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Skin tuberculosis
Last reviewed: 04.07.2025

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Tuberculosis of the skin is a chronic disease with exacerbations and relapses. Factors contributing to the development of exacerbations and relapses are insufficient duration of the main course of treatment, inadequacy of anti-relapse treatment, poor tolerance of anti-tuberculosis drugs, and developing resistance of mycobacteria strains to them.
In other words, tuberculosis of the skin is a syndrome of skin lesions in tuberculosis along with other evolutionarily formed syndromes of extrapulmonary tuberculosis. This circumstance determines the unity of their pathogenetic mechanisms. This also explains other features of tuberculosis of the skin, namely, the diversity and "blurring" of forms, the periodically observed sharp decrease in morbidity. The discrepancy between the clinical picture of various forms and pathogenetic ideas about the periods of development of the disease does not allow the development of a single generally accepted classification of tuberculosis of the skin.
Tuberculosis of the skin is characterized by its long course. It is often diagnosed late, and it is difficult to treat, which leads to the accumulation of contingents of patients. The disease itself, its complications and consequences often persist for life, leading to noticeable cosmetic defects and even disfigurement. Over 80% of all cases of tuberculosis of the skin are diagnosed more than 5 years after the onset of the disease. The reason for this is that general practitioners and even phthisiatricians are extremely poorly informed about the clinical manifestations, diagnostic methods and treatment of tuberculosis of the skin. And if the latter is true for extrapulmonary tuberculosis in general, then phthisiodermatology is in the worst position.
Causes of tuberculosis of the skin
Tuberculosis of the skin is most often the result of lymphogenous or hematogenous spread of infection, per conutuitatem, less often - exogenous.
A provoking role in the development of tuberculosis is played by a decrease in non-specific resistance of the body, acute infections, injuries, functional disorders of the nervous system, endocrine disorders, primarily diabetes mellitus, malnutrition, hypovitaminosis, pregnancy, corticosteroid and cytostatic therapy.
There is no generally accepted classification of tuberculosis of the skin. Based on data on the routes of infection and spread of tuberculosis infection, the state of immunity and allergies, taking into account the period of the disease, scientists divided the various manifestations of cutaneous tuberculosis into two groups:
- tuberculosis of the skin that develops in previously uninfected individuals, including primary affect, primary complex, primary affect at the site of BCG vaccination, miliary tuberculosis, colliquative tuberculosis (primary hematogenous scrofuloderma), and
- tuberculosis of the skin that has developed in previously infected individuals, including predominantly local forms, such as tuberculous lupus, warty tuberculosis, scrofuloderma, ulcerative periorificial tuberculosis, predominantly disseminated - papulonecrotic tuberculosis, scrofulous lichen, indurated erythema, disseminated miliary lupus.
Currently, there are 4 types of mycobacteria: human, bovine, avian and cold-blooded. For humans, the human and bovine types are pathogenic. Tuberculosis affects men and women in equal proportions. But men usually suffer from the warty form of tuberculosis, and women from the lupus form of tuberculosis. Healthy skin is an unfavorable environment for the vital activity of mycobacteria. The development of tuberculosis of the skin is usually facilitated by: hormonal dysfunction, hypo- or avitaminosis, diseases of the nervous system, metabolic disorders (water and mineral), unsatisfactory social and living conditions and infectious diseases. Tuberculosis recurs in winter and autumn. Exacerbations more often occur in patients with tuberculous lupus and Bazin's indurative erythema, less often - in patients with papulonecrotic tuberculosis.
All of the above factors reduce the immune system and susceptibility to Mycobacterium tuberculosis. Cutaneous tuberculosis is the most common opportunistic infection in HIV-infected patients, especially in developing countries. Infection occurs by endoexogenous and autoinoculation routes.
Depending on the method of infection, tuberculosis of the skin is classified as follows:
Exogenous infection:
- primary tuberculosis of the skin (tuberculous chancre) develops at the site of penetration of the pathogen into the skin in people who are not vaccinated and have not had tuberculosis;
- Warty tuberculosis of the skin develops at the site of penetration of the pathogen into the skin in people who have had or are suffering from tuberculosis.
