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Table of Contents 
Year : 2014  |  Volume : 59  |  Issue : 1  |  Page : 80-81
Tuberculosis verrucosa cutis presenting as diffuse plantar keratoderma: An unusual sight

1 Department of Skin and Venereal Disease, Post Graduate Institute Medical Sciences, Rohtak, Haryana, India
2 Department of General Medicine, Post Graduate Institute Medical Sciences, Rohtak, Haryana, India
3 Department of Dentistry, Tripura Health Services, Tripura, India

Date of Web Publication23-Dec-2013

Correspondence Address:
Sangita Ghosh
42\136 New Ballygunge Road, Kolkata - 700 039
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5154.123511

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Tuberculosis verrucosa cutis (TVC) is a common cutaneous form of paucibacillary tuberculosis in an individual with moderate to high degree of immunity to Mycobacterium tuberculosis infection. Clinical appearance of TVC is mostly very typical with well-defined warty plaques presenting mostly on hands, knees, ankle, and buttocks; however several atypical morphology of the lesions have also been described. We hereby report a case of TVC, masquerading as asymptomatic diffuse keratoderma of left foot for nine months, in an otherwise healthy individual, obstructing easy diagnosis of cutaneous tuberculosis. Diagnosis was confirmed by histopathology.

Keywords: Diffuse keratoderma, tuberculosis verrucosa cutis, warty tuberculosis

How to cite this article:
Ghosh S, Aggarwal K, Jain VK, Chaudhuri S, Ghosh E, Arshdeep. Tuberculosis verrucosa cutis presenting as diffuse plantar keratoderma: An unusual sight. Indian J Dermatol 2014;59:80-1

How to cite this URL:
Ghosh S, Aggarwal K, Jain VK, Chaudhuri S, Ghosh E, Arshdeep. Tuberculosis verrucosa cutis presenting as diffuse plantar keratoderma: An unusual sight. Indian J Dermatol [serial online] 2014 [cited 2020 Nov 24];59:80-1. Available from: https://www.e-ijd.org/text.asp?2014/59/1/80/123511

What was known?
Tuberculosis verrucosa cutis is an indolent warty plaque.like form of cutaneous tuberculosis in a previously infected person with moderate to high degree of immunity.

   Introduction Top

Tuberculosis verrucosa cutis (TVC); also known as warty tuberculosis, anatomist's warts, or prosector's warts; is an indolent, warty plaque-like form of paucibacillary cutaneous tuberculosis, resulting from inoculation of Mycobacterium tuberculosis into the skin of a previously infected patient, with moderate to high degree of immunity. [1] Clinically, it has a typical appearance; starting as a small, asymptomatic, warty papule which progresses over time to become a verrucous plaque with an irregular serpiginous outline and finger-like projections. We report a case of TVC, masquerading as asymptomatic diffuse keratoderma of left foot for 9 months, in an otherwise healthy individual, obstructing easy diagnosis of cutaneous tuberculosis.

   Case Report Top

A 52-year-old male farmer, presented with a 9-month long history of thickening of left plantar skin, along with diffuse pedal edema of the same foot for last 2 months. He reported a history of a thorn prick injury 1 month preceding the onset of symptoms. At the onset, patient experienced only roughness of plantar skin which progressively developed a verrucous surface involving almost 80% of plantar skin of left foot. However, it remained asymptomatic until recent times, when he felt a chronic dull pain which was aggravated on walking. Patient had no past history of tuberculosis or any other systemic illness. He denied any history suggestive of immunodeficiency or constitutional symptoms of tuberculosis. He was a nonalcoholic and nonsmoker with a negative family history of tuberculosis.

On examination; he had left-sided, pitting, pedal edema. Almost 80% of plantar skin of left foot had developed diffuse keratoderma. The surface of the lesion was verrucous with variable degree of thickening becoming plaque-like at places, sparing the toes and instep, with ill-defined borders [Figure 1]. Posteriorly, the verrucous lesion had a well defined 2 cm broad linear extension up to the ankle. There was no evidence of scarring or any signs of healing. The other foot was uninvolved. He had no other cutaneous, mucosal lesions, or nail abnormalities. He was well-built and nourished, without any other abnormal systemic findings. There was no active focus of infection as evidenced by absence of fever, lymphadenopathy, leukocytosis, and a normal chest radiograph. There were two prominent BCG scar marks on his left arm. Routine investigations showed hemoglobin to be 12 g/dL; total leukocyte count of 11,000/mm 3 ; differential count was 59 neutrophils (N), 2 eosinophils (E), 39 lymphocytes (L); and erythrocyte sedimentation rate was 45 mm in the first hour. Chest X-ray revealed no foci of old or recent tuberculosis or evidence of any other abnormalities. Mantoux reaction reading after 48 h was 20 mm. With these details, a provisional diagnosis of TVC was made and a punch biopsy was taken from the heel area. Histopathology of the plantar skin sample showed striking pseudoepitheliomatous hyperplasia with diffuse tuberculoid granulomatous inflammation in dermis [Figure 2]. There was no underlying bony involvement on X-ray of the foot. Patient was started on standard antitubercular regimen.
Figure 1: (a) Widespread plantar keratoderma of left foot with thick warty surface and relative sparing of instep and ball of foot and toes, (b) Same foot after treatment with anti-tubercular therapy for 6 months

