Tuberculids are a manifestation of cutaneous tuberculosis (TB), resulting from delayed hypersensitivity reactions to Mycobacterium tuberculosis (M. tb) or mycobacterial antigens in individuals with strong cell-mediated immunity. The diagnostic criteria include tuberculoid granuloma on histopathology, strongly positive Mantoux test, absence of M. tb in smear and culture, and resolution of skin lesions with antituberculosis therapy (ATT).
Materials and Methods
In January 2022, an extensive review of the published literature of the past 10 years using the PubMed database was conducted using the following keywords: lichen scrofulosorum, papulonecrotic tuberculid, erythema induratum, and erythema nodosum tuberculosis. Two hundred and thirty five articles were retrieved, which were then manually screened for pertinent articles regarding any update on etiopathogenesis, clinical presentations, associations, investigative modalities, and treatments. Studies were selected based on titles and abstracts and were then read in full.
The prevalence of tuberculids among cutaneous TB varies from 4% to as high as 44.2% across various parts of the world.[1–4] Whereas erythema induratum of Bazin is reported as the most common tuberculid in many parts of the world,[3–5] studies from India report lichen scrofulosorum as the most common.[2,6]
Erythema induratum of Bazin has been typically known to affect young to middle-aged women. In a study of 22 patients of erythema induratum of Bazin, 90.9% were women, the mean age being 57.2 ± 12.9 years. The lesions were located in the lower extremity in all patients and in the upper extremity in 31.8%.
Lichen scrofulosorum is known to be common in children. In a study of 221 patients of lichen scrofulosorum, 156 (70.5%) were children. The trunk was the most common site involved (98.6%), followed by the lower limb (25.33%), upper limb (15.83%), face (5%), and external genitalia (3.6%).
The clinical classification of tuberculids is given in Table 1.
In lichen scrofulosorum and papulonecrotic tuberculids, M. tb is the consistently reported causative organism, hence termed as true tuberculids. Erythema nodosum and erythema induratum can have a variety of etiological factors, of which one is M. tb, hence termed as facultative tuberculids.
Rare causes of lichen scrofulosorum include Mycobacterium szulgai, Mycobacterium avium-intracellulare complex, Mycobacterium leprae, Mycobacterium bovis, or the bacillus Calmette–Guerin (BCG) vaccination and purified protein derivative used in Mantoux testing.[9–13]
Similarly, papulonecrotic tuberculids have been rarely known to occur secondary to Mycobacterium kansasii, Mycobacterium avium-intracellulare complex, BCG vaccination, and Mantoux testing.[14–17] There have been few case reports of the occurrence of papulonecrotic tuberculid in HIV-positive patients with variable CD4 counts and viral loads. This association is interesting as tuberculids characteristically occur in patients with good immunity. One plausible explanation suggested by Farrell et al. is that it could be related to immune dysregulation and paradoxical activation of immune responses.
Erythema induratum has been reported in association with tubercular causes including Mycobacterium chelonei and BCG vaccination as well as non-tubercular causes including infections such as chronic hepatitis C, Nocardia, Pseudomonas, and Fusarium; diseases such as Takayasu arteritis, and Crohn’s disease; and drugs such as propylthiouracil, TNF alpha inhibitors, BRAF and MEK inhibitors.[19–26] It is now recommended to use the term “Erythema induratum of Bazin” when the association with TB is proven and “nodular vasculitis” for non-tuberculous causes.
Erythema nodosum can result from a wide array of conditions including bacterial, viral, fungal, and protozoal infections, drugs, malignancies, and autoimmune diseases.
The consensus is that tuberculids are immunological reactions to degenerated dead bacilli or antigenic fractions of Mycobacterium rather than true infection. This process occurs in patients with good immunity, as evidenced by medium to strong tuberculin sensitivity in most patients. Evidence of Mantoux test positivity was observed in 79% to 83.2% of cases in recent studies.[5,8] Rare cases with negative tuberculin tests could be due to temporal variability in the immune status of the patient. Hematogenous dissemination of mycobacteria occurs from an active internal tuberculous infection, which is followed by a type III hypersensitivity response. The continuous formation of antigen–antibody complexes then leads to a type IV hypersensitivity reaction, resulting in granuloma formation. The reaction pattern that occurs is highly individualized and unpredictable, and why one individual develops a certain type of tuberculid, and why most of the others do not develop any, is not known.
There are reports of tuberculids occurring after the start of anti-tubercular treatment, probably due to inflammatory response that may follow the treatment of a multibacillary infection.
