A 39‐year‐old housewife sustained inadvertent trauma to the right index finger about 6 years ago, whilst stitching clothes. A couple of weeks later, the site of trauma became hard and gritty. Ever since, it has progressed slowly, without any appreciable outward sign. It was not associated with any discomfort/pain. Consequent on an opinion from a surgeon, it was decided to operate on the right index finger. During the operation, under local anesthesia, a hard and gritty material was removed. The material was subjected to histopathologic study. Several stitches were applied to the wound. It failed to respond to antimicrobial therapy over a 4‐week period, prompting the patient to seek another opinion. Examination of the skin surface revealed a plaque with an irregular configuration on and around the distal interphalangeal joint of the right index finger. It was erythematous and pigmented. The top of the plaque was irregular and had alternating elevations and depressions (Fig. 1). Diascopy was negative for apple jelly nodule. A bacillus Calmette–Guérin (BCG) vaccination scar was identified on the left deltoid. There was no regional lymphadenopathy or systemic abnormality. Mantoux test with intradermal injection of 0.1 mL SPAN's tuberculin (purified protein derivative/5 tuberculin units/0.1 mL) (Span Diagnostic Ltd., Murat, India) was negative after 72 h. Investigations, including total and differential leukocyte count, erythrocyte sedimentation rate, serum biochemistry, and renal and liver function tests, were within the normal range, as was a chest X‐ray. 1 Tuberculosis verrucosa cutis before (a) and after (b) antitubercular therapy (ATT) Hematoxylin and eosin‐stained sections prepared from the biopsy taken from the lesion revealed noteworthy changes in the epidermis and the dermis. The former was marked by the presence of hyperkeratosis, acanthosis, and papillomatosis, whilst the latter contained tubercle granulomas. Each of the granulomas was well formed and consisted of large numbers of lymphocytes, histiocytes, and foreign body (Langerhans’) giant cells (Fig. 2). Caseation necrosis and acid‐fast bacilli could not be demonstrated. The preceding revelations were fairly conducive to the diagnosis. Accordingly, antitubercular therapy (ATT), comprising 450 mg of rifampicin, 300 mg of isonicotinic acid hydrazide, and 800 mg of ethambutol, was recommended for oral administration each day for 60 days. The outcome of the treatment was satisfactory, resulting in perceptible regression of the skin lesion (Fig. 1b). The patient was advised to continue the treatment for another 30 days, after which 450 mg of rifampicin and 300 mg of isonicotinic acid hydrazide were to be continued for another 6 months. 2 Tuberculosis verrucosa cutis depicting well‐formed tubercle(s) comprising lymphocytes, histiocytes, neutrophils, and a few giant cells (hematoxylin and eosin, × 100)

Case 1 A 24‐year‐old crockery merchant reported on July 1, 1999 with a symptomatic, progressive, recalcitrant, reddish, noduloulcerative eruption on the left cheek. The patient was apparently well 3 months prior to reporting, when he suddenly experienced a mildly itchy raised eruption, probably following a (mosquito) bite. After scratching with the nail, he broke the continuity of the skin at the site. Since then the eruptions had increased in size, despite the use of antimicrobials (unknown). There was no recent history of cough/expectoration/evening rise in temperature or weight loss. Examination of the lesion was striking and was characterized by a noduloulcerative lesion (size, 2 × 2 cm). It was located on an erythematous brick‐red base. Marked induration was present (Fig. 1a). Apple‐jelly nodules were demonstrated on diascopy. A bacillus Calmette‐Guérin (BCG) vaccination scar was identified on the left deltoid. There was no regional lymphadenopathy, nor any systemic abnormality. A Mantoux test, with the intradermal injection of 0.1 mL SPAN's tuberculin (PPD/5 TU/0.1 mL), was negative after 72 h. Investigations, including total and differential leukocyte count, erythrocyte sedimentation rate, serum biochemistry, and renal and liver function tests, were normal, as was a chest X‐ray. Tuberculosis (TB) enzyme‐linked immunoabsorbent assay (ELISA) immunoglobulin M (IgM) antibodies (Ab): Mycobacterium tuberculosis IgM Ab titer was 0.5 (< 0.8: negative). 1 (a) A noduloulcerative lesion located on an erythematous brick‐red base. (b) Regression of the lesion after antitubercular therapy Hematoxylin and eosin‐stained sections prepared from the lesion showed multiple, well‐formed tubercles. Each tubercle consisted of epithelioid and giant cells and a peripheral zone of lymphocytes. Caseation necrosis was absent. A few plasma cells were also identified. The tubercles predominantly occupied the upper dermis, hugging the epidermis (Fig. 2). Secondary epidermal changes in the form of hyperkeratosis, acanthosis, and papillomatosis were observed. Tubercle bacilli could not be demonstrated. The diagnosis of lupus vulgaris was tenable; accordingly, conventional antitubercular therapy (ATT), comprising rifampicin 450 mg, isoniazid 300 mg, pyrazinamide 1500 mg, and ethambutol 800 mg, was administered. The last two drugs were withdrawn after 2 months, while the first two were continued for a 6‐month period. The response to the treatment was remarkable (Fig. 1b). 2 Multiple tubercles: each tubercle was formed by epithelioid, giant cells and a peripheral zone of lymphocytes (hematoxylin and eosin, × 100) Case 2 A 34‐year‐old business man presented with a symptom‐free, nonhealing plaque over the front of the right lower leg. It had appeared 8 months previously as a brownish black spot, and was associated with mild itching. The eruption did not progress for 3 months, after which it started to increase in size, acquiring its current position. Inadvertent trauma/injury to the area was not denied by the patient. A well‐circumscri...

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