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145]

Review Article

Pediatric Cutaneous Tuberculosis: Indian Scenario

Abstract Bhushan Kumar,

Burden of tuberculosis still persists in developing countries despite major advances in its treatment Sheetanshu Kumar1
strategies. Cutaneous tuberculosis which is a form of extra-pulmonary tuberculosis is seen in a small Consultant Dermatologist,
but significant subset of patients visiting dermatology outpatient services. Cutaneous tuberculosis Shalby Multi speciality
is characterized by a spectrum of multiple distinct clinical and histopathology presentations. A Hospital, Mohali, Punjab,
significant proportion of patients with cutaneous tuberculosis are seen in paediatric age group. 1
Senior Resident, Department
Clinical features in children remain mostly the same as that in adults with cutaneous tuberculosis. of Dermatology, Venereology
However, systemic and lymph node involvement and incidence of disseminated disease is observed and Leprology, Postgraduate
more commonly in paediatric age group . Awareness among clinicians of the clinical manifestations Institute of Medical Education
and Research, Chandigarh,
of cutaneous tuberculosis is of paramount importance for early diagnosis and management of cases
India
with paediatric cutaneous tuberculosis. This would significantly prevent morbidity and complications
of the disease . This review aims to discuss the epidemiology, clinical and histopathological features,
diagnosis, differential diagnosis and treatment options in children with tuberculosis, especially in the
Indian context.

Keywords: Cutaneous tuberculosis; lupus vulgaris; paediatric cutaneous tuberculosis;

scrofuloderma; tubercular

Introduction Around 18% of newly detected TB cases

in India (2015) were extrapulmonary
Tuberculosis (TB) is known as a disease
according to WHO data. Cutaneous TB,
of poverty. The burden of TB, especially a form of extrapulmonary TB, accounts
in developing countries like India still for around 0.9% of patients attending
remains a daunting challenge for the global dermatology outpatients.[3] Cutaneous TB
and national health programs. According has a spectrum of multiple yet distinct
to the WHO Global TB report 2017, the clinical presentations both in adults and
estimated incidence of TB in India in children. Children constitute a significant
2015 was around 2.8 million (27%) out proportion of overall cutaneous TB
of an estimated global incidence of 10.4 cases and present mostly with similar
million. In India, the annual incidence of clinical features as that of adult cutaneous
TB in pediatric age group was 0.26 million TB. Involvement of lymph node and
accounting for 8.9% of overall incidence.[1] systemic organs along with disseminated
The persistence of TB as a global health presentation is more common in pediatric Address for correspondence:
problem can be attributed to socioeconomic patients.[3‑6] Thus, early diagnosis and Dr. Bhushan Kumar,
Former Professor & Head,
factors such as overcrowding, poor living treatment are imperative to avoid significant Department of Dermatology,
conditions, poor nutrition, immigration morbidity and complications in children. Venereology and Leprology,
as well as medical factors such as surge The objective of this review is to discuss Postgraduate Institute of
clinical features, diagnosis, and treatment Medical Education and
in HIV‑positive patients and infections Research, #81, Sector 16A,
with multidrug‑resistant strains. Delay options in cutaneous TB among infants and Chandigarh ‑ 160 015, India.
in diagnosis and proper treatment of children in the Indian context. E‑mail: kumarbhushan@
hotmail.com
TB patients is a major concern in a
History[7]
country like India. TB was declared as a
global emergency in 1993 by WHO, but TB has been a known entity to humans Access this article online
unfortunately apart from the emergence of since ancient times. The tomb portraits
drug‑resistant strains, nothing much has of ancient Egypt (3400 BC) civilizations Website: www.ijpd.in

changed.[2] exhibit individuals with hunchbacks DOI: 10.4103/ijpd.IJPD_63_18

demonstrating Pott spine deformities which Quick Response Code:

Thisisanopenaccessjournal,andarticlesaredistributedundertheterms
have been confirmed by the examination
of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and the new How to cite this article: Kumar B, Kumar S. Pediatric
creations are licensed under the identical terms. cutaneous tuberculosis: Indian scenario. Indian J
For reprints contact: reprints@medknow.com Paediatr Dermatol 2018;19:202-11.

