10.5826/dpc.1204a203
Introduction: Cutaneous tuberculosis is an uncommon form of tuberculosis, accounting for 1-2% of all forms of extra-pulmonary tuberculosis. Knowledge of the dermoscopy characteristics of different clinical types of cutaneous tuberculosis can help timely diagnosis resulting in better outcomes.
Materials and methods: All clinically suspected and biopsy confirmed cases of cutaneous tuberculosis seen from July 2019 through December 2021 were retrospectively recruited. Information including age, gender, disease duration, site and morphology of lesions, and presence of concomitant tuberculosis elsewhere was noted. Two investigators retrospectively reviewed the dermoscopic characteristics of these cases.
Results: Twenty-two patients comprised of 12 women and ten men met the inclusion criteria. Lupus vulgaris was the commonest presentation of cutaneous tuberculosis seen in 13 patients. Five had scrofuloderma, two had tuberculosis verrucosa cutis and one patient each had lichen scrofulosorum and papulo-necrotic tuberculid. Yellow-orange structureless areas (100%), linear/dot vessels (100%), white scales (92.3%), and white structureless areas (84.6%) were the predominant dermoscopy findings in lupus vulgaris. In scrofuloderma, linear vessels and white structureless areas were visible in all cases. Dirty white scales with a papillated surface were characteristically seen in tuberculosis verrucosa cutis, with one of the two patients each showing vessels and yellow-orange structureless areas. White globules with surrounding erythema were seen in lichen scrofulosorum and yellow-orange structureless areas with keratin plugs in papulo-necrotic tuberculid.
Conclusion: A thorough understanding of the characteristic dermoscopy of cutaneous tuberculosis can help suspect the diagnosis early resulting in better management opportunity.
text/xml
2160-9381
2359
en
Sheenam Sethi
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
scrofuloderma
Dermoscopy of the diverse spectrum of cutaneous tuberculosis in the skin of color
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2022-02-01
2022-10-31
2022-12-05
e2022203
Dermatol Pract Concept
Introduction: Cutaneous tuberculosis is an uncommon form of tuberculosis, accounting for 1-2% of all forms of extra-pulmonary tuberculosis. Knowledge of the dermoscopy characteristics of different clinical types of cutaneous tuberculosis can help timely diagnosis resulting in better outcomes.
Materials and methods: All clinically suspected and biopsy confirmed cases of cutaneous tuberculosis seen from July 2019 through December 2021 were retrospectively recruited. Information including age, gender, disease duration, site and morphology of lesions, and presence of concomitant tuberculosis elsewhere was noted. Two investigators retrospectively reviewed the dermoscopic characteristics of these cases.
Results: Twenty-two patients comprised of 12 women and ten men met the inclusion criteria. Lupus vulgaris was the commonest presentation of cutaneous tuberculosis seen in 13 patients. Five had scrofuloderma, two had tuberculosis verrucosa cutis and one patient each had lichen scrofulosorum and papulo-necrotic tuberculid. Yellow-orange structureless areas (100%), linear/dot vessels (100%), white scales (92.3%), and white structureless areas (84.6%) were the predominant dermoscopy findings in lupus vulgaris. In scrofuloderma, linear vessels and white structureless areas were visible in all cases. Dirty white scales with a papillated surface were characteristically seen in tuberculosis verrucosa cutis, with one of the two patients each showing vessels and yellow-orange structureless areas. White globules with surrounding erythema were seen in lichen scrofulosorum and yellow-orange structureless areas with keratin plugs in papulo-necrotic tuberculid.
Conclusion: A thorough understanding of the characteristic dermoscopy of cutaneous tuberculosis can help suspect the diagnosis early resulting in better management opportunity.
Sheenam Sethi
2022/10/31
10.5826/dpc.1204a203
e2022203
Himalayan Institute of Medical Sciences, Dehradun, India
2160-9381
scrofuloderma
en
e2022203
Jassi R, Yadav A, Chander R. Dermoscopy of Lichen Scrofulosorum. Indian Dermatol Online J. 2020 Jan 24;11(5):876-877.
Dermoscopy of the diverse spectrum of cutaneous tuberculosis in the skin of color
https://dpcj.org/index.php/dpc/article/download/2359/1823
 Dermoscopy of the Diverse Spectrum of Cutaneous
         Tuberculosis in the Skin of Color
                                 Rashmi Jindal1, Payal Chauhan2, Sheenam Sethi1


