Lupus vulgaris

Robert Willan (1757–1812).

• Tuberculosis cutis luposa.

Most common form of skin tuberculosis.

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

Cutaneous Tbc infestation is caused by haematogenic, lymphogenic sowing or per continuitatem, but also by exogenous sowing.

• localization
• face, mammae, extremities and mucous membranes.
• Primary afflorescence: erythematous-brownish, lentil-sized, partly serpiginous, partly confluent papules. Diascopically a apple jelly coloured nodule appears. It spreads peripherally. If the slight (!) speciality already breaks through the skin, one speaks of a positive probe phenomenon or mandrin phenomenon.
• Often there is also pulmonary tuberculosis.

• Clinic.
• Tuberculin test (Mendel-Mantoux). 
• Quantiferon test. 
• Biopsy (both dermatopathological and microbiological examination).
• Thorax X-ray or CT thorax.
• Sonography of the abdomen and kidneys.
• Collect sputum on 3 consecutive mornings (fasting up to 4 hours).
• On 3 consecutive mornings, pass urine (fluid restriction the evening before!). 
• Bronchoalveolar lavage (BAL).

Partially carcinomatous degeneration possible (carcinoma in lupo).

Chronic course.

• Excision if possible.

Therapy schedule:

• The initial phase should last 8 weeks/2 months. During this time, the majority of bacteria will be killed. In the following therapy phase (which lasts for months), an attempt is made to eliminate the remaining bacteria. The antituberculous therapy should be continued for at least 2 months after the absence of skin symptoms.

• The therapy should last individually between 12-24, but at least 6 months!

Induction phase (2 months):

• Rifampicin p.o. 10 mg/kg bw/d
• Isoniazid p.o. 5 mg/kg bw. (with Vit B 6)
• Pyrazinamid 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 month.

Consolidation phase:

• Induction phase (2 months):
• Rifampicin p.o. 10 mg/kg bw/ d
• Isoniazid p.o. 5 mg/kg bw. (with Vit B 6)
• Ethambutol p.o. 15 mg/kg bw/d (may be omitted if isoniazid resistance has been excluded)
• HIV Patients: Therapy must be done at ≥ 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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4.  Gooptu, Marks, Thomas , James. Squamous cell carcinoma associated with lupus vulgaris. Clin Exp Dermatol 1998;23:99-102. 
5.  Margolis DJ, Hoffstad O , Bilker W. Association or lack of association between tetracycline class antibiotics used for Akne vulgaris and lupus erythematosus. Br J Dermatol 2007;157:540-6. 
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.