There has been a new and interesting observation regarding a possible sexual route of tuberculid of the penis from reproductive tract TB of the partner. Mycobacteria could be inoculated directly onto the glans penis during sexual activity as it is the most common site to be microtraumatized during sexual contact, and inoculation is easier than into the more keratinized epithelium of the shaft.[28,29]
Tuberculids have also been linked with immune activation of Kawasaki disease in a case report of two infants in Japan, where the infants developed papulonecrotic tuberculid and lichen scrofulosorum during the convalescent phase of Kawasaki disease.
Clinical Features Including Atypical Manifestations
Micropapular: Lichen scrofulosorum
Lichen scrofulosorum presents as multiple, flat-topped, follicular and perifollicular, skin-colored, lichenoid, or erythematous asymptomatic usually grouped papules [Figure 1]. Usually, generalized involvement over the trunk or proximal extremities including the buttocks is common, but localized forms involving the face, genitals, or palmoplantar area can also be seen.[31–33] The surface of the lesions may show fine scaling or horny spines. The lesions resolve in about 2 weeks, but crops may come and go over several months. Systemic symptoms such as fever, weight loss, and malaise may be present.
An underlying focus of infection can be detected in 60–70% of cases. The most frequent foci are lymph nodes (cervical, hilar, axillary, or mediastinal) and lungs, but other forms such as generalized lymphadenopathy, miliary TB, tuberculomas in the central nervous system, bone TB, and more recently, phlyctenular conjunctivitis and tonsillar TB have been rarely seen.[33–36]
Other types of cutaneous TB, such as scrofuloderma, lupus vulgaris, TB gumma, and TB verrucosa cutis,[37,38] as well as other tuberculids such as papulonecrotic tuberculids, erythema induratum can present along with lichen scrofulosorum.[39,40] Notably, transformation from papulonecrotic tuberculids to lichen scrofulosorum has been seen.
Papular: Papulonecrotic tuberculid
Papulonecrotic tuberculids present as recurrent crops of symmetrically distributed firm and dusky-red papules with central ulceration, which heal with atrophic varioliform scarring. They are commonly seen over perniotic areas such as the ears, acral parts of limbs, and extensors of lower limbs but can also occur on the lower abdomen, trunk, buttocks, and scalp. Localized forms mainly involve the genitalia, especially the glans penis [Figure 2].
Usually, an underlying focus of infection is found in 38–75% of cases. Lymph nodes are the most common primary site, followed by the lungs, bones, and rarely genitourinary, nasopharyngeal, and renal tracts.
Among other types of cutaneous TB, it has coexisted with lupus vulgaris, scrofuloderma and tubercular gummas, and other tuberculids.[27,40,44,45]
Nodular: Erythema induratum of Bazin and Erythema nodosum
Erythema induratum of Bazin affects young to middle-aged women but may rarely be seen in children. It presents as bilateral, tender, erythematous nodules or subcutaneous plaques involving the flexor aspect of thighs and legs and uncommonly on upper limbs, trunk, and buttocks.[47,48] However, unilateral presentations have also been reported. They usually ulcerate centrally and heal with atrophic, hyperpigmented scarring [Figure 3]. The disease runs a chronic course with recurrent lesions.
Underlying active TB is not seen commonly, but previously treated infection has been reported in as many as 11–31% of patients.[47,48]
Coexistence with other forms of cutaneous TB including scrofuloderma and tuberculids (lichen scrofulosorum, papulonecrotic tuberculid) is rare but known.[39,45,50]
Erythema nodosum presents as recurrent crops of tender, erythematous, subcutaneous nodules on the extensor aspect of extremities which subsides in 3–7 days, leaving behind hyperpigmentation [Figure 4]. Ulceration and atrophic scarring as seen in erythema induratum of Bazin are distinctly absent.
Erythema nodosum is seen worldwide and is mostly idiopathic (55%); in children, frequent association with streptococcal infections are seen. TB is an important cause in areas where TB is endemic and must be excluded in all cases. In the majority of the cases, a focus of infection may not always be detected after a detailed workup. Some authors have even justified a therapeutic trial of anti-tubercular therapy in such cases with a strongly positive Mantoux test (>20 mm) and subsequent follow-up for recurrences. Globally, however, the incidence of TB has decreased. In a study of 24 children with erythema nodosum from Israel, no underlying focus of TB was detected in any.
Atypical Presentations of Tuberculids
Table 2 lists the atypical presentations of various types of tuberculids.
Discoid or annular lichen scrofulosorum: Lichenoid grouping results in the formation of rough discoid plaques that tend to coalesce.
Psoriasiform lichen scrofulosorum: Extensive inflammatory plaques with fine, adherent scales resembling psoriasis even exhibiting Koebner’s phenomenon have been reported.[55,56]
Granuloma annulare-like lichen scrofulosorum: Arcuate, yellow-brownish plaques with beaded morphology have been seen.
