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Patient Education
Wound Care: Keep lesions covered and moist with antibiotic ointment or petrolatum to aid in rapid healing
Follow-up Actions
Evacuation/Consultation Criteria: Evacuation not usually indicated. Consult dermatology or infectious
disease as needed.
Skin: Cutaneous Tuberculosis
Lt Col Gerald Peters, USAF, MCIntroduction: Cutaneous tuberculosis (TB) commonly represents skin manifestations of underlying pulmonary
TB. It can also mean primary skin inoculation with TB, which is very rare. (see Respiratory: TB).
Mycobacterium tuberculosis infects almost 2 billion people in the world (about 1 out of 3 living humans). It
is an acid-fast, aerobic, gram-positive bacterium with both human and bovine forms. The BCG vaccine (not
used in the US) is derived from the latter. Only about 1% of all TB patients will have skin lesions. Most
cutaneous TB is indicative of systemic TB infection and can be the first sign of TB, especially in patients
with HIV infection.
Subjective: Symptoms
Most are asymptomatic, some have a painless nodule progressing to painful ulcer, itching is uncommon.
Objective: Signs
Using Basic Tools: Primary skin inoculation: Non-tender, well-circumscribed ulcer; non-tender
lymphadenopathy (3-8 weeks later); these characteristics are the ulceroglandular complex
Cutaneous manifestations of pulmonary TB: Variable presentations: boggy, indurated, erythematous skin
and purulent ulcerations overlying infected subcutaneous tissue and enlarged lymph nodes (scrofuloderma);
brown-red papules, soft and apple-jelly like, most common on the face, ears, buttocks and breasts (lupus
vulgaris); discrete, blue-red to brown, tiny papules, some capped with minute vesicles, which burst to leave
a crust and may affect all body parts, but the trunk, thighs, buttocks and genitalia are predisposed (Miliary
TB); and others.
Using Advanced Tools: Place a PPD. A positive test does not indicate active TB, only exposure.
Assessment:
Differential Diagnosis
Primary Skin Inoculation - primary syphilis, tularemia, cat scratch disease, sporotrichosis, and others.
Cutaneous Manifestations of Pulmonary TB: extensive list including tertiary syphilis, deep fungal infections,
chronic granulomatous disease, leishmaniasis, sarcoidosis, squamous cell carcinoma, and many others
Plan:
Treatment
Primary: There are at least 13 different agents to choose from. Many organisms are multi-drug resistant.
See Respiratory: TB section for details.
Primitive: None effective
Empiric: Basic health measures, including clean and nutritious food and water, immunizations, and sanitation
to help fight the infection.
Patient Education
General: TB is not an emergency. If exposed, the risk of developing TB is 5% in the first year. Get evaluated
thoroughly by experts with in 1-2 months. There is a risk of re-infection from trauma and exposure to the
organism in meat handlers, veterinarians and staff and persons involved in autopsies and undertaker duties.