Endogenous infection:
- tuberculous lupus (lupoid tuberculosis);
- scrofuloderma (secondary scrofuloderma);
- colliquative tuberculosis of the skin (primary scrofuloderma);
- miliary tuberculosis of the skin;
- ulcerative tuberculosis of the skin and mucous membranes (Jarisch-Chiari tuberculosis).
Sometimes tuberculosis of the skin develops after BCG vaccination and is called post-vaccination.
Histopathology of cutaneous tuberculosis
The process is localized in the upper part of the dermis, but can extend to the subcutaneous tissue. It is represented by epithelioid cell granuloma with giant Langhans cells surrounded by a lymphocytic ridge. Fibrosis is observed in the healing areas.
Histogenesis of tuberculosis of the skin
The main factors influencing the development of the pathological process are the massiveness of infection and the virulence of bacteria, the state of the immune reactivity of the organism. Tuberculous inflammation is considered a classic example of inflammation on an immune basis. T-cells, specifically sensitized to mycobacterial antigens, are considered as the central link in the manifestation of the organism's resistance to the infectious agent. The role of humoral immunity in the formation of resistance to tuberculosis is still unclear, as is the role of autoimmune reactions. There is evidence of the great importance of the allergic component in the occurrence of disseminated forms of tuberculosis of the skin. The cellular mechanisms of immunity, primarily the T-system of immunity, have been studied best in this disease. According to M.P. Elshanskaya and V.V. According to Erokhina (1984), at the early stages of experimental tuberculosis, the thymus-dependent zones of the spleen and lymph nodes expand due to their infiltration by lymphocytes and the development of blast transformation, and there is increased migration of lymphocytes from the thymus. E.G. Isaeva and N.A. Lapteva (1984) observed phase changes in the activity of various T-cell subpopulations during the development of tuberculosis. In this case, short-term stimulation of the T-helper function in the initial stages of the disease was replaced by the accumulation of T-suppressors during the generalization of the process. The most characteristic of tuberculosis, DTH and granulomatous reaction, which develops under conditions of prolonged persistence of mycobacteria in macrophage cells, are closely related to the function of the T-immune system.
Tuberculous granuloma consists mainly of epithelioid cells, among which are giant Pirogov-Langhans cells, surrounded by a bank of mononuclear elements containing lysosomal enzymes, which then develop into macrophages. Mycobacteria are detected in the phagosomes of the latter during electron microscopic examination. In the center of the tuberculous granuloma there is often caseous necrosis, which is also an expression of delayed-type hypersensitivity. It should be noted that granulomatous inflammation is not observed at all stages of the development of the tuberculous process, not in all clinical forms of tuberculosis of the skin. Thus, a specific tuberculous infiltrate is most characteristic of tuberculous lupus. In other forms, granulomatous structures are usually combined with a nonspecific inflammatory infiltrate.
In the early phase of the inflammatory reaction in the skin at the site of mycobacteria introduction, nonspecific phenomena of exudation and alteration are most pronounced; neutrophilic granulocytes predominate in the infiltrates, and lymphocytes are few in number.
Polymorphism of clinical and histological manifestations of tuberculosis of the skin largely depends on the general condition of the organism, primarily on its immunity, the age of the patients, the presence or absence of foci of infection in other organs and systems, the properties of the skin, primarily microcirculatory disorders. It is possible that each form of tuberculosis of the skin can be controlled by genetic factors, which, acting against the background of predisposition to tuberculosis, can lead to its development in a certain area, for example, in the skin.
Classification of tuberculosis of the skin
All the numerous forms of the disease are divided into two fairly clearly defined groups.
- True tuberculosis of the skin, also called localized, true, bacterial or granulomatous.
- Skin lesions resulting from allergic (“paraspecific” according to A.I. Strukov) immune inflammation, mainly in the form of allergic vasculitis, called disseminated, hyperergic cutaneous tuberculosis and classified by J. Darier as “tuberculides”.
The vast majority (more than 70%) of cases of tuberculosis of the skin belong to the 1st group; It should be noted that lichenoid tuberculosis of the skin (lichen scrofulosorum) occupies an intermediate position and is often placed in the group of tuberculids.
Diseases included in the 2nd group are well-known allergic vasculitis, devoid of specific features. The pathomorphological and clinical picture of these forms is distinguished by a certain uniqueness, and along with changes of a non-specific nature, tuberculous tubercles can also be detected histologically.
