Cutaneous Tuberculosis


Last updated: February 2024

What is cutaneous tuberculosis?

Cutaneous tuberculosis (CTB) is a skin infection caused by mycobacterium tuberculosis, which mainly causes lung infection, but can involve other organ systems. Most skin tuberculosis (TB) is the result of spread from internal organs to the skin, but occasionally the bacterium can be directly inoculated into the skin.

Who gets cutaneous tuberculosis?

Skin manifestations of TB infection are rare, accounting for up to 2% of all TB infections, even in the countries where TB is common. 1, 2 In endemic countries, CTB is more common in children than in adults.2

Some factors that may increase the risk of contracting tuberculosis, include:

  • Close contact with an individual with active TB
  • Living in or traveling to countries or communities with a high prevalence of TB
  • Living in densely populated communities, including institutional settings (i.e., aged care residences, long-stay hospitals, and prisons)
  • Working in healthcare environments and hospitals

What causes cutaneous tuberculosis?

Cutaneous tuberculosis is nearly always caused by Mycobacterium tuberculosis (M. tuberculosis), the tubercle bacillus.

It may follow:

  • Direct inoculation of tubercle bacilli into the skin
  • Spread to the skin via the bloodstream
  • Extension into the skin from an underlying infective focus or organ

What does cutaneous tuberculosis look like?

The spectrum of clinical manifestations is wide and depends upon:

  • History of previous exposure to the bacteria that causes tuberculosis or bacille Calmette-Guerin (BCG) vaccination.
  • The immune status of the patient – general health, presence or absence of other infections and whether has developed immunity.
  • Whether the infection has developed by direct inoculation or has spread from internal organs or by bloodstream.

Primary Inoculation Tuberculosis

Also known as tuberculous chancre, this occurs through direct exposure with the mycobacterium via an injury that caused a break in the skin. This may include accidental injury, tattooing, piercings, or injections.

It is a rare form of CTB occurring in individuals that have not had prior exposure to the mycobacterium.

In rare cases children, non-immune individuals amidst high TB prevalence regions or poor living conditions can be affected.

  • Appears as a painless brown-red papule or nodule 2-4 weeks after initial injury. This can then develop into a painless ulcer. Most cases do not resolve without treatment.
  • Enlarged lymph nodes may be present, especially in children
  • May affect face, eyes, mouth, hands and legs

Tuberculosis Verrucosa Vutis

Presents as a slow growing, painless, warty plaque at the site of inoculation and occurs in individuals that have had previous exposure to the mycobacterium. This form of infection through direct exposure is more common than primary inoculation tuberculosis. Commonly affected sites include the lower legs and buttocks.

Lupus Vulgaris

Presents as a chronic, slow growing, painless brown-red plaque. Lupus vulgaris (LV) is one of the more common presentations of CTB and occurs as a result of mycobacterium spread from the bloodstream or internal organs in patients with moderate to high immunity. If the individual has developed a fairly high level of immunity to the presence of the bacteria, then the skin lesions seen are often localised and well-defined.


Presents as painless, ulcerated plaques with fistula or sinus formation and discharge. It is common in endemic areas and occurs over affected lymph nodes, bones or joints. Lesions may spontaneously heal with scarring.

Orificial Tuberculosis

Occurs in advanced disease with organ involvement and patients with weakened immune systems, where they may develop painful or painless papules, nodules or ulcers in the mouth, nasal passage, and anogenital skin or mucosa.

Miliary Tuberculosis

For individuals with little immune resistance to the infection, malnourished, have infections such as HIV or on immune suppressive medications, the mycobacterium may spread via the blood stream. Individuals may develop red papules and pustules. It is associated with poorer outcomes.

Metastatic Tuberculous Abscess

Also occurring in individuals with weakened immune systems, this presents as fluctuant, subcutaneous nodules that may penetrate the skin and form draining sinuses and ulcers. These are usually found on the arms and legs and are due to the spread of the mycobacterium via the bloodstream.


Tuberculid is probably best considered as an allergic reaction to parts of mycobacterium tuberculosis in individuals with a high level of immunity to the bacteria.

How is cutaneous tuberculosis diagnosed?

The diagnosis of cutaneous tuberculosis is made by tissue (skin biopsy) microscopy, culture and polymerase chain reaction (PCR). Other tests may include tuberculin skin test or an interferon gamma release assay blood test.

How is cutaneous tuberculosis treated?

Treatment options will vary depending on the individual and their needs.

The aim of treatment is to:

  • eradicate the bacterium;
  • prevent transmission, screening contacts;
  • prevent relapse; and
  • prevent the development of drug resistance.

Active cutaneous TB may be treated with anti-tubercular antibiotics (i.e., isoniazid, rifampicin, pyrazinamide and ethambutol) or surgical excision. Latent TB may be treated to prevent reactivation of TB infection.

Drug resistant TB is when M. tuberculosis is resistant to at least one of the first-line anti-TB drugs. Multidrug-resistant TB is when M. tuberculosis is resistant to more than one of the anti-TB drugs, which include at least isoniazid and rifampicin. Drug resistance occurs when anti-TB treatment is not adhered to, or the individual may be infected with a resistant strain per se. It is an emerging problem in CTB. CTB is best managed in consultation with an infectious diseases specialist.

Screening of contacts is an essential part of comprehensive management.

Screening for co-infections such as leprosy and HIV is recommended.

What is the likely outcome of cutaneous tuberculosis?

Some manifestations of cutaneous tuberculosis, such as miliary tuberculosis and metastatic tuberculous abscess, may indicate extensive systemic involvement that can be life-threatening and associated with poorer outcomes.

Adequate and appropriately administered multi-drug therapy can be successful. Nevertheless, the resolution of some skin lesions may take time to heal with scarring being a common complication.

  1. Charifa A, Mangat R, Oakley AM. Cutaneous Tuberculosis. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
  2. Kaul S, Kaur I, Mehta S, et al. Cutaneous tuberculosis. Part I: Pathogenesis, classification, and clinical features. Journal of the American Academy of Dermatology 2023; 89: 1091–1103.
Mia Yue Yu, Lois Zhang and Dr Monisha GuptaFebruary 2024
Mia Yue Yu and Dr Monisha GuptaJune 2018


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