification is crucial, as skin lesions may signal disseminated disease, particularly in immunocompromised individuals.
What is Cutaneous Tuberculosis?
Cutaneous tuberculosis refers to TB infection localized to the skin, manifesting as ulcers, plaques, nodules, or verrucous lesions. It is classified into primary forms (e.g., tuberculous chancre from direct inoculation in non-immune hosts), secondary forms (e.g., lupus vulgaris from reactivation or haematogenous spread in sensitized individuals), contiguous forms (e.g., scrofuloderma from underlying lymph node involvement), and tuberculids (immune-mediated reactions without viable bacilli). Globally, incidence is higher in endemic areas, but migration and immunosuppression increase cases worldwide. Diagnosis integrates clinical, histopathological, microbiological, and molecular evidence.
Who Gets Cutaneous Tuberculosis?
CTB affects all ages but is more common in children (primary inoculation) and adults in endemic regions. Risk factors include TB-endemic areas (e.g., Asia, Africa), HIV/AIDS, immunosuppression (steroids, biologics), close TB contacts, and occupations with skin trauma (e.g., farmers for tuberculosis verrucosa cutis). In high-burden countries, scrofuloderma predominates in children; lupus vulgaris is frequent in Europe among previously exposed individuals. Immunocompromised patients may develop multibacillary forms like miliary TB.
Related Conditions
- Leprosy: Hypopigmented patches, thickened nerves, acid-fast bacilli (Mycobacterium leprae).
- Sarcoidosis: Non-caseating granulomas, no bacilli, systemic involvement.
- Deep fungal infections (e.g., sporotrichosis): Sporotrichoid pattern, culture-positive.
- Pyoderma gangrenosum: Sterile neutrophilic ulcers, pathergy.
- Syphilis: Primary chancre, serology-positive.
Primary Inoculation Tuberculosis / Tuberculous Chancre
Primary inoculation TB occurs 2–4 weeks post-inoculation via skin injury in non-immune individuals, forming a firm papule evolving into a painless ulcer with undermined edges and granulomatous base. Regional lymphadenopathy develops; TST converts positive. Common in children from piercings or trauma on face, hands, legs. Histology shows microabscesses with numerous AFB; poor prognosis in immunosuppressed.
- Image 1: Tuberculous chancre on lower lip – shallow ulcer with granular base in a child post-trauma.
- Image 2: Sporotrichoid spread along arm – linear nodules from lymphatic dissemination.
Scrofuloderma
Scrofuloderma results from contiguous spread from underlying TB lymphadenitis, bone, or joint TB, causing subcutaneous abscesses that rupture into ‘cold’ ulcers with irregular edges and undermined sinus tracts. Neck (cervical nodes) is classic; heals with atrophic scarring. Predominant in children; AFB detectable in pus.
- Image 3: Scrofuloderma on neck – multiple discharging sinuses overlying enlarged cervical nodes.
- Image 4: Scrofuloderma on axilla – violaceous plaque with central ulceration.
Lupus Vulgaris
The most common secondary CTB form (55% of cases), lupus vulgaris arises from haematogenous or lymphatic spread in sensitized hosts. Presents as reddish-brown plaques with apple-jelly nodules on diascopy, on face/neck. Variants: plaque, vegetative, ulcerative, tumour. Chronic, leads to scarring, contractures, squamous cell carcinoma risk. Histology: bare tubercles, scant AFB.
- Image 5: Facial lupus vulgaris – irregular plaque with central atrophy.
- Image 6: Ulcerative lupus vulgaris on nose – mutilating destruction.
- Image 7: Tumour form on ear – nodular swelling.
Tuberculosis Verrucosa Cutis
Occurs on minor trauma sites (knees, elbows, hands, buttocks) in sensitized individuals with high immunity, presenting as warty, psoriasiform plaques with keratotic edges and central clearing. Persists years; koebnerization possible. Histology: pseudoepitheliomatous hyperplasia, few AFB.
- Image 8: Verrucous plaque on knee – hyperkeratotic with nail-like crusts.