A special case is the insufficiently studied miliary disseminated lupus of the face (lupus miliaris disseminatits). Close to the 1st, but attributed by some authors to the 2nd group. There are also skin diseases, the tuberculous etiology of which has not been proven. These are acute or chronic erythema nodosum, nodular vasculitis, annular granuloma, Lewandowsky's rosacea-like tuberculosis and a number of allergic vasculitides associated indirectly with tuberculous infection.
In domestic literature, for the convenience of practicing physicians, tuberculosis of the skin is classified as follows: localized forms (tuberculous lupus, colliquative, warty, miliary-ulcerative tuberculosis), disseminated forms (papulonecrotic, indurative, lichenoid).
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Primary tuberculosis of the skin
Synonyms: tuberculous chancre; primary tuberculous affect. Children are mostly affected. Usually, at the site of infection, 2-4 weeks after infection, an asymptomatic reddish-brown papule of a dense consistency appears, turning into a superficial painless ulcer, which in some patients takes on a chancroid appearance (tuberculous chancre). Lymphangitis and lymphadenitis appear after 2-4 weeks. After several months, the primary lesion heals with the formation of a scar, but generalization of the process with the development of disseminated forms may also occur.
Pathomorphology
At the early stage of the process, the changes are non-specific, characterized by tissue destruction, in which numerous mycobacteria are found, infiltration by neutrophilic granulocytes. Later, monocytes and macrophages dominate in the infiltrate, then epithelioid cells appear, among them giant Pirogov-Langhans cells are found. The number of epithelioid cells increases, and mycobacteria decreases, after some time, fibroplastic transformation of the lesion and formation of a scar occur.
Tuberculosis of the skin, acute miliary disseminated
A very rare form, occurs against the background of general disseminated tuberculosis as a result of hematogenous dissemination. Characterized by the appearance on the skin of the trunk and extremities of symmetrical small reddish-brown or bluish spotty-papular rashes, pustular, vesicular, hemorrhagic elements, sometimes nodular formations, including subcutaneous ones.
Pathomorphology
The central part of the papule is a microabscess containing neutrophilic granulocytes, necrotic cell debris and a large number of tuberculosis mycobacteria surrounded by a zone of macrophages. In the mild form, the histological picture resembles that described above, but mycobacteria are almost never found in the lesion.
Tuberculous lupus (lupus vulgaris)
It is one of the most common forms of tuberculosis of the skin. The disease often begins in school age and in women. It is characterized by the appearance of several specific soft tubercles (lupomas) located in the dermis, pink in color with clear boundaries with a diameter of 2-3 mm. The elements are often localized on the face (nose, upper lip, auricles), but can also be found in other areas. Lupomas tend to grow peripherally, forming continuous lesions (flat shape). With diascopy (pressure with a glass slide), the color of the tubercle becomes yellowish (the "apple jelly" phenomenon), and when pressing on the tubercle with a button probe, extreme softness is detected and it easily falls through, leaving a depression in the tubercle (the "probe" symptom or Pospelov's symptom). Lupoma can resolve either dryly, when the tubercles undergo fibrosis with destruction of collagen and elastic fibers and formation of cicatricial atrophy, resembling crumpled tissue paper, or under the influence of various injuries, when the tubercles can ulcerate (ulcerative form) with formation of superficial ulcers with soft uneven edges and easily bleeding. In clinical practice, tumor-like, warty, mutilating and other forms of tuberculous lupus are encountered. In some patients, the mucous membrane of the nasal cavity, hard and soft palate, lips, gums is affected. Vulgar lupus is chronic, sluggish, with deterioration in cold weather and can be complicated by the development of lupus carcinoma.
Colliquative tuberculosis of the skin (scrofuloderma)
It is found in people, especially children, suffering from tuberculosis of the subcutaneous lymph nodes, from where mycobacteria are introduced into the skin. In the submandibular region, on the neck, limbs, dense, slightly painful nodes appear, located in the deep layers of the skin and rapidly increasing in volume, reaching 3-5 cm in diameter and tightly fused with the underlying tissues. The skin above the nodes acquires a bluish tint. Then the central part of the elements softens and deep, soft, almost painless ulcers are formed, connected to each other by fistulous tracts, from which bloody contents are released with the inclusion of necrotic tissue. The ulcers have undermined edges, flaccid granulation. After the ulcers heal, very characteristic "torn", "bridge-shaped" scars of irregular shape remain.
