Lupus vulgaris

Robert Willan (1757-1812).

• Tuberculosis cutis luposa.

The most common form of cutaneous tuberculosis.

• Women are affected twice as often.
• Rarely occurring, but still the most common form of cutaneous tuberculosis.
• Independent of age.

Cutaneous TB infection occurs by haematogenous, lymphogenous seeding or per continuitatem, but can also occur exogenously.

• Localisation
• Face, mammae, extremities and mucous membranes.
• Primary florescence: erythematous-brownish, lenticular, partly serpiginous, partly confluent papules. Diascopically, an apple jelly-coloured nodule is seen. It spreads to the periphery. If one breaks through the skin with the light! If the mild papule breaks through the skin, it is called a positive probe phenomenon or stylet phenomenon.
• Frequently, there is also pulmonary tuberculosis.

• Clinic.
• Tuberculin test (Mendel-Mantoux).
• Quantiferon test.
• Biopsy (both dermatopathological and microbiological examination).
• Thoracic X-ray or CT- chest.
• Sonography of abdomen and kidneys.
• Collect sputum on 3 consecutive mornings (fasting up to 4h).
• Pass urine on 3 consecutive mornings (fluid restriction the night before!).
• Bronchoalveolar lavage (BAL).

Partially carcinomatous degeneration possible (carcinoma in lupo).

Chronic progression.

• Excision if possible.

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 individually between 12-24, 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 last ≥ 7 months. Ethambutol should be replaced by streptomycin p.o. 15-20 mg/kg bw/d (from > 60 y. max 750 mg) in case of additional therapy with NNRTIs.

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4.  Gooptu, Marks, Thomas , James. Squamous cell carcinoma associated with lupus vulgaris. Clin Exp Dermatol 1998;23:99-102. 
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6.  Motta A, Feliciani C, Toto P, De Benedetto A, Morelli F , Tulli A. Lupus vulgaris developing at the site of misdiagnosed scrofuloderma. Journal of the European Academy of Dermatology and Venereology 2003;17:313-5. 
7.  Pandhi D , Reddy BSN. Lupus Vulgaris Mimicking Lichen Simplex Chronicus. The Journal of Dermatology 2001;28:369-72. 
8.  Senol M, Ozcan A, Mizrak B, Turgut AC, Karaca S , Kocer H. A Case of Lupus Vulgaris with Unusual Location. The Journal of Dermatology 2003;30:566-9.