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CUTICAL TUBERCULOSIS
dr. Kristo A. Nababan, Sp.KK
Department of Skin and Genital Health of Medical Faculty of
USU
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INTRODUCTION
Developing countries
Lower socioeconomic
EPIDEMIOLOGY
Western countries : lupus vulgaris
Tropical region (Indonesia) affected by
scrofuloderma and cutical verucose tuberculosis
Children and younger adults
Transmission : inhalation, direct inoculation on
skin
ETIOLOGY
Tuberculosis Mycobacterium : 91.5%
Atypical mycobacterium : 8.5%
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BACTERIOLOGY
Tuberculosis mycobacterium -
Features :
Acid resistant
Unmovable
Aerobe
Optimal growth temperature 37C
Bacteriologic examination consists of :
Microscopic culture ( Ziehl Neelsen coloring
agent)
Culture ( Lawenstein Jensen culture)
Experimental animal
Biochemical test
Resistance test
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CLASSIFICATION :

1. Pure skin tuberculosis
The causative germs are found in skin abnormality
accomplished by typical histophatological features
Primary cutical tuberculosis
Primary tuberculoss inoculation /cancer tuberulosis
Cutical milliaris tuberculosis
Tuberkulosis kutis sekunder
- Skrofuloderma
- Verukosa cutial Tuberculoss
Cutial gumosa tuberculoss
Cutical oriphicialis tuerculosis
Lupus vulgaris
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2. Tuberculoid
It is a reaction of ID -- on skin abnormality, the
causative agent unfound, the germ is found in other
places of body ( lung)
Papulae
Papulonecrotic tuberculosis
Liken schlofulosorum
Granulomae and ulceronodulus
- Erythema nodosum
- Erythema induratum bazin
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PATHOGENESIS
Directly transmission to skin from organ under
the skin infected by tuberculosis (scrophuloderma)
Direct transmission on skin around oriphisum
(cuticle oriphisialis tuerculosis)
Hematogenously transmission (lupus vulgaris)
Direct transmission of the mucosa infected by
tuberculosis (lupus vulgaris)
The germ directly penetrate into the skin with the
reduced local resistance (cutical verucose
tuberculosis)
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CLINICAL PHENOMENOS
PURE CUTICAL TUBERCULOSIS
a. PRIMARY CUTICAL TUBERCULOSIS

1.CANCHRE TUBERCULOSIS
Primary affect papule, pustule, indolen ulcus around
livide.
Budding time : 2 3 weeks
Limphangitis, lymphadenitis after primary affect (
positive tuberculin).
All above : primary complex
Ulcus with unduration: chancre tuberculosis