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Kumar and Kumar: Pediatric cutaneous tuberculosis

of mummies from that era.[8] Old Chinese writings with cutaneous TB. As reported by Pandhi et al.,[3] majority
from 2700 BC describes people with emaciation and of the patients belonged to lower socioeconomic class
symptoms of fever cough and hemoptysis suggestive of living in crowded localities.
TB.[8] Hammurabi, the renowned monarch philosopher of
As compared to adults, children with cutaneous TB have
Babylonians, has also mentioned about TB in his illustrious
a higher propensity for lymph node and systemic organ
code of law of ancient Mesopotamia.[8] involvement.[16] The prevalence of systemic involvement
Earliest mentions of cutaneous TB has been in gospels and among paediatric cutaneous TB has ranged from 12.7% to
old testaments in which cutaneous disease resembling lupus 53.2% in Indian studies.[3‑6] Lungs were the most common
vulgaris (LV) has been termed Tsara’ath.[7] Term “Lupus” systemic organ to be involved followed by bones and
which means ‘wolves” in Latin has been used for skin abdominal organs.[4]
conditions associated with chronic and disfiguring lesions in
mediaeval ages.[9] It was in 1887 when William Tilbury Fox Classification and Clinical Features
first used the term “LV” specifically for cutaneous TB.[9] Cutaneous TB can be classified on the basis of route of
Ancient French writers used the term “scrofulous gumma” infection[17] and bacterial load[18] as summarized in Table 1.
for scrofuloderma.[10] Ernest Besnier elaborated about There exists another simple classification of cutaneous
scrofulous gumma in 1883 after the earlier writings of TB for easy comprehension as illustrated in Table 2.[19,20]
Jean Alibert and Delpech.[10] First published case in history
recognizing the association of mycobacterial infection with
cutaneous lesions was description of his own prosector’s Table 1: Various classification systems of cutaneous
wart by Rene Laennec’ in 1826.[11] tuberculosis[17,18]
Presentation
Detailed elucidation of histopathological features of Classification system based
cutaneous TB was first published by Carl Rokintansky and on route of infection[17]
Rudolf Virchow.[7] Giant cells and epithelioid cells in skin Exogenous route Tuberculous chancre, LV, and TVC
biopsy of LV were first described by Forster in 1855.[9] Endogenous route
Contiguous spread Scrofuloderma, Orificial tuberculosis
Epidemiology Hematogenous spread Acute miliary TB, metastatic
tuberculous abscess (gummatous
The proportion of childhood cutaneous TB among overall
TB), tuberculids, and LV
cutaneous TB incidence in previous studies from India was
Lymphatic spread LV
63/199 (31.7%),[6] 75/402 (18.7%),[5] 68/142 (47.9%),[3] and Classification system
103/191 (53.9%).[4] Apart from India, the prevalence of based on bacillary load[18]
pediatric cutaneous TB reported were 82% in Pakistan,[12] Multibacillary Tuberculous chancre, scrofuloderma,
6% in Tunisia,[13] 24.3% in Ethiopia,[14] and 36.3% in orificial TB, acute miliary TB, and
Hong‑Kong[15] of the total cases of cutaneous TB. The gummatous TB
disparity in case definition of “childhood” ranging Paucibacillary TVC, LV, and tuberculids
from <14 years to <19 years might have contributed to the LV ‑ Lupus vulgaris; TVC ‑ Tuberculosis verrucosa cutis;
difference in prevalence among these studies apart from the TB ‑ Tuberculosis
regional disparity in prevalence.
In substantial majority of the cases, the age group of Table 2: Simpler classification of cutaneous
10–14 years was predominantly affected. The time delay in tuberculosis[19,20]
definite diagnosis after disease onset ranged from 2 months True TB
to 10 years as reported by Ramesh et  al.[6] Kumar et  al.[5] Primary Tuberculous chancre
found that the time delay in seeking treatment was less than Miliary TB
a year in 69% of cases while the delay was >3 years in Secondary Scrofuloderma
only 9% of cases. Delay in seeking treatment is one of the LV
factors in predisposing patients to the risk of widespread TVC
and disseminated disease and its sequelae of deformity and Tubercular gumma
disfigurement. Orificial TB
Tuberculids
A considerable number of pediatric patients were found to Lichen scrofulosorum
have one or more household contacts with positive history PNT
of TB in all reported studies. The percentage was noted to Erythema nodosum
be 41% by Pandhi et  al.,[3] 32% by Vashisht et  al.,[4] and Erythema induratum
19% by Kumar et  al.[5] implying that household contacts LV ‑ Lupus vulgaris; TVC ‑ Tuberculosis verrucosa cutis;
were one of the major source of infections to the children TB - Tuberculosis; PNT ‑ Papulonecrotic tuberculid