1 Himalayan Institute of Medical Sciences, Dehradun, India
2 All India Institute of Medical Sciences, Bilaspur, India



Key words: dermoscopy, cutaneous tuberculosis, lupus vulgaris, scrofuloderma
Citation: Jindal R, Chauhan P, Sethi S. Dermoscopy of the diverse spectrum of cutaneous tuberculosis in the skin of color.
Dermatol Pract Concept. 2022;12(4):e2022203. DOI: https://doi.org/10.5826/dpc.1204a203
Accepted: March 14, 2022; Published: October 2022
Copyright: ©2022 Jindal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Rashmi Jindal, MD, Department of Dermatology, Venereology & Leprosy, Himalayan Institute of Medical Sciences,
Swami Ram Nagar, Doiwala, Dehradun. Phone: 0135-2471358, 9639657109, E-mail: rashmijindal98@gmail.com




  ABSTRACT             Introduction: Cutaneous tuberculosis is an uncommon form of tuberculosis, accounting for 1%-2%
                       of all forms of extra-pulmonary tuberculosis. Knowledge of the dermoscopic characteristics of dif-
                       ferent clinical types of cutaneous tuberculosis can help timely diagnosis resulting in better outcomes.
                       Objectives: To characterize the Dermoscopy findings in different clinical types of cutaneous tubercu-
                       losis in dark skin phototypes.
                       Methods: All clinically suspected and biopsy confirmed cases of cutaneous tuberculosis seen from
                       July 2019 through December 2021 were retrospectively recruited. Information including age, gender,
                       disease duration, site and morphology of lesions, and presence of concomitant tuberculosis elsewhere
                       was noted. Two investigators retrospectively reviewed the dermoscopic characteristics of these cases.
                       Results: Twenty-two patients comprised of 12 women and 10 men met the inclusion criteria. Lupus
                       vulgaris was the commonest presentation of cutaneous tuberculosis seen in 13 patients. Five had scrof-
                       uloderma, 2 had tuberculosis verrucosa cutis and 1 patient each had lichen scrofulosorum and papulo-­
                       necrotic tuberculid. Yellow-orange structureless areas (100%), linear/dot vessels (100%), white scales
                       (92.3%), and white structureless areas (84.6%) were the predominant dermoscopy findings in lu-
                       pus vulgaris. In scrofuloderma, linear vessels and white structureless areas were visible in all cases.
                       Dirty white scales with a papillated surface were characteristically seen in tuberculosis verrucosa cu-
                       tis, with 1 of the 2 patients each showing vessels and yellow-orange structureless areas. White globules
                       with surrounding erythema were seen in lichen scrofulosorum and yellow-orange structureless areas
                       with keratin plugs in papulo-necrotic tuberculid.
                       Conclusions: A thorough understanding of the characteristic dermoscopy of cutaneous tuberculosis
                       can help suspect the diagnosis early resulting in better management opportunity.




