Tuberculosis verrucosa cutis. Experience from eastern Turkey.

T verrucosa cutis (TBVC) is a paucibacillary form of cutaneous tuberculosis caused by exogenous reinfection in previously sensitized individuals. Inoculation occurs at sites of minor wounds or abrasions, and rarely from the patient’s own sputum. The TBVC usually occurs on the hands in adults, and on the lower extremities in children. In western countries, TBVC is a rare form of cutaneous tuberculosis, however, in the Asian subcontinent it may be quite common.1,2 A total of 304,566 patients were admitted to the dermatology outpatient clinics of Ataturk University Medical School Hospital, Erzurum, east of Turkey, between 1975 and 2005. One hundred and sixty eight (0.05%) patients diagnosed as cutaneous tuberculosis were retrospectively analyzed, 22 (13.09%) were found to have TBVC. Age ranged between 4-70, (mean age: 39.72 [male:female 0.83]). The localizations of lesions were: one (4.5%) head-neck region, 17 (72.3%) upper limbs, 5 (22.3%) lower limbs, and hand and foot involvement in one patient. Mean duration of lesion was 3.63 years, ranging one to 10 years. Seventeen (77.3%) tested positive for tuberculosis skin test, and 3 (13.6%) with positive culture results. The incidence of TBVC varies in different regions and countries of the world, and is recently seen more frequently in Asia.1,2 In a published prospective study of 20 years, 6% of all cases of cutaneous tuberculosis were TBVC.2 In different regions, the ratio of TBVC was detected as 7% in Morocco,3 4% in Hong Kong,4 and 18.95% in Pakistan.5 In our study, the ratio of TBVC was detected as 13.1%. This frequency is lower than that of Pakistan, though higher than the others. Ho et al4 reported that the mean age of TBVC in Hong Kong was 59.5, with male:female ratio of 0.25. In our study, the mean age was 39.72, with male:female ratio of 0.83, which was lower than the previous study in favor of male. The mean duration was detected at 11.3 years in a previous study,4 however, it is 3.6 in our study. Although TBVC occurs generally on the hands, the predilection sites for children are the lower extremities (knees, thighs, and buttocks). In Europe, TBVC lesions are most encountered on the hands, although the lower limbs and buttocks are the most frequently affected sites in eastern countries.2 In our study, the most localized involvement was the upper limbs (72.3%) and the lower limbs (22.3%). Moreover, the ratio of positive Mantoux skin test was 77.3%. The laboratory diagnosis of paucibacillary forms of cutaneous tuberculosis, such as TBVC, is difficult. Culture has a low sensitivity in paucibacillary conditions and may take several weeks to obtain available result, causing delays in initiating the therapy. In some studies, microscopy and culture are often negative.1 We are unable to find any publications on the culture results in TBVC in the English literature, however, a positive culture was found in 13.3% in our study. In conclusion, tuberculosis is still an important health problem in underdeveloped and developing countries. The TBVC is paucibacillary tuberculosis. The female ratio is close to the male ratio. It is commonly seen in a person who has high immunity, and is frequently localized on the upper limbs.