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Kumar and Kumar: Pediatric cutaneous tuberculosis
In this classification, cutaneous TB is classified as true TB
and tuberculids. True TB is further classified as primary or
secondary based on the previous sensitization.
The clinical presentations of various forms of cutaneous
TB are described briefly.
Scrofuloderma
Scrofuloderma is the most common form of cutaneous TB
among children.[3‑5] The proportion of scrofuloderma was
found to be 53.3% by Kumar et al.[5] and 36.9% by Vashisht
et al.[4] Scrofuloderma arises due to contiguous spread of an
underlying tuberculous focus to the overlying skin. Lymph
nodes are the most common underlying foci out of which
cervical lymph nodes being the most common group being
involved.[4] The habit of drinking unboiled or unpasteurized
milk in rural areas may be one of the contributory factors
for infection of cervical lymph nodes.[5] Inguinal, axillary,
submandibular, epitrochlear, and supratrochlear lymph
nodes are among other commonly affected group of lymph
nodes.[19,20]
Systemic TB foci are seen in up to 66% of cutaneous TB
cases. Bones, joints, testes, breast, and lacrimal glands
are the other underlying foci of infections leading to
scrofuloderma. Hepatic and intestinal TB also is the rare
source of cutaneous infections.[3]
Clinically, scrofuloderma is characterized by asymptomatic
subcutaneous swellings which persist for several months
before softening and ulcerating to form discharging
sinuses and ulcers. Typically, the ulcers are shallow with
undermined and bluish edges [Figure 1]. Scrofuloderma in
children may present with multiple and widespread lesions
as compared to adult scrofuloderma where the lesions are
more localized [Figure 2]. Scrofuloderma heals typically
with cribriform, bridging, and puckered scars.[19,20]
Lupus vulgaris
LV is the most common variant of cutaneous TB in adults,
but in pediatric age group, it is the second most common
after scrofuloderma.[5,16] The proportion of LV among all
children with cutaneous TB in major studies from India
has been given in Table 3. Predominantly, LV is observed
most commonly affecting lower half of the body in Indian
children including lower trunk, thighs, buttocks, legs, and
feet [Figure 3].[3,4,6] This pattern can be attributed to the
widespread habit of spitting and defecating in open areas
and the children squatting and playing without proper
clothes and footwear, more so in children with lower
socioeconomic background.[6,16] LV is usually known to
manifest in previously sensitized individuals. Although
the lesions of LV are solitary, multiple and multifocal
lesions can be noted in pediatric age group [Figure 4].[19,20]
The typical lesion of LV is characterized by its onset as
asymptomatic papule or small plaque which progresses
gradually to form a well‑demarcated plaque with evidence
204 Indian Journal of Paediatric Dermatology | Volume 19 | Issue 3 | July-September 2018
of activity at one area and simultaneous healing, atrophy,
and scarring at other area resulting in a geographic
pattern [Figure 5]. The enlarging plaque is formed by
coalescing of multiple microgranulomatous papules which
on diascopy are seen as soft, reddish‑brown, “apple jelly”
nodules more easily appreciated in fair skin. The lesions
are usually dry but seropurulent discharge, crusting, and
secondary bacterial infection can be seen.[19,20]
Severe scarring may lead to fibrosis, contractures of the
joints, and mutilation in children.[19,20] Oral, genital, and
nasal mucosa can also be involved often as an extension
of skin involvement. LV localized to genitalia in children,
although rare, can lead to severe mutilation and scarring,
especially of vulva.[6] Rarely, destruction of ear and nose
can also be seen [Figure 6]. Contractures involving knee,
elbow, and wrist joints are other disabling sequelae of
LV.[3,6,16,21]
Morphological variants of LV include classic plaque
[Figure 7] or keratotic type [Figure 8], hypertrophic,
ulcerative, atrophic, and papulonodular. Keratotic type
is most commonly seen whereas ulcerative and atrophic
variants are the least common in children.[19,20]
Apart from the classical clinical variants, kissing LV,
involving the gluteal cleft, and multifocal lesions involving
the head‑and‑neck area, extremities, and mucosae are
the unusual clinical variants of LV reported in children.
Symmetrical LV involving the knees and ankles possibly
due to exogenous inoculation of the organism has been
reported. Atypical forms of LV can be seen in children
such as deeply destructive papillomatous and sclerotic
variants leading to deformities of the limbs. LV with a
sporotrichoid pattern due to lymphatic spread has also been
described [Figure 9].[4,5,19,20] LV developing at the site of
Bacillus Calmette–Guerin (BCG) vaccination and near the
opening of scrofuloderma sinus has also been reported.
Constitutional symptoms are generally absent or very
mild and systemic involvement is less commonly seen as
compared to scrofuloderma. Regional lymphadenopathy is
frequently associated with LV.[4,5,19,20]
Tuberculosis verrucosa cutis
Also known as warty TB, tuberculosis verrucosa cutis
(TVC) manifests after exogenous inoculation of tubercule
bacilli in previously sensitized individuals with good
immunity. The prevalence of TVC predominantly in
pediatric group has been <4.5% in studies reported
from India.[16] The lower part of the extremities is most
commonly involved due to trauma. Lesions of TVC present
characteristically as verrucous papules and plaques, with
fissures, clefts, and crusting over the surface  [Figure 10].
Lesions may extrude pus, and perilesional inflammation
and erythema may be seen. Serpiginous outline is seen
commonly due to irregular extension of the lesions with
involution at the center.[16,19,20] Symmetrical lesions of TVC
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Kumar and Kumar: Pediatric cutaneous tuberculosis