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Figure 2: Histopathology of the plantar skin showing pseudocarcinomatous proliferation of epidermis and diffuse tuberculous granuloma, with histiocytes and giant cells, in the dermis (H and E, original magnification × 10)

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   Discussion Top

Cutaneous tuberculosis still remains an enigma to todays dermatologists because of the wide variations in its clinical appearance, histopathology, immunology, and treatment response. In atypical variants of cutaneous tuberculosis, one has to rely on investigations like histopathology, acid-fast bacilli (AFB) culture, or polymerase chain reaction (PCR) for confirmatory diagnosis. Cutaneous tuberculosis accounts for only 1.5% of all cases of extrapulmonary tuberculosis and 0.15% of all skin outpatients. [2],[3] According to a study conducted in North India in 2011, the most common variant of cutaneous tuberculosis was lupus vulgaris (55%), followed by scrofuloderma (25%), orificial tuberculosis (5%), and TVC (5%). [4]

Lesions of TVC occur on the areas exposed to trauma and infected sputum or other tubercular material. In Europe, the lesions are most likely to occur on the hands; whereas in Asia, the knees, ankles, and buttocks are mainly involved. [5] Several atypical presentations of TVC have been described in the literature. Rarely, the whole lesion may be massive with infiltrated papillomatous excrescence and firm consistency, with areas of relative softening. Sometimes clinical resemblance to warts, hypertrophic lichen planus, oriental sore, chromoblastomycosis, etc., can create diagnostic dilemma. Psoriasiform, sporotrichoid, and keloidal appearance of TVC has also been described and sometimes it can even clinically mimic lupus vulgaris. [6] Occasionally, exudative and crusted features are predominant. Deeply destructive papillomatous and sclerotic forms, exuberant granulomatous form, and even multifocal TVC have been reported in the literature. [5],[7],[8]

Histopathology shows nodular or diffuse tuberculoid granulomatous inflammation involving the papillar and reticular dermis. The granuloma consists of lymphocytes, plasma cells, epithelioid cells; with or without Langhans or foreign body giant cells. The overlying epidermis shows moderate to severe hyperplasia (pseudoepitheliomatous hyperplasia).

Cases of warty tuberculosis had been treated in the past with isoniazid alone, but led to the emergence of drug resistance. The addition of rifampicin was successful in overcoming this resistance. [9] TVC masquerading as plantar keratoderma, to the best of our knowledge, has not been reported so far. Hence deserves reporting in order to highlight the nature of atypical morphology that TVC can also present with.

   References Top

1.Sehgal VN, Wagh SA. Cutaneous tuberculosis. Current concepts. Int J Dermatol 1990;29:237-52.  Back to cited text no. 1
2.Kakakhel KU, Fritsch P. Cutaneous tuberculosis. Int J Dermatol 1989;28:355-362.  Back to cited text no. 2
3.Sehgal VN, Jain MK, Srivastava G. Changing pattern of cutaneous tuberculosis: A prospective study. Int J Dermatol 1989;28:231-6.  Back to cited text no. 3
4.Puri N. A clinical and histopathological profile of patients with cutaneous tuberculosis. Indian J Dermatol 2011;56:550-2.  Back to cited text no. 4
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5.Wong KO, Lee KP, Chin SF. Tuberculosis of the skin in Hong Kong (A review of 160 cases). Br J Dermatol 1968;80:424-9.  Back to cited text no. 5
6.Michelson HE. Criteria for the diagnosis of certain tuberculodermas. JAMA 1948;138:721-6.  Back to cited text no. 6
7.Foo CC, Tan HH. A case of tuberculosis verrucosa cutis--undiagnosed for 44 years and resulting in fixed-flexion deformity of the arm. Clin Exp Dermatol 2005;30:149-51.  Back to cited text no. 7
8.Prasad PVS, Ambujam S, Paul EK, Krishnasamy B, Veliath AJ. Multifocal tuberculosis verrucosa cutis: An unusual presentation. Ind J Tub 2002;49:229-31.  Back to cited text no. 8
9.Chemotherapy and management of tuberculosis in the United Kingdom: Recommendations 1998. Joint Tuberculosis Committee of the British Thoracic Society. Thorax 1998;53:536-48.  Back to cited text no. 9

What is new?
Atypical morphology of TVC like deeply destructive papillomatous and sclerotic forms, exuberant granulomatous, or even multifocal TVC have been mentioned in the literature; however TVC presenting as diffuse plantar keratoderma is unusual and needs to be highlighted to avoid misdiagnosis and wrong or delayed treatment of a condition as common as TVC.


  [Figure 1], [Figure 2]

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