Original Article | Dermatol Pract Concept. 2022;12(4):e2022203                                                                      1
Introduction                                                        dermoscopy images were available. Dermoscopy was per-
                                                                    formed in these cases as a routine, and images were captured
Dermoscopy is widely used for diagnosing various inflam-            with iPhone 11 (12-megapixel camera; Apple Inc., Cupertino,
matory, neoplastic and pigmentary dermatoses. Its utility           California) attached to Dermlite DL200 hybrid (10x magni-
in suspecting infective as well as granulomatous diseases is        fication, 3Gen, San Juan Capistrano, California). Two inves-
progressively established. Cutaneous tuberculosis is an un-         tigators (RJ, PC) retrospectively reviewed the dermoscopic
common form of tuberculosis, accounting for 1%-2% of all            characteristics of these cases. The dermoscopy findings were
forms of extra-pulmonary tuberculosis, however the associ-          recorded following the standardized terminology according
ated morbidity warrants prompt diagnosis and treatment [1].         to the International Dermoscopy Society (IDS) consensus
In India, lupus vulgaris (LV) is the most frequent clinical type    document on dermoscopy in general dermatology (3). Sta-
reported in adults and scrofuloderma in children [2]. Knowl-        tistical analysis was performed using SPSS software (version
edge of the dermoscopy characteristics of different clinical        22; SPSS Inc.). Categorical variables were expressed as num-
types of cutaneous tuberculosis can help timely diagnosis re-       ber and percentage, and numerical data were expressed as
sulting in better treatment outcomes.                               mean and standard deviation. Being a retrospective study in-
                                                                    stitutional review board approval was not required.

Objectives
                                                                    Results
To characterize the Dermoscopy findings in different clinical
types of cutaneous tuberculosis in dark skin phototypes. The        Twenty-two patients with cutaneous tuberculosis, 12 women
available literature on the dermoscopy of diverse spectrum          and 10 men, met the inclusion criteria. LV was the common-
of cutaneous tuberculosis is limited; thus, the present study       est presentation of cutaneous tuberculosis seen in 13 pa-
was planned to bridge this knowledge gap.                           tients. Five had scrofuloderma, 2 had tuberculosis verrucosa
                                                                    cutis (TVC) and 1 patient each had lichen scrofulosorum and
                                                                    papulo-necrotic tuberculid (PNT). The face was the most fre-
Methods
                                                                    quent site involved; 7 patients of LV and 4 of scrofuloderma
All clinically suspected and biopsy confirmed cases of cuta-        had facial lesions (Table 1). A primary focus was identified in
neous tuberculosis seen from July 2019 through December             the patient with PNT; however, no focus could be recognized
2021 (2 and a half years) were retrospectively recruited. De-       in the girl with lichen scrofulosorum despite an extensive
tailed information regarding age, gender, disease duration,         search. None of the patients with LV, scrofuloderma, and
site and morphology of lesions, and presence of concomi-            TVC had concomitant tuberculosis elsewhere. Dermoscopy
tant tuberculosis elsewhere was noted. The final analysis was       images were evaluated for the diverse morphology of cutane-
done only for cases where a skin biopsy was performed and           ous tuberculosis (Table 2).



       Table 1. Clinical and demographic characteristics of patients with cutaneous tuberculosis.
                                                                            Age               Duration
       Type of          Number          Male:         Fitzpatrick        Mean ± SD          Mean (range),
    Cutaneous TB        of cases      Female, N      skin type, N         (years)             months                  Site, N
 Lupus vulgaris       13             4:9           III: 3            33.7±18.9             11 (2-30)            Face (7)
                                                   IV: 5                                                        Neck (1)
                                                   V: 5                                                         Upper limb (3)
                                                                                                                Lower limb (2)
 Scrofuloderma        5              3:2           III: 1            33.2±19.8             9.6 (6-12)           Face (4)
                                                   IV: 2                                                        Neck (1)
                                                   V:2
 Tuberculosis         2              2:0           IV:1              17 and 42 years       24 and 36            Upper limb (2)
 verrucosa cutis                                   V:1
 Lichen               1              Female        IV                12 years              9                    Trunk &
 scrofulosorum                                                                                                  Extremities
 Papulonecrotic       1              Male          IV                32 years              4                    Legs and feet
 tuberculid

SD = standard deviation; TB = tuberculosis.