Figure 1: Scrofuloderma (Photograph courtesy: Prof. Archana Singal, Figure 2: Scrofuloderma in sporotrichoid pattern (Photograph courtesy:
UCMS, Delhi) Prof. Archana Singal, UCMS, Delhi)

Figure 3: Lupus vulgaris over buttocks-central zone of scarring and Figure 4: Multiple lesions of lupus vulgaris: Keratotic and ulcerative variants
peripheral zone of activity-plaque variant (Photo courtesy: Prof. Archana (Photo courtesy: Prof. Archana Singal, UCMS, Delhi)
Singal, UCMS, Delhi)

Figure 5: Plaque variant of lupus vulgaris with central zone of atrophy and Figure 6: Mutilating lupus vulgaris over face (Photo courtesy: Prof. Archana
scarring with peripheral zone of activity Singal, UCMS, Delhi)

Figure 7: Lupus vulgaris over knee-plaque variant (Photo courtesy: Prof.

Archana Singal, UCMS, Delhi) Figure 8: Lupus vulgaris over dorsum of hand-keratotic variant

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Kumar and Kumar: Pediatric cutaneous tuberculosis
Figure 9: Lupus vulgaris in sporotrichoid pattern
Figure  10: Tuberculosis verrucosa cutis (Photo courtesy: Prof. Archana
Singal, UCMS, Delhi)
a b
Figure 11: (a and b) Lichen scrofulosorum- multiple, pinhead-sized grouped,
follicular, and parafollicular papules over trunk (Photographs 11a and b
courtesy: Prof. Archana Singal, UCMS, Delhi)
on the extremities have been described.[22] There is absence
of constitutional symptoms while lymph nodes may be
enlarged.[20]
Tuberculous gumma
Tubercular gumma, also known as metastatic abscess,
results from disseminated infection by the hematogenous
route from a primary focus during periods of lowered
206
resistance. Children with malnutrition, immunosuppression,
or lymphomas are more susceptible compared to general
population.[20] It is considered to be the severe variant
of scrofuloderma by few authors. The typical lesion
is characterized as single or multiple soft, dermal, or
subcutaneous nodules which soften(s) to form fluctuant
nontender abscesses and later breaking down to form ulcers
or sinuses with undermined edges. Multiple confluent
swellings and sinuses affecting contiguous groups of lymph
nodes with finger‑like extensions radiating across the neck
or chest wall can be seen sometimes. On histopathology,
tubercles with caseation necrosis are characteristically seen.
Acid‑fast bacteria (AFB) are usually easily isolated from
the pus.[16,20]
Tuberculosis cutis orificalis
It is caused by autoinoculation of the organisms in
individuals with abdominal or pulmonary TB and is seen
rarely in children. Oral cavity is the most commonly
involved site followed by the genital or anal mucosa.
Shallow, granulomatous, and painful ulcer with undermined
bluish edges is the typical presentation.[19]
Acute miliary tuberculosis
Acute miliary TB is the more florid variant of TB due
to hematogenous dissemination of Mycobacterium
tuberculosis. Cutaneous findings consist of widespread
erythematous papules, pustules, or vesicles or nonspecific
lesions. Marked constitutional symptoms are common along
with internal organ involvement especially the lungs and
meninges. Tuberculin skin test is typically negative. Acute
inflammatory cells with numerous microabscesses are seen
on histopathology. The organisms are usually demonstrated
on aspiration smear or histopathology.[19,20]
Tuberculids
Tuberculids result from a delayed‑type hypersensitivity
reaction to occult tubercle bacilli in a patient with moderate
to high immunity. The diagnostic criteria of tuberculids
include tuberculoid granuloma on histopathology, strongly
positive Mantoux test, absence of M. Tuberculosis in
smear and culture, and resolution of skin lesions with
antituberculous therapy (ATT). Classification of tuberculids
is discussed in Table 1. Erythema nodosum is considered
to be a facultative tuberculid as M. Tuberculosis is one of
the many causative factors for erythema nodosum. Despite
the smear and culture negativity for M. tuberculosis,
polymerase chain reaction (PCR) techniques have identified
mycobacterial DNA in the lesional tissue of all types of
tuberculids.[19,20]
Lichen scrofulosorum
Lichen scrofulosorum is the most common variant of
tuberculids seen in children. The prevalence of lichen
scrofulosorum in different Indian studies in children is
summarized in Table 3. While earlier Indian studies had
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Kumar and Kumar: Pediatric cutaneous tuberculosis