Lichen planus-like lichen scrofulosorum: Multiple, itchy, flat-topped papular lesions having polygonal shapes and shiny surfaces with sharply defined erythema have been reported.
Micropustular lichen scrofulosorum: There is a case report of acne-like lesions of lichen scrofulosorum on the face and psoriasiform plaques studded with pustules.[59,60]
Molluscum-like papulonecrotic tuberculids: Papulonecrotic tuberculids can present as pink, umbilicated, and molluscum-like papules.
Perforating granuloma annulare-like papulonecrotic tuberculids: Erythematous umbilicated papules centered by a small crust and with discrete perilesional desquamation have been described.
Pityriasis lichenoides chronica-like papulonecrotic tuberculids.
Papulonecrotic tuberculids associated with ophthalmological complications: Uveitis and optic neuritis have been described as a part of the immune-mediated reaction in association with papulonecrotic tuberculids.[64,65]
Papulonecrotic tuberculids associated with Poncet disease: Poncet disease is a rare, paucibacillary manifestation of TB having an immune-mediated, inflammatory, non-erosive, and non-deforming asymmetric oligoarthritis. Both papulonecrotic tuberculids and Poncet disease were reported in a patient, both being temporally related and resolving with ATT.
Ecthyma gangrenosum-like erythema induratum: Multiple necrotic ulcers with black eschars over both legs were seen in an immunocompromised adult.
Disseminated erythema induratum: Disseminated lesions of erythema induratum have been rarely reported.
Verrucous tuberculids: It presents with follicular and perifollicular verrucous papules, nodules, and plaques on the face, earlobes, and extremities. Histopathology revealed parakeratotic follicular plug invaginating into the dermis with multiple caseating epithelioid cell granulomas.
Nodular granulomatous phlebitis: Considered to be the fourth type of tuberculids by some authors, it is characterized by subcutaneous nodules along the course of veins of the legs, which on biopsy show epithelioid cell granulomas and Langhans giant cells in the walls of cutaneous veins.[70,71]
Nodular tuberculid (NT): It is another entity first described by Jordaan and colleagues presenting as 1 to 2 cm red or blue non-ulcerating nodules, usually of the lower limbs, with granulomatous vasculitis at the dermal-subcutaneous junction. In this, the pathology is found at the dermal-subcutaneous junction, in contrast to the superficial dermis in papulonecrotic tuberculids and subcutaneous fat in erythema induratum.
Tuberculous mastitis: It is considered to be a form of NT affecting the breast tissue. Unilateral ulcerative plaques, nodules, abscesses, and occasionally sinuses are seen in young female patients usually with a positive contact history of TB. On histology, granulomas are seen with fat necrosis.
Koebnerization: It has been reported in lichen scrofulosorum, papulonecrotic tuberculids, and erythema induratum. The postulated pathogenic factors include immunologic, vascular, dermal, enzymatic, inhibitory, neural, genetic, and hormonal influence.[74–76]
Lichen scrofulosorum: Lichen nitidus, lichen spinulosus, keratosis pilaris, lichenoid sarcoidosis, and pityriasis rubra pilaris.
Papulonecrotic tuberculid: Pityriasis lichenoides et varioliformis acuta, secondary syphilis, necrotizing leukocytoclastic vasculitis, and perforating dermatosis.
Erythema induratum: Polyarteritis nodosa, lupus profundus, subcutaneous sarcoidosis, cutaneous lymphoma (subcutaneous panniculitis-like T-cell lymphoma).
- Mantoux: Tuberculin positivity is a part of the diagnostic criteria of tuberculids. A rare case of lichen scrofulosorum with a negative test attributed to malnutrition has been documented.
- Interferon-γ releasing assay (IGRA): It was introduced as a promising tool in the diagnosis of latent TB having several advantages over the tuberculin skin test including higher specificity and no influence from past BCG exposure. Its use has been evaluated in patients with erythema induratum, which may not have a tubercular cause. A retrospective study evaluating 22 patients of erythema induratum of Bazin demonstrated a positive response to IGRA in all cases (100%), and the authors suggested that if erythema induratum of Bazin is clinicopathologically suspected, IGRA should be performed due to its excellent diagnostic performance.[48,77] However, the World Health Organization discourages its use in low- and middle-income countries.
- Dermoscopy: Dermoscopy of two pediatric cases of lichen scrofulosorum showed pale round monomorphic grouped perifollicular dots with a central brown follicular plug and marginal rim of fine white scaling [Figure 5]. More studies are needed to document the dermoscopic features of various types of tuberculids and whether this tool can be used in accurately differentiating tuberculids from other conditions.
- Histopathology: Table 3 describes the histopathological features of each type which are characteristic and help in differentiating it from other conditions.
