A 14-year-old girl presented with a 2-year history of gradually developing, asymptomatic, reddish, raised lesions over the scalp, face, arms and trunk. The family history was significant for tuberculosis. Her grandmother was found to have pulmonary tuberculosis.
Clinical examination revealed reddish-brown, soft papules forming two large plaques by coalescence over the scalp and back (Figs 1 and 2).
On the face and arms, lesions were small, gelatinous, infiltrated plaques (Fig. 3). Under diascopic study these plaques had an apple-jelly appearance. Hair loss was complete in the solitary lupus lesion on the scalp. Scarring was not present in this area at the time of examination. Bucal, nasal and conjunctival mucosae were not involved. No signs of extracutaneous involvement were demonstrated.
Laboratory findings were within normal range except for the erythrocyte sedimentation rate (ESR) 40 mm and hemoglobin (Hb) 10.5 g/dL. Mantoux test (with 10 tuberculin units [TU] of purified protein deviate [PPD]) showed a reaction of 25 mm. X-ray studies of the chest and screening for extrapulmonary tuberculosis (bone, lymphadenopathy, genitourinary and abdominal systems) were unremarkable. Histologic examination from the lesion of the arm showed granulomatous infiltrate in the upper and mid-dermis extending to the deep dermis, composed of epitheloid cells and numerous Langhans giant cells. In these granulomas caseation necrosis was absent (Fig. 4). Culture was not available in the present case and acid-fast bacilli were not detected in the biopsy specimen on Ziehl-Neelsen staining.
The diagnosis of lupus vulgaris was made and a daily treatment with isoniazid 5 mg/kg, rifampicin 10 mg/kg and ethambutol 15 mg/kg was begun. Cutaneous lesions started to show regression within 2 months of treatment. After 1 year of the therapy, the skin lesions showed minimal atrophic scarring.