Secondary scrofuloderma
Unlike hematogenous colliquative tuberculosis, scrofuloderma occurs secondarily from lymph nodes affected by tuberculosis or other extrapulmonary forms of tuberculosis. It is more often observed in children. The nodes are located deep, in places where lymph nodes are localized, most often cervical, or around fistulas in osteoarticular tuberculosis. When they are opened, deep ulcers are formed, after healing of which retracted bridge-shaped, fringed scars remain. Tubercles often appear on the scars, warty (fungal) foci may be observed.
The pathomorphology of primary and secondary scrofuloderma is similar. In the upper parts of the dermis, the changes are predominantly nonspecific (foci of necrobiosis surrounded by mononuclear infiltrate), in its deeper parts and in the subcutaneous tissue, tuberculoileal structures with pronounced necrosis and significant inflammatory infiltration are noted. Mycobacteria are usually found in the superficial parts of the affected area.
Verrucous tuberculosis of the skin
It often occurs with exogenous infection of the skin and is found in pathologists, slaughterhouse workers, veterinarians in contact with animals sick with tuberculosis. Clinically, it begins with the appearance of small painless grayish-red warty elements surrounded by a narrow inflammatory border, round, oval or polycyclic outlines covered with thin scales. Gradually increasing in size and merging, they form a solid warty, sometimes papillomatous lesion, sharply outlined, irregular, polycyclic outlines of a brownish-red color with horny layers, surrounded by a crown of bluish-red erythema. With regression, a scar is formed at the site of the lesion. Rare variants are keloid-like, sclerotic, vegetative, similar to warty tuberculous lupus. On the fingers, back and palmar surfaces of the hands, soles appear painless nodules (or tubercles) of pinkish-bluish or reddish color with bluish honeycomb, surrounded by a narrow inflammatory border. In the central part there are warty growths with horny masses.
Pathomorphology
Acanthosis, hyperkeratosis and papillomatosis are expressed. Under the epidermis there is an acute inflammatory infiltrate consisting of neutrophilic granulocytes and lymphocytes, abscesses are noted in the upper parts of the dermis and inside the epidermis. In the middle part of the dermis there are tuberculoid structures with a small caseous center. Mycobacteria are significantly more numerous than in tuberculous lupus, they can be easily found in sections stained by the Ziehl-Neelsen method.
Miliary-ulcerative tuberculosis
Occurs in weakened patients with active tuberculosis of the lungs, intestines and other organs. As a result of autoinoculation with urine, feces, sputum containing a large number of mycobacteria, skin lesions occur. The usual localization is the mucous membranes of natural openings (mouth, nose, anus) and the skin surrounding them. Small yellowish-red tubercles appear, which quickly ulcerate, merge with each other, forming painful superficial easily bleeding ulcers with an uneven bottom and tiny abscesses ("Trel grains").
Tuberculosis of the skin papulonecrotic
Occurs more often in women. Characterized by disseminated soft rounded hemispherical papules (more precisely, tubercles) the size of a pinhead to a pea, brownish-reddish or bluish-reddish in color. The elements are painless, have a dense consistency, a smooth or slightly flaky surface. They are localized scatteredly on the shins, thighs, buttocks, extensor surfaces of the upper limbs, mainly in the area of the joints.
A necrotic scab forms in the central part of the elements, after which it falls off, leaving “stamped” scars.
Tuberculosis of the skin indurative (erythema indurative Bazin)
More often observed in young women. On the shins, thighs, upper limbs, abdomen appear dense, slightly painful nodes fused with the skin, 1-3 cm in diameter. At first, the skin over the nodes is not changed, then it becomes reddish with a bluish tint. Over time, the node is absorbed and in its place remains a sunken brownish area of cicatricial atrophy. In some patients, ulceration of the nodes is observed and painful shallow ulcers are formed, which are characterized by a torpid course.