- Polymerase chain reaction (PCR): Previously, many studies have demonstrated PCR positivity in the biopsy specimens of tuberculids. A recent study evaluated the use of nested PCR targeting the IS6110 insertion sequence of M. tb to improve the M. tb detection rate in blood samples of 14 patients of erythema nodosum or erythema induratum of Bazin. Eleven (78.6%) patients tested positive, but the difference between the outcomes of the QuantiFERON and the IS6110-nested PCR tests was not statistically significant. More studies are needed to establish the efficacy and usefulness of these PCR-based blood tests in diagnosing underlying TB in suspected tuberculid cases.
Despite the presence of strong tuberculin positivity and characteristic clinical and histopathological features of each subtype of tuberculid, establishing a diagnosis of tuberculids beyond any doubt may not be possible in every case. In developing countries such as India, a modification of the criteria recommended for cutaneous TB may be used as a guideline:
- Patients have characteristic histopathological features of true tuberculids.
- Patients have strong tuberculin positivity along with a highly suggestive clinical picture of true tuberculids even though histopathological features are equivocal.
- Clinically and histopathologically, lesions are suggestive of tuberculids, and there is a systemic tuberculous focus elsewhere in the body.
- Patients have strong tuberculin positivity with clinical and histopathological features of non-specific or undescribed tuberculids when other causes have been ruled out.
Treatment of tuberculids follows the same regimen recommended for true cutaneous TB consisting of an intensive phase of isoniazid, rifampicin, pyrazinamide, and ethambutol for 8 weeks, followed by a continuation phase of isoniazid, rifampicin, and ethambutol for 16 weeks according to the weight band. In an adult woman with papulonecrotic tuberculids, a triple-drug regimen with rifampicin, isoniazid, and pyrazinamide was given for 6 months. After an initial clinical remission, the patient developed recurrence of lesions after 4 months. The patient was then retreated with the four-drug regimen for 9 months, but the lesions continued to recur for 2 years. The authors attributed the failure of treatment to the low compliance of the patient but also kept the possibility of drug resistance. Thus, one must ensure that the standard four anti-tubercular drug regimen is strictly followed.
Incomplete treatment has been raised as a concern in erythema induratum of Bazin. In an 11-year retrospective review of 21 cases of erythema induratum of Bazin, 76% had improvement or resolution of disease after ATT of a median duration of 6 months (range 5–9 months). Some authors propose a longer period of treatment with isoniazid, maintaining for up to two years in erythema induratum of Bazin. Dapsone, potassium iodide, and doxycycline have been used as adjuvants to treat the inflammation, as well as corticosteroids or tuberculin protein in various dilutions for desensitization.
There is a case report of successful treatment of erythema induratum with topical application of 3.75% isoniazid twice daily (prepared by crushing and mixing 15 isoniazid 100 mg tablets with 40 g zinc oxide ointment).
Tuberculids, though considered a controversial entity by some, still appear to be related to tuberculous infection. Some of them have been removed from the list, e.g. LMDF (Lupus miliaris disseminatus faciei) and rarer presentations are being added. The essential pathogenesis is that this is a hypersensitivity related to tubercle bacillary antigens that continues. Unusual presentations of cutaneous tuberculosis may sometimes mimic tuberculids both clinically and histopathologically. Strong mantoux positivity, characteristic histopathological features and absence of M. tuberculosis in culture help in establishing diagnosis. Though acid-fast bacilli are not demonstrable by definition, PCR has been found to be positive in many cases. An underlying focus of infection may not always be found but standard antitubercular therapy should be given to all patients of tuberculids.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Dr. Shruti Sharma, Scientist D, National Institute of Pathology, ICMR, Safdarjung Hospital, New Delhi 110029.
1. Mathur M, Pandey SN. Clinicohistological profile of cutaneous tuberculosis in central Nepal. Kathmandu Univ Med J (KUMJ) 2014;12:238–41.
2. Sharma S, Sehgal VN, Bhattacharya SN, Mahajan G, Gupta R. Clinicopathologic spectrum of cutaneous tuberculosis:A retrospective analysis of 165 Indians. Am J Dermatopathol 2015;37:444–50.
3. Mann D, Sant'Anna FM, Schmaltz CAS, Rolla V, Freitas DFS, Lyra MR, et al. Cutaneous tuberculosis in Rio de Janeiro, Brazil:Description of a series of 75 cases. Int J Dermatol 2019;58:1451–9.
4. Zhang J, Fan YK, Wang P, Chen QQ, Wang G, Xu AE, et al. Cutaneous tuberculosis in China-A multicentre retrospective study of cases diagnosed between 1957 and 2013. J Eur Acad Dermatol Venereol 2018;32:632–8.
