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Papulonecrotic Tuberculids Medication

  • Author: Manuel Valdebran, MD; Chief Editor: William D James, MD  more...
Updated: Jan 12, 2015

Medication Summary

The goal of pharmacotherapy is to eradicate the underlying mycobacterial infection that causes papulonecrotic tuberculid.


Antitubercular agents

Class Summary

These agents are effective in the treatment of mycobacterial infections. Therapy with a 4-drug combination of rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) is recommended to avoid the development of resistance.

Isoniazid (Laniazid, Nydrazid)


Isoniazid is the best combination of effectiveness, low cost, and minor adverse effects. It is a first-line drug unless resistance or another contraindication is known. Therapeutic regimens of less than 6 months demonstrate an unacceptably high relapse rate. Coadministration of pyridoxine is recommended to minimize the risk of peripheral neuropathy secondary to isoniazid therapy. Prophylactic doses of 6-50 mg of pyridoxine daily are recommended. Twice-weekly dosing is not recommended in HIV patients with CD4 lymphocyte counts of less than 100 cells/µL.

Rifampin (Rifadin, Rimactane)


Rifampin is for use in combination with at least one other anti-TB drug. It inhibits DNA-dependent bacterial RNA polymerase but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 months or until 6 months have elapsed from conversion to sputum culture negativity.



Pyrazinamide is a pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against M tuberculosis, depending on the concentration of the drug attained at the site of infection; its mechanism of action is unknown. Administer for the initial 2 months of a 6-month or longer treatment regimen for drug-susceptible patients. Treat drug-resistant patients with individualized regimens.

Ethambutol (Myambutol)


Ethambutol diffuses into actively growing mycobacterial cells, such as tubercle bacilli. It impairs cell metabolism by inhibiting the synthesis of one or more metabolites, which, in turn, causes cell death. No cross-resistance is demonstrated. Mycobacterial resistance is frequent with previous therapy. Use ethambutol in these patients in combination with second-line drugs that have not been previously administered. Administer daily until permanent bacteriologic conversion and maximal clinical improvement is seen. Absorption is not significantly altered by food.

Contributor Information and Disclosures

Manuel Valdebran, MD Visiting Dermatopathology Fellow, University of California, San Francisco, School of Medicine

Manuel Valdebran, MD is a member of the following medical societies: International Dermoscopy Society, Medical Dermatology Society, Society for Pediatric Dermatology

Disclosure: Nothing to disclose.


Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.


David Barnette Jr, MD Voluntary Associate Clinical Professor, University of California San Diego School of Medicine

David Barnette Jr, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology

Disclosure: Nothing to disclose.

Robert L Chen, MD, PhD Instructor, Department of Medicine, Section of Dermatology, University of Chicago Medical Center

Robert L Chen, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Dermatology Foundation, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

  1. Darier MJ. Des "tuberculides" cutanees. Ann Dermatol Syph. 1896. 7:1431-36.

  2. Tirumalae R, Yeliur IK, Antony M, George G, Kenneth J. Papulonecrotic tuberculid-clinicopathologic and molecular features of 12 Indian patients. Dermatol Pract Concept. 2014 Apr. 4(2):17-22. [Medline]. [Full Text].

  3. Sloan JB, Medenica M. Papulonecrotic tuberculid in a 9-year-old American girl: case report and review of the literature. Pediatr Dermatol. 1990 Sep. 7(3):191-5. [Medline].

  4. Iden DL, Rogers RS 3rd, Schroeter AL. Papulonecrotic tuberculid secondary to Mycobacterium bovis. Arch Dermatol. 1978 Apr. 114(4):564-6. [Medline].

  5. Freiman A, Ting P, Miller M, Greenaway C. Papulonecrotic tuberculid: a rare form of cutaneous tuberculosis. Cutis. 2005 Jun. 75(6):341-6. [Medline].

  6. Morrison JG, Fourie ED. The papulonecrotic tuberculide. From Arthus reaction to lupus vulgaris. Br J Dermatol. 1974 Sep. 91(3):263-70. [Medline].

  7. Senol M, Ozcan A, Aydin A, Karincaoglu Y, Sasmaz S, Sener S. Disseminated lupus vulgaris and papulonecrotic tuberculid: case report. Pediatr Dermatol. 2000 Mar-Apr. 17(2):133-5. [Medline].

  8. Milligan A, Chen K, Graham-Brown RA. Two tuberculides in one patient--a case report of papulonecrotic tuberculide and erythema induratum occurring together. Clin Exp Dermatol. 1990 Jan. 15(1):21-3. [Medline].

  9. Thappa DM, Karthikeyan K, Jayanthi S. Tuberculid in a child: transformation from papulonecrotic to lichen scrofulosorum. Pediatr Dermatol. 2003 Jan-Feb. 20(1):91-3. [Medline].

  10. Asiniwasis R, Dutil MT, Walsh S. Molluscum-Like Papules as a Presentation of Early Papulonecrotic Tuberculid in Association with Nodular Tuberculid in a Male with Asymptomatic Active Pulmonary Tuberculosis. J Cutan Med Surg. 2014 Aug 1. 18(0):1-4. [Medline].

  11. Chalermdamrichai P, Puavilai S, Jerasutus S, Boonsarngsuk V, Kiattboonsri S, Suwatanapongched T. Sarcoidosis presenting as papulonecrotic tuberculid-like lesions: report of a case. J Med Assoc Thai. 2004 Jul. 87(7):839-44. [Medline].

  12. Sim JH, Whang KU. Application of the QuantiFERON®-TB Gold test in erythema induratum. J Dermatolog Treat. 2014 Jun. 25(3):260-3. [Medline].

  13. Puri N. A clinical and histopathological profile of patients with cutaneous tuberculosis. Indian J Dermatol. 2011 Sep-Oct. 56(5):550-2. [Medline]. [Full Text].

  14. [Guideline] World Health Organization. Recommendations for Investigating Contacts of Persons with Infectious Tuberculosis in Low- and Middle-Income Countries. Available at Accessed: October 23, 2014.

Bilaterally symmetric papulonecrotic lesions on the lower extremities.
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