Table 3: Major Indian studies on childhood cutaneous tuberculosis

Ramesh et al.,[6] Kumar et al.,[5] Pandhi et al.,[3] Vashisht et al.,[4]
n (%) n (%) n (%) n (%)
Sample size 63 75 68 103
Location Delhi Chandigarh Delhi Delhi
Duration of study 7 years 25 years 15 months 18 months
Age group included in the study ≤15 ≤16 ≤14 <19
Proportion of childhood cases 63/199 (31.7) 65/402 (18.7) 68/142 (47.9) 103/191 (53.9)
Male: female ratio 0.91:1 0.74:1 0.7:1 0.98:1
BCG vaccination (%) 57.2 50 41.2 51.4
Clinical subtypes and their percentage
Scrofuloderma 23 (36.5), neck 40 (53.3), neck 30 (44.1), neck 38 (36.9), neck
LV 40 (63.5) lower 30 (40.0), face, 15 (22.1) face, 22 (21.3%), lower
limbs lower limbs lower limbs limbs, face
TBVC ‑ 3 (4.0) 3 (4.4) 4 (3.9)
Gumma ‑ 1 (1.3) 0 2 (1.9)
Lichen srofulosorum 0 1 (1.3) 16 (23.5) 34 (33.0)
PNT 0 0 0 4 (3.9)
Others ‑ ‑ ‑ 3 (2.9)
Multiple patterns 1 0 4 5
Systemic involvement 8 (12.7) 16 (21.3) 26 (38.2) 55 (53.4)
Mantoux reactivity 62 (98.4) 61 (85.9) 66 (97.1) 68 (66.0)
Clinicohistological concordance ND 48 (64.0) 54 (80.6) 73 (70.9)
AFB positivity on histology 3 (4.7%) 13 (17.3%) 2 (2.9) 17 (16.5)
AFB positivity on cytology ND ND 7 (10.3) 19 (18.4)
AFB culture positivity 4 (6.3) ND 6 (8.8) 11 (10.7)
Percentage of patients completed treatment 38.1 ND 73.5 84.5
TBVC ‑ Tuberculosis verrucosa cutis; BCG ‑ Bacillus Calmette‑Guérin; PNT ‑ Papulonecrotic tuberculid; AFB ‑ Acid‑fast bacilli; ND- Not done

reported lower frequency of LS, recent reports show Papulonecrotic tuberculid

higher prevalence.[16] Higher index of suspicion may be
responsible for higher prevalence in recent studies. Lichen
scrofulosorum is an underdiagnosed and underreported
condition as subtle and asymptomatic lesions are either
missed or misdiagnosed as other follicular conditions
such as lichen nitidus, keratosis pilaris, and pityriasis
rubra pilaris. Although M. tuberculosis is commonly
associated with lichen scrofulosorum, rare association with
Mycobacterium avium intracellulare and Mycobacterium
szulgai infections have been reported.[23]
Lichen scrofulosorum typically presents as asymptomatic
or mildly symptomatic, pin‑head‑sized grouped or
clustered follicular, and parafollicular papules mostly
over the trunk [Figure 11a and b] or proximal extremities
which can be skin colored, erythematous, or lichenoid
in color.[20] The papules are characteristically flat‑topped
although overlying micropustules or crusting can be seen.
Extensive psoriasiform lesions have been reported in
lichen scrofulosorum.[24] Coexistence with other forms of
cutaneous TB such as scrofuloderma, LV, and erythema
induratum has been seen.
Underlying focus of TB is seen in substantial majority with
lymph nodes (cervical, mediastinal or hilar) being the most
common involved foci, followed by lung and bone.[4,20]
Papulonecrotic tuberculid (PNT) is a less common form
of tuberculid as compared to lichen scrofulosorum.
The prevalence of PNT in children was around 4% in
as reported by Vashisht et  al.[4] while earlier studies
reported almost zero prevalence of PNT.[3,5,6] The typical
lesions are characterized by symptomatic symmetrically
distributed firm and dusky‑red necrotizing papules over the
extremities which heal by varioliform scarring. The acral
regions are the common sites of predilection; however,
lesions localized to buttocks and face have been described.
Association with pulmonary and lymph node TB and
phlyctenular conjunctivitis have been described.[16,19,20]
Erythema induratum of Bazin
It is the rarest form of tuberculid with no childhood case
reported from India till date.[23] It is characterized by
subcutaneous nodules over posterior aspect of legs which break
down to form an ulcer healing with atrophic scar. Lobular
panniculitis with vasculitis is seen on biopsy along with
strongly positive Mantoux test. PCR for mycobacterial DNA
is positive in more than 50% of cases.[25] Frequent association
with pulmonary TB is seen.[26] While erythema induratum and
nodular vasculitis has been used interchangeably in the past, it
has been found that not all cases are associated with TB. It has
been proposed that the term “erythema induratum of Bazin”