5. Spelta K, Diniz LM. Cutaneous tuberculosis:A 26-year retrospective study in an endemic area of tuberculosis, Vitória, Espírito Santo, Brazil. Rev Inst Med Trop Sao Paulo 2016;58:49.
6. Panda M, Patro N, Kar BR, Sirka CS, Sahu B, Dash M. Revisiting tuberculids
- Five year experience in a tertiary care teaching hospital. Indian J Med Res 2016;144:297–9.
7. Kara Polat A, Gore Karaali M, Esra Koku Aksu A, Asli Turgut Erdemir V, Leblebici C, Salih Gurel M. A rare cutaneous tuberculosis form, erythema induratum
of Bazin:6 years'experience. Acta Dermatovenerol Alp Pannonica Adriat 2020;29:123–8.
8. Singal A, Kaur I, Pandhi D, Gandhi V, Jakhar D, Grover C. Clinico-epidemiological profile of lichen scrofulosorum
:A 22-year, single-center, retrospective study. Int J Dermatol 2021;60:1278–84.
9. Ross GL, Chong H, Collyns T, Gascoyne-Binzi DM, Sarkany RP. Lichen scrofulosorum
caused by Mycobacterium szulgai:A new cause of a tuberculide reaction. Br J Dermatol 2007;156:586–7.
10. Komatsu H, Terunuma A, Tabata N, Tagami H. Mycobacterium avium infection of the skin associated with lichen scrofulosorum
:Report of three cases. Br J Dermatol 1999;141:554–7.
11. Fiallo P, Cabiddu F, Clapasson A, Parodi A. Lichen scrofulosorum
caused by Mycobacterium leprae:First report. Int J Dermatol 2014;53:1244–8.
12. Evans RG, Warner J. Lichen scrofulosorum
following B. C. G. Arch Dis Child 1967;42:448.
13. Selva Prabu SK. Mantoux skin test induced Lichen scrofulosorum
. J Evolution Med Den Sci 2014;3:12390–3.
14. Callahan EF, Licata AL, Madison JF. Cutaneous Mycobacterium kansasii infection associated with a papulonecrotic tuberculid
reaction. J Am Acad Dermatol 1997;36:497–9.
15. Urso B, Georgesen C, Harp J. Papulonecrotic tuberculid
secondary to Mycobacterium avium complex. Cutis 2019;104:E11–3.
16. Miyamura T, Egashira S, Yoshino Y, Sawatari M, Nishihara T, Ihn H. Papulonecrotic tuberculid
after Bacillus Calmette-Guérin (BCG) vaccination with lung infiltration that mimics disseminated BCG infection. J Dermatol 2019;46:e267–8.
17. Dongre AM, Sanghavi SA, Khopkar US. Papulonecrotic tuberculid
at the site of tuberculin test in a patient with concomitant erythema induratum
and papulonecrotic tuberculid
. Indian J Dermatol Venereol Leprol 2013;79:248–51.
18. Mann D, Sant'Anna FM, Schmaltz CAS, Freitas DFS, Rolla VC, Cavalcante SC, et al. Cutaneous tuberculosis and HIV infection at a referral centre in Rio de Janeiro, Brazil. Mem Inst Oswaldo Cruz 2018;113:e180184.
19. Inoue T, Fukumoto T, Ansai S, Kimura T. Erythema induratum
of Bazin in an infant after Bacille Calmette-Guerin vaccination. J Dermatol 2006;33:268–72.
20. Campbell SM, Winkelmann RR, Sammons DL. Erythema induratum
caused by Mycobacterium chelonei in an immunocompetent patient. J Clin Aesthet Dermatol 2013;6:38–40.
21. Fernandes SS, Carvalho J, Leite S, Afonso M, Pinto J, Veloso R, et al. Erythema induratum
and chronic hepatitis C infection. J Clin Virol 2009;44:333–6.
22. Gilchrist H, Patterson JW. Erythema nodosum
and erythema induratum
(nodular vasculitis):diagnosis and management. Dermatol Ther 2010;23:320–7.
23. Kabuto M, Nakanishi G, Kimura H, Tanaka T, Fujimoto N. Erythema induratum
(nodular vasculitis) associated with Takayasu arteritis. Eur J Dermatol 2017;27:410–2.
24. Misago N, Narisawa Y. Erythema induratum
(nodular vasculitis) associated with Crohn's disease:A rare type of metastatic Crohn's disease. Am J Dermatopathol 2012;34:325–9.
25. Baba N, Takashima W, Tokuriki A, Ameshima S, Hasegawa M. Erythema induratum
of Bazin which occurred after tumor necrosis factor antagonist therapy. J Dermatol 2017;44:e87–8.