Lichenoid tuberculosis (scrofulous lichen)
It is found in patients with tuberculosis of internal organs. On the skin of the monster, less often - the limbs and face, miliary papules of soft consistency, yellowish-brown or normal skin color appear. They tend to group, disappear without a trace. Sometimes scales are observed in the center of the element. Flat papules found in this form of tuberculosis resemble red flat lichen. Clinically manifests itself in the form of asymptomatic lichenoid, follicular or perifollicular rashes, often with horny scales on the surface, yellowish-brown, reddish or pale pink. With fusion and close arrangement of elements, large lesions of oval or ring-shaped form may occur. Regressing, tubercles leave superficial scars.
Pathomorphology
In the dermis, predominantly epithelioid cell granulomas are found, located mainly perifollicularly, as a rule, without caseous necrosis in the center and with a weak lymphocytic reaction around them.
Tuberculous lupus (syn. lupus cutaneous tuberculosis)
The pathogen enters the skin by the lymphatic-hematogenous route from other foci of tuberculosis infection in the body. The primary element is a tubercle (lupoma). A characteristic sign is a soft consistency, revealed by pressing with a probe, which seems to tear the tubercle, falling into it ("probe symptom"). With diascopy, the color of the lupoma changes to yellowish-brown (the "apple jelly" phenomenon). The most common form is flat lupus. The surface of the lesion is usually smooth, but there may be warty growths resembling warty tuberculosis of the skin, pronounced gingival keratosis resembling a cutaneous horn. Ulceration is quite common. With a tendency to spread over the surface, new elements appear. serpiginizing foci, and in depth - destruction of subcutaneous tissue, cartilaginous part of the nose, ears, rejection of phalanges of fingers, etc. Lupus carcinoma can be a complication of tuberculous lupus. In place of regressed foci, a superficial scar remains, in the area of which, as well as around, the appearance of new lupomas is characteristic. Rare variants of tuberculous lupus are tumor-like, warty, early infiltrative, erythematous-like, sarcoid-like.
Pathomorphology
Specific changes in the form of tuberculous tubercles and tuberculoid infiltrates are most often found in the dermis. Tuberculous tubercles consist of clusters of epithelioid cells with varying degrees of necrosis, surrounded by a bank of mononuclear cells. As a rule, among the epithelioid elements there are varying numbers of giant cells of the Pirogov-Langhanea type. Tuberculoid infiltrate is a diffuse infiltration of the dermis by mononuclear elements, among which are epithelioid tubercles of various sizes. Sometimes the infiltrate spreads to the deep parts of the dermis and the subcutaneous fat layer. In this case, destruction of skin appendages and necrosis in the epithelioid tubercles are observed. In some cases, especially with ulceration. In the dermis, nonspecific inflammatory infiltrate predominates, tuberculoileal granulomas are less common. Changes in the epidermis are secondary, its atrophy and destruction, acanthosis, hyperkeratosis, and sometimes parakeratosis are observed. Pseudoepithelial hyperplasia and cancer development are possible along the edges of ulcerative lesions. There are very few mycobacteria in the lesions with this form of tuberculosis, they are not always visible in sections. Even infected guinea pigs do not always develop tuberculosis.
Tuberculous lupus should be differentiated from diseases in which tuberculoid structures are detected in the skin (syphilis, leprosy, fungal infections). It is most difficult to differentiate this disease from sarcoidosis due to the lack of absolute histological criteria. It should be taken into account that in sarcoidosis, granulomas are located in the thickness of the dermis and are separated from the epidermis by a strip of unchanged collagen. In addition, in sarcoidosis, granulomas consist mainly of epithelioid cells, there are almost no lymphoid elements, and they are extremely rarely subject to necrosis.
Tuberculosis of the skin and mucous membranes, ulcerative periorificial
A rare, exogenously occurring form of tuberculosis of the mucous membranes and adjacent skin areas due to massive autoinoculation of infection in progressive exudative tuberculosis of internal organs (lungs, digestive tract, urinary system). Men are more often affected. On the mucous membranes, around natural openings, less often on surgical wounds, multiple miliary nodules are found, quickly disintegrating with the formation of small superficial, but sharply painful ulcers, with an uneven granular bottom, surrounded by an inflammatory rim. Ulcers can merge.