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Kumar and Kumar: Pediatric cutaneous tuberculosis
should be reserved for those cases only which are associated
with TB. The term “erythema induratum of Whitefield” had
been used in the past and presently nodular vasculitis, for
cases not associated with TB.
Sporotrichoid skin tuberculosis
Lymphatic spread of the tubercular infection from a
primary entry focus can lead to linear arrangement of
the lesions, mostly over the extremities. Such pattern
is called sporotrichoid pattern as it resembles the linear
lesions of sporotrichosis. Sporotrichoid skin TB has most
commonly been reported among children from developing
countries.[27,28] Similar to sporotrichosis, cord‑like
thickening of the lymphatics may also occur. Regional
lymphadenopathy and ulceration can also be seen. Among
the variants of cutaneous TB, scrofuloderma and LV lesions
often present in sporotrichoid pattern. Retrograde lymphatic
spread of the organism from inguinal lymph nodes can lead
to inverse sporotrichoid pattern. This refers to occurrence
of linear lesions in proximal lower extremities, mostly
associated with TBVC and tubercular gumma.[19,20]
Bacillus Calmette–Guerin and cutaneous tuberculosis
Although BCG seems to have a significant efficacy in
prevention of pulmonary, miliary, meningeal and other
forms of systemic TB,[29,30] the role of BCG in prevention
of cutaneous TB is not well established. BCG vaccination
was found to be effective in prevention of skin TB in the
study by Zodpey et  al. with an efficacy of 60.9%.[31] No
difference in the incidence and clinical presentation of
cutaneous TB was found between BCG vaccinated and
unvaccinated children in one of the earlier studies.[6] LV,
scrofuloderma, tuberculids and erythema nodosum have
been reported at the site of BCG vaccination. As compared
to typical cutaneous TB, cutaneous TB induced by BCG
vaccination develops more quickly and is less severe in
presentation and easier to treat.[19]
HIV and cutaneous tuberculosis
Some forms of cutaneous TB, tubercular ulcers, PNT, and
miliary forms are more frequent and severe in HIV‑positive
individuals. In any of the major studies from India, no
child with cutaneous TB was found to be HIV positive.
Hence, larger studies are required to establish the impact of
HIV seropositivity on cutaneous TB in children.[16,20]
Diagnosis
The diagnosis of cutaneous TB is based on clinical features
and laboratory tests. Differential diagnoses usually include
atypical mycobacterial infections, deep fungal infections
such as chromoblastomycosis and sporotrichosis, sarcoidosis,
cutaneous leishmaniasis and leprosy. Major laboratory
investigations include direct demonstration of AFB on
Ziehl–Neelsen (ZN) stained smears or biopsies, histopathology,
isolation by culture or detection by PCR, and Mantoux test.
Multiple meta‑analysis and WHO studies have confirmed that
208 Indian Journal of Paediatric Dermatology | Volume 19 | Issue 3 | July-September 2018
serological antibody detection tests for TB are of no clinical
utility owing to their inaccuracy and inconsistency and have
been strongly discouraged for the diagnosis of TB.[32]
Histopathology
Biopsy for histopathology[33] and culture should be taken
from the edge of the sinus or ulcer which would show
tuberculoid granuloma along with neutrophils, eosinophils,
and caseation necrosis. Characteristic tubercular epithelioid
cell granulomas with lymphocytes and Langhans type
giant cells are the hallmark of cutaneous TB. However,
nonspecific changes can be seen in some cases. In addition,
the presence of tuberculoid granulomas in other diseases
can pose a diagnostic dilemma. Clinicopathological
correlation has been observed in 64%–85% of cases of
cutaneous TB in children.[3,4] LV is more often associated
with classical tubercular histopathology as compared to
scrofuloderma. Histopathology is especially useful for the
diagnosis of tuberculids in cases where ZN staining and
isolation by culture is not possible.[16]
Cutaneous tuberculosis variants with well‑formed
granulomas without caseation necrosis
Lupus vulgaris
The typical histopathology of LV shows epithelioid
granulomas in the upper dermis with lymphocytes and
Langhans giant cells in around 80% of cases. Rarely, foreign
body or sarcoidal granuloma can also be seen. Nonspecific
changes are seen in around 20% cases.[16] The epidermis is
characterized by atrophy or hypertrophy with acanthosis,
papillomatosis and sometimes pseudoepitheliomatous
hyperplasia. There is dense lymphocytic infiltrate. Fibrosis
is seen in areas of scarring. There is a paucity of AFB and
detection of bacilli by staining and culture is difficult.[19]
Lichen scrofulosorum
Epithelioid cell granuloma with cuff of lymphocytes
surrounding the follicles and sweat ducts, located
more superficially in dermis are demonstrated on
histopathology.[4,23] Giant cell, caseous necrosis, and AFB
are not seen usually. PCR and culture for tubercle bacilli
from lesional skin biopsies are usually negative.[23]
Cutaneous tuberculosis variants with granulomas and
caseous necrosis
Tuberculosis verrucosa cutis
The typical histopathology shows hypertrophic changes
such as pseudoepitheliomatous hyperplasia, tuberculoid
granulomas with caseous necrosis in the mid‑dermis, and
the presence of acute infiltrate in the upper dermis. AFB
are demonstrated rarely.[4,16]
Acute miliary tuberculosis
Nonspecific inflammatory infiltrate mainly of lymphocytes
