What are the skin manifestations of Tuberculosis (TB) and their management strategies?

From the Guidelines

Skin manifestations of tuberculosis (TB) include several distinct forms, such as scrofuloderma, lupus vulgaris, tuberculosis verrucosa cutis, tuberculous chancre, and tuberculids, which require prompt recognition and treatment to prevent morbidity and mortality. The main cutaneous TB types present with varying symptoms, including firm nodules, ulcers, reddish-brown plaques, and "apple jelly" appearance on diascopy. Management of cutaneous TB follows standard TB treatment protocols with a multi-drug approach, as outlined in the study by 1.

Key Considerations for Management

• The first-line regimen consists of a 2-month intensive phase with isoniazid, rifampin, ethambutol, and pyrazinamide, followed by a 4-month continuation phase with isoniazid and rifampin, as this combination has been shown to be effective in treating TB while minimizing the risk of adverse events 1.
• Pyridoxine (vitamin B6) should be added to prevent isoniazid-induced neuropathy, a common adverse event associated with TB treatment 1.
• Treatment duration may extend to 9-12 months for more severe cases, and patients should be evaluated for pulmonary and systemic TB involvement, as cutaneous manifestations often indicate underlying disease.
• Drug resistance testing is essential before initiating therapy, and treatment adherence must be monitored to prevent resistance development, as highlighted in the study by 1.

Adverse Event Management

• Common adverse events associated with TB treatment include rash, vomiting, diarrhea, peripheral neuropathy, and neuropsychiatric effects, which can be managed through symptomatic relief, dose adjustment, or switching to alternative medications 1.
• In cases of severe adverse events, such as Stevens-Johnson reactions, immediate cessation of all drugs is necessary, followed by sequential reintroduction of medications to identify the offending agent 1.

Importance of Adherence and Monitoring

• Treatment adherence is crucial to prevent resistance development and ensure effective treatment outcomes, as emphasized in the study by 1.
• Patients should be closely monitored for adverse events, and creative mechanisms, such as reward systems and mobile telephone technology, can be used to encourage adherence, particularly in pediatric and adolescent patients 1.

From the Research

Skin Manifestations of Tuberculosis (TB)

• Cutaneous tuberculosis (CTB) is an uncommon manifestation of TB, comprising 1-1.5% of all extra-pulmonary TB cases 2
• CTB can manifest as small papules, warty lesions, massive ulcers, or plaques, which can be highly deformative 2
• The lesions can be caused by Mycobacterium tuberculosis or atypical mycobacterium species, with varying responses to treatment 2

Management Strategies for Cutaneous Tuberculosis

• Treatment options for CTB are limited to conventional oral therapy and occasional surgical intervention 2
• True CTB is typically treated with a combination of rifampicin, ethambutol, pyrazinamide, isoniazid, and streptomycin, tailored to individual needs 2
• Atypical mycobacterium infections are often resistant to anti-tuberculous drugs and may only respond to certain antibiotics 2
• A therapeutic trial of antitubercular drugs can be used to confirm the diagnosis of CTB, with a response expected within 6 weeks of therapy 3

Treatment Regimens for Tuberculosis

• A 6-month regimen consisting of isoniazid, rifampin, and pyrazinamide is the preferred treatment for patients with fully susceptible organisms 4, 5
• Ethambutol or streptomycin may be included in the initial regimen until drug susceptibility studies are available 4, 5
• Alternative regimens, such as a 9-month regimen of isoniazid and rifampin, may be used in certain cases 4, 5
• Directly observed therapy (DOT) is recommended to ensure patient compliance and prevent the development of drug-resistant strains 4, 5

Special Considerations

• Patients with HIV co-infection may require prolonged therapy and close monitoring of clinical and bacteriologic response 4, 5
• Children should be managed similarly to adults, using appropriately adjusted doses of drugs 4, 5
• Extrapulmonary tuberculosis, including cutaneous tuberculosis, should be managed according to the principles and drug regimens outlined for pulmonary tuberculosis 4, 5