Pathomorphology
Around the ulcer, a non-specific inflammatory infiltrate is found with a predominance of neutrophilic granulocytes. In the deeper parts of the dermis, tuberculoid granulomas are found in most cases, usually with necrosis in the center.
Tuberculosis of the skin papulonecrotic (folliclis, acnitis Barthelemy)
The disease is based on allergic vasculitis, which develops as a result of sensitization to mycobacteria tuberculosis or their metabolic products. This form of tuberculosis occurs in adolescents and young adults, more often in women. The rash is localized mainly on the skin of the extensor surfaces of the extremities and buttocks. In the central part of most elements, necrosis develops with the formation of a crater-shaped ulcer covered with a tightly adhering crust, surrounded by a slightly protruding rim. After healing, characteristic, as if stamped scars remain, often surrounded by a narrow pigmented rim. Polymorphism of the rash is characteristic, due to the existence of papules in various stages of development.
Pathomorphology
In the center of the lesion there is a section of necrosis of the epidermis and upper part of the dermis, surrounded by a zone of non-specific inflammatory infiltrate, in the peripheral parts of which typical tuberculoid structures with pronounced caseous necrosis are found. Changes in the vessels are noted in the form of thickening of their walls and infiltration by inflammatory elements, i.e. vasculitis develops, which is probably the cause of necrosis.
Tuberculosis of the skin, indurated (indurated erythema of Bazin)
This form is based on dermo-hypodermal allergic vasculitis caused by increased sensitivity to mycobacteria tuberculosis, which enter the skin mainly hematogenously. It develops mainly in girls and young women suffering from impaired peripheral circulation and hypofunction of the sex glands. Clinically, it is characterized by the presence mainly on the shins in the area of the gastrocnemius muscles of symmetrical, deeply located, few nodes of a doughy or dense-elastic consistency with a diameter of 1-5 cm. Lymphangitis associated with the lesions is often observed. After regression of the nodes, pigmentation and mild atrophy remain. In approximately 30% of cases, the nodes ulcerate. After healing, retracted scars with hyperpigmentation along the periphery remain.
Pathomorphology
In fresh elements, changes are limited to the subcutaneous fat layer, although the infiltrate may also be in the dermis. The granulomatous structure of the infiltrate, vascular changes, and foci of necrosis are characteristic. Sometimes the infiltrate may be nonspecific, but small tuberculoid foci can be seen among the inflammatory elements. Pronounced changes in the vessels are noted in the form of thrombovasculitis of small arteries and veins, which often leads to necrosis. Dense erythema is differentiated from nodular erythema by the presence of a more massive infiltrate and foci of caseous necrosis, which is not present in nodular erythema.
Tuberculosis of the skin of the face miliary disseminated
A rare type of tuberculosis, probably a localized variant of papulonecrotic tuberculosis of the skin. Characterized by the presence of isolated paired papules on the linden of yellowish-reddish or reddish-brown color, hemispherical with a pustular center, soft consistency, giving the phenomenon of "apple jelly" during diascopy. The rash is usually superficial. There is polymorphism due to different stages of development of elements. After regression, scars are left behind.
Pathomorphology
In the superficial layers of the dermis there are typical tuberculoid granulomas with necrosis in the center.
Differential diagnosis is carried out with tubercular syphilid, skin cancer, leishmaniasis, deep mycoses, and skin angiitis.
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Treatment of tuberculosis of the skin
Conduct complex therapy using tuberculostatic agents, drugs aimed at increasing the immune system, normalizing metabolic disorders. Tuberculostatic drugs are divided into the following groups according to their therapeutic effect:
- the most effective drugs: isoniazid, rifampicin;
- drugs of moderate effectiveness: ethambutol, streptomycin, prothionamide (ethionamide), pyrazinamide, kanamycium, florimycin (viomycin);
- moderately active drugs: PAS, thibon (thioacetazone).
Particularly effective in combination with anti-tuberculosis drugs is the use of vitamins (especially group B), antioxidants (a-tocopherol, sodium thiosulfate, dibunol), immunomodulators (immunomodulin, sodium nucleinate, thymalin), anabolic steroids, physiotherapeutic measures (UV irradiation in suberythemal doses, electrophoresis) and therapeutic nutrition.
Drugs