and plasma cells is seen. Focal caseous necrosis can be
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Kumar and Kumar: Pediatric cutaneous tuberculosis
seen with formation of microabscesses occasionally. AFB
are frequently demonstrated with their number varying
according to the severity of the condition.[33]
Tuberculosis cutis orificialis
Tuberculoid granulomas with caseous necrosis is seen in
deep dermis around the site of ulceration.[33]
Papulonecrotic tuberculid
Wedge‑shaped necrosis along with nonspecific perivascular
infiltrate or typical tubercular granulomas surrounding the
necrosis are the typical histopathological findings, along
with leukocytoclastic vasculitis, and perivascular edema
or follicular necrosis with suppuration. AFB is not usually
demonstrable in PNT lesion; however, it is not unusual
to detect M. tuberculosis DNA by PCR.[16,34] It has been
suggested by Jordaan et al. to use the term “papulonecrotic
TB” over “PNT where M. tuberculosis DNA can be
confirmed by PCR.[35]
Cutaneous tuberculosis variants with poorly formed
granulomas with intense caseous necrosis
Scrofuloderma
Scrofuloderma is characterized by the presence of large
central necrosis with the formation of abscess and in most
cases, suppuration. Traces of the granuloma and AFB when
present are seen at the periphery of the lesion.[33]
Mantoux test
Mantoux test is a simple screening test to detect the
presence of tubercular infection. Induration of 10 mm or
more is suggestive of infection but does not confirm the
presence of active disease.
The sensitivity of Mantoux test for cutaneous TB ranges
from 33% to 96% with a cutoff of 10 mm. In the study
by Ramam et  al.,[36] specificity of Mantoux with a cutoff
of 10 mm was found to be 62.5%. The sensitivity of
Mantoux test in unvaccinated patients is much higher,
close to 97%.[36]
The sensitivity and intensity of Mantoux test varies widely
among the different presentations of cutaneous TB. While
Mantoux test is usually negative in tuberculous chancre,
miliary TB and TB orificialis, strongly reactive Mantoux
is seen usually in scrofuloderma, LV, TVC, and the
tuberculids.[8]
Exposure to environmental mycobacteria as well as recent
BCG vaccination within 1 year can lead to false‑positive
results. Age <2 months, pregnancy, and immunosuppressed
states such as malnutrition, diabetes, and HIV can be
associated with false‑negative reactions.[33] The rate of
Mantoux positivity in major Indian studies on pediatric
cutaneous TB has been given in Table 2. Vesiculation
and ulceration can occur in children after severe Mantoux
reaction.[3,4]
Indian Journal of Paediatric Dermatology | Volume 19 | Issue 3 | July-September 2018
Direct demonstration of acid‑fast bacteria
Direct demonstration of AFB in skin biopsy specimens
using ZN stain is a confirmatory test for the diagnosis
of cutaneous TB. Compared to culture, it is less
time‑consuming. However, the sensitivity is inferior
and observer dependent as compared to culture and
molecular‑based tests.[16]
Culture
Positive culture is considered to be the gold standard for
diagnosis of cutaneous TB as for any other infectious
disease. Culture has an additional advantage of being
able to test drug susceptibility. Traditional L‑J medium
has low rates of positivity for cutaneous TB especially
in children.[3,4] Owing to low sensitivity and tedious
procedure of traditional culture systems, newer culture
methods such as Radiometric BACTEC TB culture system
and liquid media are gaining popularity. Middlebrook
7H12 broth medium containing C‑14 labeled palmitic
acid for radiometric detection of mycobacteria is used in
BACTEC culture method.[37] In a study by Aggarwal et al.,
the sensitivity (62.8% vs. 25.7%) and mean detection
time (17.3 days vs. 39.4 days) of BACTEC system fared
better as compared to conventional L‑J medium. The study
also concluded that the combined isolation rate using both
media was superior as compared to either medium used
separately.[37]
Polymerase chain reaction
PCR is a rapid method with a reasonable sensitivity and
specificity to detect cutaneous TB.[25,38] IS‑6110 gene
specific for M. tuberculosis complex is the most common
target used in PCR.[25,38] Nonetheless, PCR requires
intensive labor and skill and is susceptible to technical
errors. Carryover contamination may lead to false‑positive
results. Degraded target DNA, insufficient extraction of
target DNA, and clinical samples‑containing PCR inhibitor
substances are common causes of false‑negative results.[37]
PCR is not able to distinguish live from dead bacilli. High
cost of this technique and inability to test drug susceptibility
are additional disadvantages of PCR.[16]
Therapeutic trial with antituberculous therapy
The rapid clinical response in case of cutaneous TB has
led to the concept of therapeutic challenge with ATT as
a diagnostic modality in doubtful cases where laboratory
results are equivocal.[39,40] As suggested by Ramam et  al.,
5 weeks were found to be an adequate duration for a
therapeutic trial in suspected cases of cutaneous TB. In
the absence of any significant response by 5  weeks, the
authors concluded that further treatment was unlikely to be
beneficial.[41,42] In these cases, possibility of MDR‑TB or a
diagnosis other than cutaneous TB should be considered.
However, tuberculids are an exception as they may require
more than 5 weeks to respond. Thus, prolonging the
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Kumar and Kumar: Pediatric cutaneous tuberculosis