26. Iafolla MA, Ramsay J, Wismer J, McWhirter E. Cobimetinib- and vemurafenib-induced granulomatous dermatitis and erythema induratum
:A case report. SAGE Open Med Case Rep 2019;7:2050313X19847358 doi:10.1177/2050313X19847358.
27. Rambhia KD, Kharkar V, Mahajan S, Khopkar US. Multifocal tuberculous gummas and bilateral scrofuloderma followed by papulonecrotic tuberculids
developing during anti-tubercular therapy. Indian J Dermatol Venereol Leprol 2016;82:424–6.
28. Gupta V, Bhatia R, Singh UB, Ramam M, Gupta S. Penile 'tuberculid':Could it be sexually acquired primary inoculation tuberculosis?. J Eur Acad Dermatol Venereol 2016;30:e164–6.
29. Singal A, Pandhi D. Lichen scrofulosorum
and endometrial tuberculosis:A novel association. Int J Dermatol 2016;55:322–4.
30. Yamada H, Ohta H, Hasegawa S, Azuma Y, Hasegawa M, Kadoya R, et al. Two infants with tuberculid associated with Kawasaki disease. Hum Vaccin Immunother 2016;12:2772–6.
31. Vanhooteghem O, Doffiny Y. Lichen scrofulosorum
of the face. Dermatology 1996;192:393–5.
32. Gandhi V, Vij A, Bhattacharya SN. Lichen scrofulosorum
on the genitalia –An unusual presentation. Int J Dermatol 2007;46:548–9.
33. Beena KR, Ramesh V, Mukherjee A. Lichen scrofulosorum
–A series of eight cases. Dermatology 2000;201:272–4.
34. Singal A, Bhattacharya SN. Lichen scrofulosorum
:A prospective study of 39 patients. Int J Dermatol 2005;44:489–93.
35. Madan S, Beri S, Sethi M, Garg T, Nangia A. Lichen scrofulosorum
and phlyctenular conjunctivitis. Natl Med J India 2021;34:58–9.
36. Harit A, Sahoo AK, Singh I. A rare association of tonsillar tuberculosis and lichen scrofulosorum
. Egypt J Otolaryngol 2021;37:19.
37. Okoh NU, Nnaji T, Onyekonwu CL, Emeka CM. Lupus vulgaris and lichen scrofulosorum
with disseminated tuberculosis. Niger Med J 2020;61:169–72.
38. Kakakhel K. Simultaneous occurrence of tuberculous gumma, tuberculosis verrucosa cutis, and lichen scrofulosorum
. Int J Dermatol 1998;37:867–9.
39. Park YM, Hong JK, Cho SH, Cho BK. Concomitant lichen scrofulosorum
and erythema induratum
. J Am Acad Dermatol 1998;38:841–3.
40. Yadav P, Mendiratta V, Nikita, Chander R. Concurrent lichen scrofulosorum
and papulonecrotic tuberculid
in a patient with tubercular lymphadenitis. Indian J Dermatol Venereol Leprol 2014;80:483.
41. Thappa DM, Karthikeyan K, Jayanthi S. Tuberculid in a child:Transformation from papulonecrotic to lichen scrofulosorum
. Pediatr Dermatol 2003;20:91–3.
42. Ramesh V, Ramam M, Pahwa P, Malhotra S. The clinical presentations of penile tuberculosis. Int J Dermatol 2013;52:759–61.
43. Wilson-Jones E, Winkelmann RK. Papulonecrotic tuberculid
:A neglected disease in Western countries. J Am Acad Dermatol 1986;14:815–26.
44. Wang TT, Liu HJ, Wang L. A rare case of lupus vulgaris with papulonecrotic tuberculid
and discoid lupus erythematosus. Chin Med J (Engl) 2017;130:2134–5.
45. Kim GW, Park HJ, Kim HS, Chin HW, Kim SH, Ko HC, et al. Simultaneous occurrence of papulonecrotic tuberculid
and erythema induratum
in a patient with pulmonary tuberculosis. Pediatr Dermatol 2013;30:256–9.
46. Lee YS, Lee JH, Choi JE, Kim JY, Han TY. Erythema induratum
of Bazin in a 10-year-old boy. Pediatr Dermatol 2021;38:290–1.
47. Magalhães TS, Dammert VG, Samorano LP, Litvoc MN, Nico MMS. Erythema induratum
of Bazin:Epidemiological, clinical and laboratorial profile of 54 patients. J Dermatol 2018;45:628–9.
48. Na SY, Park SY, Cho HH, Choi JW, Choi M, Park HS, et al. Application of IFN-g releasing assay for the diagnosis of erythema induratum
of Bazin. J Eur Acad Dermatol Venereol 2014;28:41–5.
