Lichen scrophulosorum

Hebra 1860.

Tuberculosis cutis lichenoides.

In the context of a TB infection, lichenoid papules occur in a hyperergic immune state.

In particular, occurring in childhood and adolescence.

Strong immune reaction in the context of a TB infection.

• Symmetrically, perifollicularly and follicularly arranged, yellow-brown, erythematous papules.

• History.
• Clinical.
• Tuberculin test (Mendel-Mantoux). 
• Quantiferon test.
• Biopsy.

• To exclude systemic involvement:
• Thoracic X-ray or CT- thorax.
• Sonography of abdomen and kidneys.
• In the morning (fasting up to 4h) on 3 consecutive days, sputum must be collected.
• Pass urine in the morning on 3 consecutive days (fluid restriction the evening before!).
• Bronchoalveolar lavage (BAL).

• Especially on the lateral trunk.

Tuberculoid structures, Langhans giant cells, necrosis. 

• Spontaneous healing within weeks.
• Ggl. recurrences.

Topical therapy.

Elocom.

Therapy regimen:

The initial phase should last for 8 weeks/2 months. During this time, the majority of bacteria are killed. In the subsequent phase of therapy (lasting for months), attempts are made to eliminate the remaining bacteria. Antituberculous therapy should be continued for at least 2 months after the skin is free of symptoms.

Therapy should last between 12-24 months individually, but at least 6 months!

Induction phase (2 months):

• Rifampicin p.o. 10 mg/kg bw/d
• Isoniazide p.o. 5 mg/kg bw. (with Vit B 6)
• Pyrazinamide p.o. 35 mg/ bw/ d if necessary combination with allopurinol!
• Ethambutol p.o. 15 mg/kg bw/ d
• A clear improvement can be seen in the vast majority of cases after 1 ½ months.

·        Consolidation phase:

• Induction phase (2 months):
• Rifampicin p.o. 10 mg/kg bw/d
• Isoniazide p.o. 5 mg/kg bw. (with Vit B 6)
• Ethambutol p.o. 15 mg/kg bw/d (can also be omitted if isoniazid resistance has been ruled out)
• HIV patients: therapy must be given for 7 months. Ethambutol should be replaced by streptomycin p.o. 15-20 mg/kg bw/d (from 60 years max 750 mg) in case of additional therapy with NNRTI.

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2.  Joshi HS, Zacharia A , Warrier A. Lichen scrofulosorum. BMJ Case Rep 2014;2014. 
3.  Patra S, Patro B, Patel R, Aneja S , Sarkar D. Lichen scrofulosorum presenting as pyrexia of unknown origin. J Coll Physicians Surg Pak 2014;24:141-2. 
4.  Singal A , Pandhi D. Lichen scrofulosorum and endometrial tuberculosis: a novel association. Int J Dermatol 2016;55:322-4. 
5.  Tobita R, Sumikawa Y, Imaoka K, Murata S, Dekio I, Maruyama R et al. Lichen scrofulosorum caused by pulmonary Mycobacterium avium complex (MAC) infection. Eur J Dermatol 2011;21:619-20.