therapeutic trial is advised in case of tuberculids before Table 4: Antitubercular drugs

considering alternate diagnosis.[42] Drug Dosage per day
Systemic screening for tuberculous focus First‑line drugs
Isoniazid 4‑6 mg/kg
In all children with cutaneous TB, thorough clinical Rifampicin 8‑12 mg/kg
assessment should be performed focusing on lymph nodes, Pyrazinamide 20‑30 mg/kg
pulmonary, gastrointestinal, nervous system, ocular, and Ethambutol 15‑20 mg/kg
musculoskeletal system. Fine‑needle aspiration cytology Second‑line drugs
and culture should be performed from any suspicious Amikacin 15 mg/kg
lesions. X‑ray of the chest and joints, computed tomography Kanamycin 15‑30 mg/kg
scan/magnetic resonance imaging of the brain and spine, Streptomycin 12‑18 mg/kg (not >750 mg)
ultrasonography of the abdomen and pelvis, sputum Ciprofloxacin 500‑1000 mg
and urine for AFB, and mycobacterial culture should be Ofloxacin 400 mg
undertaken to rule out tuberculous foci in any of the organ Levofloxacin 500 mg
suspected to be involved based on clinical findings. Gatifloxacin 400 mg

Treatment
Relaunch of our Revised National TB Control Program
(RNTCP) has resulted in better control and management
of pulmonary and extrapulmonary TB in India especially
after scaling‑up of directly observed treatment, short course
(DOTS). According to a recent study, scaled up DOTS has
been a cost‑effective strategy which has been successful
in improving the health status of Indian population. There
has been recent modification of DOTS by RNTCP in
which thrice‑weekly regimen in previous guidelines has
been replaced by daily regimen in the newer guidelines.
In addition, the continuation phase has been modified to
include three drugs in newer guidelines instead of two
drugs in the previous guidelines.
Cutaneous TB is treated as extrapulmonary TB as per
DOTS Category I recommendations. Intensive phase
consists of HRZE (isoniazid, rifampicin, pyrazinamide,
and ethambutol) given daily for 2 months followed
by maintenance phase of 4 months of HRE (isoniazid,
rifampicin, and ethambutol) daily. WHO defines MDR‑TB
as resistance to isoniazid and rifampicin and XDR‑TB
as resistance to isoniazid, rifampicin along with any
fluoroquinolone and one of the 3 second-line injectable
drugs (amikacin, capreomycin, and kanamycin). No studies
on drug resistance patterns in children have been done till
date, although few cases of drug resistance in children have
been published. The dosage of first‑line and second‑line
ATT drugs by weight has been given in Table 4.
Treatment of MDR‑TB requires the use of second‑line
drugs. The treatment regimen usually consists of five or six
drugs which include a fluoroquinolone and an injectable
administered for 6 months followed by administration of
four oral drugs for the next 18 months. The toxicity of
second‑line drugs warrants close monitoring especially in
children.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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