49. Santos Felisberto V, Delgado AR, Pinto H, Morais P. Erythema induratum
of Bazin:A case of chronic unilateral erythematous plaques in a lower limb. Isr Med Assoc J 2020;11:720–1.
50. Korekawa A, Nakano H, Sawamura D, Kitamura H, Harada K. Erythema induratum
of Bazin in a patient with scrofuloderma. Eur J Dermatol 2015;25:512–3.
51. Rizvi Z, Iqbal T, Javed A, Rizvi A. Erythema nodosum
:A consequence of tuberculosis. Cureus 2019;11:e4724.
52. Bhari N, Ramesh V. Cutaneous tuberculosis Sacchidanand SA, Savitha AS, Shilpa K, Shashi Kumar BM. IADVL Textbook of Dermatology 5th
ed Mumbai Bhalani Publishing House 2022 509–30.
53. Porges T, Shafat T, Sagy I, Zeller L, Bartal C, Khutarniuk T, et al. Clinical, epidemiological, and etiological changes in erythema nodosum
. Isr Med Assoc J 2018;20:770–2.
54. Enani MA. Lichen scrofulosorum
in a Saudi adolescent with multifocal tuberculosis. Ann Saudi Med 2008;28:213–6.
55. Dandale A, Gupta N, Dhurat R, Ghate S. Unusual presentation of lichen scrofulosorum
. Indian J Dermatol Venereol Leprol 2013;79:436–8.
56. Muradia I, Khullar G, Sharma S, Kolte S. Case report:A case of tuberculosis with psoriasiform lichen scrofulosorum
exhibiting Koebner's phenomenon followed by scrofuloderma. Am J Trop Med Hyg 2021;105:630–2.
57. Otto AI, Harsing J, Herjavecz I, Kiss M, Karpati S. Scrofuloderma associated with granuloma annulare-like lichen scrofulosorum
. Acta Derm Venereol 2009;89:640–2.
58. Kondo M, Iwata Y, Numata S, Saito K, Watanabe S, Kobayashi T, et al. Case of lichenoid-lichen scrofulosorum
:A rare variety of lichen scrofulosorum
mimicking lichen planus in an elderly patient. J Dermatol 2018;45:e148–9.
59. Weber FP. Lichen scrofulosorum
imitating psoriasis. Proc R Soc Med 1911;4:93.
60. Kumar U, Sethuraman G, Verma P, Das P, Sharma VK. Psoriasiform type of lichen scrofulosorum
:Clue to disseminated tuberculosis. Pediatr Dermatol 2011;28:532–4.
61. Asiniwasis R, Dutil MT, Walsh S. Molluscum-like papules as a presentation of early papulonecrotic tuberculid
in association with nodular tuberculid in a male with asymptomatic active pulmonary tuberculosis. J Cutan Med Surg 2015;19:159–62.
62. Pereira AR, Vieira MB, Monteiro MP, Enokihara MM, Michalany NS, Bagatin E, et al. An Bras Dermatol 2013;88:101–4.
63. Pandhi RK, Gupta LK, D'Souza P. Pityriasis lichenoides chronica in association with tubercular lymphadenitis. Indian J Dermatol Venereol Leprol 1997;63:314–6.
64. Singh PY, Sinha P, Baveja S, Sood A. Immune-mediated tuberculous uveitis –A rare association with papulonecrotic tuberculid
. Indian J Ophthalmol 2019;67:1207–9.
65. Wang Y, Li S, Bai Y, Cui Y, Zheng Z. Papulonecrotic tuberculid
with optic neuritis. Indian J Dermatol Venereol Leprol 2020;86:404–6.
66. Whitley MJ, Stout JE, Kapila A, Selim MA, Mansoori P, Marano AL. Papulonecrotic tuberculid
and poncet disease:A case of multisystem delayed-type hypersensitivity in a patient with Mycobacterium tuberculosis
infection. JAAD Case Rep 2019;5:794–7.
67. Techatawepisarn T, Chiewchanvit S, Salee P, Mahanupab P, Baosoung V, Praparattanapan J. Ecthyma gangrenosum-like lesions associated with disseminated nontuberculous mycobacterial infection in an HIV-infected patient. Southeast Asian J Trop Med Public Health 2013;44:649–54.
68. Butala N, Fraimow H, Heymann WR. Disseminated erythema induratum
in a patient with a history of tuberculosis. Cutis 2020;105:E13–5.
69. Khandpur S, Bansal A, Ramam M, Sharma VK, Das AK, Singh MK, et al. Verrucous tuberculid mimicking Kyrle disease. Int J Dermatol 2007;46:1298–301.