2                                                                       Original Article | Dermatol Pract Concept. 2022;12(4):e2022203
 Table 2. Dermoscopic characteristics of diverse                   Scrofuloderma (N = 5)
     morphology of cutaneous tuberculosis.
                                                                   All patients presented with multiple discharging sinuses and
        Dermoscopic characteristics               Number (%)
                                                                   scarring. The mean age of patients was 33.2 years, with
 Lupus vulgaris (N = 13)                                           a mean duration of lesions being 9.6 months (range 6-12
 • Yellow orange structureless areas                 13 (100)      months). The most consistent dermoscopy findings were lin-
 • Linear vessels with or without branches           11 (84.6)
                                                                   ear vessels with and without branches (100%), white struc-
 • Dot vessels                                       3 (23.1)
 • Black dot/ globules                               5 (38.5)      tureless areas (100%), and yellow-orange structureless areas
 • White lines                                       10 (76.9)     (80%) (Figure 2, A and B). Sero-sanguineous crust represent-
 • White structureless areas                         11 (84.6)     ing the sinuses and orange-brown scales were appreciated in
 • Follicular plugging                               8 (61.5)      60% of patients each (Figure 2, A and B).
 • White scales                                      12 (92.3)
 • Bluish hue                                        4 (30.8)
 • Ulceration                                        3 (23.1)      Tuberculosis Verrucosa Cutis (N = 2)
 • Perilesional white halo                           7 (53.8)
 Scrofuloderma (N = 5)                                             Tuberculosis verrucosa cutis was the morphology of cuta-
 • Yellow orange structureless areas                   4 (80)      neous tuberculosis in two men aged 17 and 42 years. One
 • Linear vessels with or without branches            5 (100)      of them had the lesion for 2 years and the other for 3 years.
 • Sero-sanguineous crust                              3 (60)      Both dermoscopically showed dirty white thick scales with a
 • White structureless areas                          5 (100)      papillated surface (Figure 2, C and D). However, only 1 had
 • Orange-brown scale                                  3 (60)
                                                                   the presence of dot vessels and curved vessels. Yellow-orange
 • Ulceration                                          2 (40)
                                                                   structureless areas were visible in one of the patients.
 Tuberculosis verrucosa cutis (N = 2)
 • Dirty white scale with papillated surface          2 (100)
 • Dot and linear curved vessels                       1 (50)      Lichen Scrofulosorum (N = 1)
 • Yellow orange structureless area                    1 (50)
 • Hemorrhagic crust                                   1 (50)      The 12-year-old-girl with lichen scrofulosorum presented

 Lichen scrofulosorum (N = 1)                         Single       with multiple grouped skin-colored papules over the trunk
 • White globules with surrounding                    patient      and extremities. On dermoscopy, numerous uniform fol-
   erythema                                                        licular and non-follicular white globules with surround-
 • Peripheral pigment network                                      ing erythema and peripheral pigment network were seen
 • Focal white scale                                               (­Figure 3A). Some of the white globules had a central black
 Papulonecrotic tuberculid (N = 1)                    Single       dot. White scales were appreciated focally.
 • Yellow-orange structureless area                   patient
 • Keratin plug
                                                                   Papulo-necrotic Tuberculid (N = 1)
                                                                   The patient was a 32-year-old man with a primary focus of