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Chancre Tuberculosis
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2. CUTICAL MILIARIS TUBERCULOSIS
- Transmission into skin from the focus
on body
- Tuberculin test : negative
- Erytheme is tightly bordered :
papule, vesicle, and pustule,
squamous, throughout purpura
- Prognosis : bad
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b. SECONDARY CUTICAL TUBERCULOSIS
1.SCROPHULODERM
Travel of percontinuitatum from the organ under
the skin infected by tuberculosis (, gland secretion,
joint, bone).
Location neck : from tonsil or lung
armpit : from pleura apex
hip fold : from extremity
Initial : tuberculosis lymphadenitis (KGB : without
acute inflammation).
Perodentitic attachment of gland to the
surrounding tissues.
Disposition gradually (cold abcess) broken
fistel disorganized extension, livide around,
tertutup pus seropurulen sikatrik skin bridge
DD : limphosarkoma, lymphoma malignum,
hidrodentitis spurative , LGV
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Schrophuloderm
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Schrophuloderm
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CRITERION OF SCROPHULODERM
RECOVERY
1. All the phystel and ulcus have closed
2. All the limph decreased ( < 1 cm and
hard consistency)
3. Cycatric is non erythematous
4. LED reduced
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2. CUTICAL VERUCOSE TUBERCULOSIS
Exogenously
Predilection : back of arm, lower leg,
feet trauma
Crescent moon travel of
serpiginose
Lenticular papule above
erythematous macula
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CUTICAL VERUCOSE
TUBERCULOSIS
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3. CUTICAL GUMOSA TUBERCULOSIS
Hemathogenously ( from lung) ,
subcutant infiltrate, tightly
bordered, biannual softer,
and descructive.
DD : guma syphilis, phrambusia,
profundae mychosis
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4. CUTICAL ORIPHISICALIS TUBERCULOSIS
Around oriphisum
- Pulmonary tuberculosis ulcus in mouth, lip
- Digestive tuberculosis ulcus around anus
- Urine bladder tuberculosis genital ulcus
The resistance is so lack, ulcus reverberated, wall divided.
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5. LUPUS VULGARIS
- Predilection : face, body and extremity
- Red nodus changed into yellow by pressure (
apple jelly color)
- Confluent to form plaque, destructive, ulcus
- Involution cicatris
- Serpiginose feature (+)
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Lupus vulgaris
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TUBERCULOID : a. Papule
1. PAPLONECROTICAL TUBERCULOSIS
- Shape : papulonecrotic, papulo pustule
- Location : facial, body, extensor extremity
- Erythematose papule, waved, enlarged
gradually into pustule crustae necrotic
tissue within 8 weeks recovered by cicatric
- The disease can last for many years
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2. LIKEN SKLOFULOSORUM
- Particularly in children
- papule milliard, the color likes a skin or erythematose
- Self structured : grouped with softer squamous
- Predilection : chest, abdomen, back, sacrum
- Residive chronic
- Recovered with cicatric
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b. GRANULOMA ULSERONODULUS
ERYTHEME NODOSUM
Extensor extremity
Nodus : erytheme nodus
DD : ENL
Reaction of ID due to streptococcus B
hemolyticus
Allergy against medications, rheumatic fever
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2. INDURATUM BAZIN ERYTHEME
- Erytheme and nodus nodus indolen
- Predilection on flexor extremity
- Supuration to form ulcus
- Sometimes without suppuration --- regression ---
hypotropic
- Residive chronic
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ARTIFICIAL EXAMINATION
- Laboratory : higher LED
- Bacteriologic : BTA, culture
- Hystopathologic : more important than bacteriologic
- Tuberculine test

TREATMENT
- Regularly to avoid resistance ( uninterrupted)
- Should be combined, minimall of 2 bacteriocidal medications (
combined INH + 2 or 3 types of other bacteriosidal
- Correct general condition
PROGNOSIS
Adequate, if the treatment meets the requirements
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MEDICATION
Standard Regimen (6 month)
1. Initial phase ( daily medications for 2 months)
Dewasa Anak
a.Isoniazid
+
b.Rifampicin > 50 kg
+ < 50 kg
c.Pyrazinamid > 50 kg
+ < 50 kg
Etambutol > 60 kg
atau < 60 kg
Streptomicin

300 mg

600 mg
450 mg
2 gr
1,5 gr
15 mg/KgBB
25 mg/KgBB
3-4 gr IM
5-8 mg/KgBB

10-12 mg/KgBB

20-35 mg/KgBB

Tdk direkomendasikan
15-20 mg/KgBB
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2. Continuous phase ( 2 medications for 4
months) isoniazid + riphampicin (with the
same dosage as in the table)

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Phase 1 : intensive ( initial).
- To eradicate active terms
- To divide as quick as possible and
- as much as possible
Phase 2 : continued
Sterilization
To eradicate germs grown gradually
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METHOD OF ADMINISTRATION AND SIDE EFFECT
Name of drug Methode of administration Side effec

INH (H) Per os, single dosage Neuritic
Ggn hepar


Rifampicin (R) Per os, single dosage Ggn hepar
when the bounce is void
Hypersensitivity


Thrombocytopenia

Pirazinamide (Z) Per os, devided dosis Ggn hepar


Streptomycin Per injection of IM Ggn N.VII disorder,
especially vestibularis
branch.

Vestibularis
Ggn hepar







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The combined HRZ is so potential
- Prior to medication, examine the function of
hepar (SGOT, SGPT, phosphatase alkaline,
and then 2 weeks later after treatment
- When the examination of 2 weeks after that
time, it still stay or reduce, the drug is
continued but if it increases, the drug given
includes INH everyday and $2 x / week
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