70. Motswaledi HM, Schulz EJ. Superficial thrombophlebitic tuberculide. Int J Dermatol 2006;45:1337–40.
71. Kwong HL, Lee JSS, Lim YL. Nodular granulomatous phlebitis:An uncommon tuberculid. JAAD Case Rep 2020;6:686–8.
72. Jordaan HF, Schneider JW, Abdulla EA. Nodular tuberculid:A report of four patients. Pediatr Dermatol 2000;17:183–8.
73. Bravo FG, Gotuzzo E. Cutaneous tuberculosis. Clin Dermatol 2007;25:173–80.
74. Pandhi D, Singal A, Wadhwa N. Lichen scrofulosorum
:Yet another disease manifesting the Koebner phenomenon. Int J Dermatol 2016;55:809–10.
75. Chhabra G, Verma P, Sharma S. Koebner phenomenon induced by Mantoux testing in a case of papulonecrotic tuberculid
. Trop Doct 2020;50:74–7.
76. Xu H, Li M, Ma H, Gu WT, Chen ZQ. Mycobacterium tuberculosis found at both skin lesions and Mantoux testing site in a patient with erythema induratum
of Bazin. J Dermatol 2017;44:1145–7.
77. Prajapati V, Steed M, Grewal P, Mahmood MN, Verma G, Brassard A. Erythema induratum
:Case series illustrating the utility of the interferon-g release assay in determining the association with tuberculosis. J Cutan Med Surg 2013;17 Suppl 1 1S6–11.
78. Jassi R, Yadav A, Chander R. Dermoscopy of lichen scrofulosorum
. Indian Dermatol Online J 2020;11:876–7.
79. Ben Jazia E, Hachfi W, Trimech M, Hmissa S, Jeddi CH, Omezzine-Letaief A. Detection of mycobacterial tuberculosis DNA in lichen scrofulosorum
. J Am Acad Dermatol 2006;55 2 Suppl S54–5.
80. Tirumalae R, Yeliur IK, Antony M, George G, Kenneth J. Papulonecrotic tuberculid
-clinicopathologic and molecular features of 12 Indian patients. Dermatol Pract Concept 2014;4:17–22.
81. Quirós E, Bettinardi A, Quirós A, Piédrola G, Maroto MC. Detection of mycobacterial DNA in papulonecrotic tuberculid
lesions by polymerase chain reaction. J Clin Lab Anal 2000;14:133–5.
82. Tan SH, Tan HH, Sun YJ, Goh CL. Clinical utility of polymerase chain reaction in the detection of Mycobacterium tuberculosis in different types of cutaneous tuberculosis and tuberculids
. Ann Acad Med Singapore 2001;30:3–10.
83. Segura S, Pujol RM, Trindade F, Requena L. Vasculitis in erythema induratum
of Bazin:A histopathologic study of 101 biopsy specimens from 86 patients. J Am Acad Dermatol 2008;59:839–51.
84. Williamson S, Auerbach J, Motaparthi K. Lichenoid granulomatous dermatitis as a tuberculid in association with spondylitis due to Mycobacterium tuberculosis. J Cutan Pathol 2020;47:946–9.
85. Kim KS, Kim JS, Kim SS, Kim CW. Association between erythema nodosum
of Bazin and Mycobacterium tuberculosis infection in Koreans. Indian J Dermatol Venereol Leprol 2022;88:196–200.
86. Niemeyer-Corbellini JP, Spinatto D, Boechat N, Carvalho AC, Pineiro-Maceira J, Azulay DR. Papulonecrotic tuberculid
on the scalp. Int J Dermatol 2008;47:1028–32.
87. Connors WJ, Fisher DA, Kunimoto DY, Jarand JM. Program-wide review and follow-up of erythema Induratum
of Bazin and tuberculosis-associated ocular inflammation management in a TB low-incidence setting:Need for improved treatment candidate selection, therapy standardization, and care collaboration. BMC Infect Dis 2019;19:97.
88. Dias MF, Bernardes Filho F, Quaresma MV, Nascimento LV, Nery JA, Azulay DR. Update on cutaneous tuberculosis. An Bras Dermatol 2014;89:925–38.
89. Sharon V, Goodarzi H, Chambers CJ, Fung MA, Armstrong AW. Erythema induratum
of Bazin. Dermato Online J 2010;16:1.
90. Mei X, Zhao J. Successful treatment of erythema induratum
with topical application of antituberculous drugs:A case report. Medicine (Baltimore) 2017;96:e9010.
91. Olson DP, Day CL, Magula NP, Sahid F, Moosa MY. Cutaneous extensively drug-resistant tuberculosis. Am J Trop Med Hyg 2007;77:551–4.