Lupus Vulgaris (N = 13)                                            tuberculosis in the brain as a tubercular abscess. He presented
                                                                   with multiple purpuric macules and hyperkeratotic papules
Eight patients had plaque type of LV and the remaining             and plaques over soles. Dermoscopy showed orange-brown
nodular type. Women (9) outnumber men (4), and the mean            structureless areas and keratin plugs (Figure 3. B and C).
age at presentation was 33.7 years. The mean duration of
illness was 11 months (range 2-30 months). Yellow-orange
                                                                   Conclusions
structureless areas were consistently visualized in all cases of
LV; these represent the epitheloid granulomas seen on his-         The application of dermoscopy for granulomatous diseases
topathology (Figure 1, A-D). Linear vessels with and with-         is gaining recognition as it gives a swift clue to the diag-
out branches were appreciated in 11 (84.6%) patients and           nosis much before histopathology results are accessible. The
dot vessels in 3 (23.1%) patients. The focal white scale was       most available literature is on dermoscopy of LV, including
another frequent feature seen in 12 (92.3%) lesions. White         a significant case series from India of 19 cases [4]. For other
lines (unspecified) and white structureless areas were seen in     clinical types, there are anecdotal reports or small case series.
10 (76.9%) and 11 (84.6%) cases, respectively (Figure 1, A,        Here we report our experience with dermoscopy of distinc-
B and D). Follicular plugging was visible dermoscopically          tive morphological types of cutaneous tuberculosis seen over
in 8 (61.5%), and a peri-lesional halo of hypopigmentation         a 2 and a half year period. A total of 22 patients with a
was observed in 7 (73.8%) patients (Figure 1, A and D).            confirmed diagnosis of tuberculosis were seen over the study



Original Article | Dermatol Pract Concept. 2022;12(4):e2022203                                                                    3
    Figure 1. (A-D) Dermoscopy of lupus vulgaris showing yellow-orange structureless areas (black star), linear vessels with and without
    branches (black arrow), white structureless areas (blue star) and lines (blue arrowheads), follicular plugging (black circle), white scales
    (blue arrow), dot vessels (black square) and peri-lesional halo (blue rectangle). (A, inset) A well-defined plaque with atrophy and an
    advancing erythematous margin




period. LV was the most typical clinical type encountered,                 skin type IV/V, the yellow-orange hue was appreciable. A
followed by scrofuloderma.                                                 retrospective study by International Dermoscopy Society
     The hallmark of granulomatous disorders is yellow-orange              reports presence of an orange-yellow hue representing the
structureless areas representing the dermal granulomas seen                dermal granulomas in patients with Fitzpatrick skin type
histologically (Table 3) [5-7]. All the patients with LV, the ma-          V/VI. In their 12 reported patients with LV, focal bright areas
jority (80%) with scrofuloderma, and the single patient with               were seen in a majority [8]. Similar yellow-orange structure-
PNT in the presented series showed yellow-orange structure-                less areas are reported in TVC; however, it was evident only
less areas. Ankad et al, in their series of 19 cases with LV,              in 1 of our patients [9]. The presence of thick white adherent
reported the presence of yellow-white globules instead of the              scales and marked papillomatosis obscured their visibility in
yellow-orange structureless areas explained due to a predom-               the other. Lichen scrofulosorum did not reveal yellow-orange
inance of Fitzpatrick skin type IV/V in their patients [4]. Al-            structureless areas, possibly since the granulomas are more
though most cases in the current series also had Fitzpatrick               petite and centered on the hair follicles.



4                                                                               Original Article | Dermatol Pract Concept. 2022;12(4):e2022203
 Figure 2. Dermoscopy of scrofuloderma showing sero-sanguineous crust representing the sinus with yellow-orange structureless areas
 (black star), white structureless areas (blue star) and linear vessels (black arrow) (A,B), clinical image showing a central sinus surrounded
 by erythema and scarring (A, inset). Dermoscopy of tuberculosis verrucosa cutis showing thick dirty white scales (blue arrow), yellow
 orange structureless areas (black star), white structureless areas (blue star) and dot/ curved vessels (blue square) (C,D), clinical image
 showing hyperkeratotic plaque over middle finger (C, inset).



