Annular Lichen Scrofulosorum – An Unusual Presentation of Micropapular Tuberculid

Special Article - Clinical Cases and Images

Austin J Dermatolog. 2016; 3(1): 1042.

Annular Lichen Scrofulosorum – An Unusual Presentation of Micropapular Tuberculid

Muhammad Irfan Anwar1*, Rabia Ghafoor2, Nazia Shazhad3 and Tahira Muqaddas3

1Department of Dermatology, Pakistan Navy Ship Shifa, Pakistan

2Department of Dermatology, Jinnah Post Graduate Medical Centre, Pakistan

3Lahore General Hospital, Pakistan

*Corresponding author: Muhammad Irfan Anwar, Department of Dermatology, Pakistan Navy Ship Shifa, Karachi, Pakistan

Received: November 26, 2015; Accepted: January 04, 2016; Published: January 06, 2016


Cutaneous tuberculids are rare manifestations of systemic tuberculosis mainly seen in children and young adults, having high degree of cellular immunity to mycobacterium tuberculosis. It is usually seen with underlying occult tuberculosis of lungs, lymph nodes, bones or after tuberculosis vaccination. It is clinically characterized by perifollicular multiple grouped or annular Micropapular eruption, predominantly over the trunk and limbs. A high index of suspicion is needed in endemic areas, as the condition imitates with many common cutaneous diseases. We herein, report a rare case of large annular lichen scrofulosorum, which is a rare morphological pattern of lichen scrofulosorum. Complete clearance of lesions was witnessed after a short course of anti tuberculous therapy.

Keywords: Annular Lichen Scrofulosorum (LS); Tuberculid; Tuberculosis


Tuberculids are cutaneous hypersentivity reactions in patients suffering from occult or apparent systemic tuberculosis. They are usually divided into Micropapular, papular and nodular types depending predominantly on the size of individual lesions. Lichen Scrofulosorum is a prototype example of Micropapular tuberculids, comprising mainly of perifollicular grouped or annular papules. The lesions are usually asymptomatic; skins colored to reddish brown papules and are mainly found on the chest, abdomen, back and proximal parts of the upper limbs. Large annular lesions extending up to 7-9 cm are extremely rare and to our knowledge have never been reported from this region, despite of endemicity of systemic tuberculosis.

Case Presentation

A 16 years old girl presented with more than 2 years history of non-pruritic skin colored, perifollicular spiny Micropapular eruption, arranged in 5 large annular plaques (Figure 1). Three of these annular lesions were present over trunk, one over left side of neck and one over right popliteal fossa. All of them were of more than 7cm of diameter and the largest one measured over popliteal fossa was of 9 cm. She denied history of fever and cough but reported significant weight loss for last few months. Peripheral lymph nodes were not enlarged. BCG scar was seen on right deltoid area. She mentioned that her mother was successfully treated for pulmonary tuberculosis with standard antituberculous drugs for 6 months. Being the only daughter in family, patient was in habit of sleeping with her mother. Clinical differentials were Lichen Scrofulosorum, Lichen nitidus, Keratosis pilaris, Phrynoderma and Micropapular sarcoidosis. Skin biopsy for histopathology was performed which showed well formed epithelioid cell granuloma with langhans type giant cells, infiltrating upper dermis and around hair follicles (Figure 2 and 3). Montoux test was positive with in duration of 11×14mm, with raised ESR of 50 mm and chest roentgenogram showed bilateral hilar lymphadenopathy with nodular and calcific foci in upper right zone. Mycobacterial Polymerase Chain Reaction (PCR) could not be done due to non-availability of test. A final diagnosis of “Annular Lichen Scrofulosorum” was made and the patient was put on 4 drugs standard Antituberculous Therapy (ATT). Her cutaneous eruptions responded very well with complete clearance after 4 weeks of therapy (Figure 4). She was advised to complete standard 6 months ATT, with monthly follow-up visits in dermatology outpatient department to monitor therapy and outcome.