- Image 9: Buttock lesion – polygonal wart-like growth.
Multibacillary Forms
In immunosuppressed patients, multibacillary CTB includes miliary papules (simultaneous haematogenous spread), lichen scrofulosorum (follicular eruption), and papulonecrotic tuberculid-like lesions with abundant AFB.
- Image 10: Miliary TB – disseminated 1–2 mm papules on trunk.
Tuberculids
Tuberculids are hypersensitivity reactions to haematogenous TB antigens in sensitized individuals with no viable skin bacilli (PCR may detect DNA). Types: papulonecrotic, lichen scrofulosorum, erythema nodosum. Resolve with anti-TB therapy for underlying infection.
Papulonecrotic Tuberculid
Symmetrical crops of necrotic papules on extremities, leaving varioliform scars.
- Image 11: Necrotic papules on legs with scars.
Lichen Scrofulosorum
Grouped lichenoid papules around hair follicles on trunk/abdomen in children.
- Image 12: Follicular papules on chest.
Diagnosis of Cutaneous Tuberculosis
Diagnosis requires correlation of history, exam, TST/IGRA, chest X-ray, biopsy (caseating granulomas, AFB via Ziehl-Neelsen), culture, PCR/NAAT. In resource-limited settings, therapeutic trial of ATT if high suspicion. Table below summarizes key tests:
| Test | Purpose | Utility in CTB |
|---|---|---|
| TST/IGRA | Detects sensitization | Positive in most; IGRA preferred post-BCG |
| Skin Biopsy | Histology/AFB | Caseating granulomas; scant AFB in paucibacillary |
| PCR/NAAT | M. tb DNA | High sensitivity in tuberculids |
| Culture | Viable bacilli | Gold standard, slow (6 weeks) |
Treatment of Cutaneous Tuberculosis
Standard ATT: 2-month intensive phase (isoniazid, rifampicin, pyrazinamide, ethambutol), followed by 4–7 months continuation (isoniazid, rifampicin). Paucibacillary forms may shorten; multidrug-resistant TB requires adjusted regimens. Surgery for recalcitrant lesions (e.g., LV). Response within 4–6 weeks confirms diagnosis.
Frequently Asked Questions (FAQs)
What does cutaneous tuberculosis look like?
Skin TB appears as ulcers (chancre, scrofuloderma), plaques/nodules (lupus vulgaris), warty growths (verrucosa cutis), or papules (tuberculids/miliary).
Is cutaneous TB contagious?
Direct contagion is rare; multibacillary forms or open ulcers pose respiratory/drainage risk if active pulmonary TB present.
How is skin TB diagnosed?
Via biopsy, AFB stain, culture, PCR, plus IGRA/TST and chest imaging to exclude extracutaneous foci.
How long does treatment for skin TB take?
Typically 6–9 months with 4-drug ATT; monitor response and resistance.
Can skin TB recur?
Yes, if incomplete treatment, reinfection, or immunosuppression; scarring permanent.
References
- Cutaneous Tuberculosis: A Practical Case Report and Review for the Dermatologist — J Clin Aesthet Dermatol. 2019-07-01. https://jcadonline.com/cutaneous-tuberculosis-a-practical-case-report-and-review-for-the-dermatologist/
- Cutaneous Tuberculosis — StatPearls [Internet]. 2023-07-17. https://www.ncbi.nlm.nih.gov/books/NBK482220/
- Cutaneous Tuberculosis — Microbiol Spectrum. 2017-03-01. https://journals.asm.org/doi/10.1128/microbiolspec.tnmi7-0010-2016
- Clinical Testing and Diagnosis for Tuberculosis — CDC. 2024-01-01. https://www.cdc.gov/tb/hcp/testing-diagnosis/index.html
- Cutaneous tuberculosis (TB) — DermNet NZ. 2023-01-01. https://dermnetnz.org/topics/cutaneous-tuberculosis
- Tuberculosis – Diagnosis & treatment — Mayo Clinic. 2024-01-01. https://www.mayoclinic.org/diseases-conditions/tuberculosis/diagnosis-treatment/drc-20351256
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