    Linear vessels with or without branches were frequently               histopathologically with proliferating collagen bundles dis-
observed in LV and represent dilated capillary loops that ap-             tributed throughout the dermis. All cases of scrofuloderma
pear well focused because of their displacement towards the               also had white structureless areas corroborating the associ-
epidermis by the underlying granulomas. Vessels were appre-               ated scarring evident clinically.
ciated in all cases with scrofuloderma and TVC; however,                      Follicular plugging in LV was reported to be higher in
PNT and lichen scrofulosorum lacked them. In lichen scrof-                the present series than in literature and was also appreci-
ulosorum, a few white globules showed peripheral erythema                 ated in PNT [4]. The serosanguineous crust was noticed in
representing focal dilatation of the capillaries.                         most patients with scrofuloderma and represented sinuses
    White structureless areas indicating the dermal fibrosis              seen clinically; at places, there was an overlying hemorrhagic
and acanthosis are well reported in LV and were seen in most              crust. Dirty white thick scales covered the lesions of TVC,
LV lesions in the written series. 76.9% of patients also had              making visualization of underlying structures difficult. The
linear white streaks arranged haphazardly and correlated                  short curved and dot vessels were only visible in one case



Original Article | Dermatol Pract Concept. 2022;12(4):e2022203                                                                                   5
Figure 3. (A) Dermoscopy of lichen scrofulosorum with monomorphic white clods, some having a central black dot (black circle) and
some peripheral erythema (black square) and increased surrounding pigment network (black star), inset showing grouped papules over
trunk. (B,C) Dermoscopy of papulo-necrotic tuberculid showing yellow-orange structureless areas (black star), inset showing purpuric
macules over soles and keratin plugs (black circle) with inset showing hyperkeratotic papules.



                      Table 3. Histopathological correlation for dermoscopy characteristics.
                    Dermoscopy characteristic                                        Histopathological correlate
 Yellow-orange structureless areas                                  Dermal granulomas
 Linear vessels                                                     Dilated dermal capillaries pushed up by granuloma
 White structureless areas                                          Dermal fibrosis and acanthosis
 White lines                                                        Dermal collagen bundles with a parallel orientation
 Follicular plugs                                                   Keratin in follicular infundibulum
 Scales                                                             Hyperkeratosis


focally. Inconspicuous vessels have been reported by Jakhar          structureless areas and lines appear significant. In scrofu-
et al in TVC, with the prominent finding in their case being         loderma additionally, serosanguineous crust representing
a yellow-red background, papillated surface, and dirty thick         the sinuses is noteworthy. Thick white scales and papillo-
scales [9]. Pale monomorphic grouped white globules with             matosis obscure sub-surface changes in TVC. Occasionally
peripheral erythema and hyperpigmentation seen in our pa-            focal curved/dot vessels can be appreciated. Grouped mono-
tient with lichen scrofulosorum have been reported in the            morphic white globules with a central black dot and sur-
past [10,11]. However, we could not appreciate telangiecta-          rounding erythema and hyperpigmentation symbolize lichen
sias as reported in the literature.                                  scrofulosorum. Yellow-orange structureless areas and kera-
    Dermoscopy of various morphologies of cutaneous                  tin plugs are appreciable in PNT. A thorough understanding
tuberculosis appears noteworthy. For LV, yellow-orange               of the characteristic dermoscopy of cutaneous tuberculosis
structureless areas, well-focused linear vessels, and white          seems necessary, especially for dermatologists working in the



6                                                                         Original Article | Dermatol Pract Concept. 2022;12(4):e2022203
endemic region. The written case series attempts to bridge                6. Chauhan P, Adya KA. Dermatoscopy of Cutaneous Granuloma-
the existing gaps in the knowledge about dermoscopy of var-                  tous Disorders. Indian Dermatol Online J. 2021;12(1):34-44.
                                                                             DOI: 10.4103/idoj.IDOJ_543_20. PMID: 33768021 PMCID:
ious clinical morphologies of cutaneous tuberculosis.
                                                                             PMC7982032.
                                                                          7. Brasiello M, Zalaudek I, Ferrara G, et al. Lupus vulgaris: a new
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Original Article | Dermatol Pract Concept. 2022;12(4):e2022203                                                                             7
