eMedicine Specialties > Dermatology > Mycobacterial Infections
Papulonecrotic Tuberculids: Treatment & Medication
Updated: Jul 9, 2009
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Treatment
Medical Care
Treatment is directed at eradicating the underlying mycobacterial infection. Tuberculosis treatment guidelines may vary from region to region and from different authorities (ie, the World Health Organization [WHO] and the Centers for Disease Control and Prevention [CDC]). Currently, for patients with active tuberculosis, a 4-drug therapy with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) is recommended to avoid the development of resistance. Papulonecrotic tuberculids respond promptly to appropriate antituberculosis therapy. New lesions cease forming within days to weeks after therapy is initiated, and existing lesions heal rapidly, usually within several months. A minimum of 6 months of anti-tuberculosis therapy is recommended. Recurrences rarely occur after appropriate therapy.
Also see the following guidelines:
- Controlling tuberculosis in the United States. Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America.11
- Guidelines for the investigation of contacts of persons with infectious tuberculosis. Recommendations from the National Tuberculosis Controllers Association and CDC.12
Medication
The goal of pharmacotherapy is to eradicate the underlying mycobacterial infection that causes papulonecrotic tuberculid.
Antitubercular agents
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)
Best combination of effectiveness, low cost, and minor adverse effects. First-line drug unless resistance or another contraindication is known. Therapeutic regimens of <6 mo demonstrate an unacceptably high relapse rate. Coadministration of pyridoxine is recommended to minimize risk of peripheral neuropathy secondary to isoniazid therapy. Prophylactic doses of 6-50 mg of pyridoxine daily are recommended. Twice-weekly dosing not recommended in HIV patients with CD4 lymphocyte counts <100 cells/µL
Adult
5 mg/kg PO qd (usually 300 mg/d); 10 mg/kg PO qd or divided bid in patients with disseminated disease; not to exceed 300 mg/d
Directly observed therapy: 15 mg/kg twice weekly; not to exceed 900 mg/d; twice-weekly dosing not recommended in HIV patients with CD4 lymphocyte counts <100 cells/µL
Pediatric
10-20 mg/kg PO qd; not to exceed 300 mg/d
Higher incidence of isoniazid-related hepatitis can occur with daily alcohol consumption; aluminum salts may decrease serum levels (administer 1-2 h before taking aluminum salts); may increase effects of anticoagulants with coadministration; may inhibit metabolic clearance of benzodiazepines; carbamazepine toxicity or isoniazid hepatotoxicity may result from concurrent use (monitor carbamazepine concentrations and liver function); coadministration with cycloserine may increase CNS adverse effects (eg, dizziness); acute behavioral and coordination changes may occur with coadministration of disulfiram; coadministration with rifampin after halothane anesthesia may result in hepatotoxicity and hepatic encephalopathy; may inhibit hepatic microsomal enzymes and increase toxicity of hydantoin
Documented hypersensitivity; previous isoniazid-associated hepatic injury or other severe adverse reactions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor patients with active chronic liver disease or severe renal dysfunction; periodic ophthalmologic examinations during isoniazid therapy are recommended even when visual symptoms do not occur
Adverse effects include anemia, seizure, systemic lupus erythematosus, thrombocytopenia, and hepatitis (severe and sometimes fatal); adverse effects following isoniazid therapy may include toxic encephalopathy, nystagmus, dizziness, and tinnitus
Rifampin (Rifadin, Rimactane)
For use in combination with at least 1 other anti-TB drug. Inhibits DNA-dependent bacterial RNA polymerase but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 mo or until 6 mo have elapsed from conversion to sputum culture negativity.
Adult
600 mg PO/IV qd
Pediatric
10-20 mg/kg PO/IV; not to exceed 600 mg/d
Induces microsomal enzymes (especially P450 CYP3A4-mediated metabolism), which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, digoxin, and other medications metabolized by this system; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue 1 or both agents if alterations in LFTs occur)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Pyrazinamide
Pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against M tuberculosis, depending on concentration of drug attained at site of infection; mechanism of action is unknown. Administer for initial 2 months of a 6-mo or longer treatment regimen for drug-susceptible patients. Treat drug-resistant patients with individualized regimens.
Adult
15-30 mg/kg PO qd; not to exceed 2 g/d
Indirectly observed therapy: 50-70 mg/kg PO 2 times/wk, not to exceed 4 g/d; or 50-70 mg/kg 3 times/wk, not to exceed 3 g/d
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; severe hepatic damage; acute gout
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only in combination with other effective anti-TB agents; inhibits renal excretion of urates; may result in hyperuricemia (usually asymptomatic); perform baseline serum uric acid determinations; discontinue drug if signs of hyperuricemia with acute gouty arthritis; perform baseline LFTs (closely monitor in liver disease); discontinue if signs of hepatocellular damage appear; caution in history of diabetes mellitus; coadministration of ethionamide may potentiate hepatotoxicity
Ethambutol (Myambutol)
Diffuses into actively growing mycobacterial cells, such as tubercle bacilli. Impairs cell metabolism by inhibiting synthesis of one or more metabolites, which, in turn, causes cell death. No cross-resistance demonstrated. Mycobacterial resistance is frequent with previous therapy. Use in these patients in combination with second-line drugs that have not been previously administered. Administer qd until permanent bacteriologic conversion and maximal clinical improvement is seen. Absorption is not significantly altered by food.
Adult
No previous anti-TB therapy: 15 mg/kg (7 mg/lb) PO qd
Previous anti-TB therapy: 25 mg/kg (11 mg/lb) PO qd
Pediatric
<13 years: Not recommended
>13 years: Administer as in adults
Aluminum salts may delay and reduce absorption (give several hours before or after ethambutol dose)
Documented hypersensitivity; optic neuritis (unless clinically indicated)
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dose in impaired renal function; may have reversible visual adverse effects if promptly discontinued
More on Papulonecrotic Tuberculids |
| Overview: Papulonecrotic Tuberculids |
| Differential Diagnoses & Workup: Papulonecrotic Tuberculids |
 Treatment & Medication: Papulonecrotic Tuberculids |
| Follow-up: Papulonecrotic Tuberculids |
| Multimedia: Papulonecrotic Tuberculids |
| References |
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References
Darier MJ. Des "tuberculides" cutanees. Ann Dermatol Syph. 1896;7:1431-36.
Sloan JB, Medenica M. Papulonecrotic tuberculid in a 9-year-old American girl: case report and review of the literature. Pediatr Dermatol. Sep 1990;7(3):191-5. [Medline].
Iden DL, Rogers RS 3rd, Schroeter AL. Papulonecrotic tuberculid secondary to Mycobacterium bovis. Arch Dermatol. Apr 1978;114(4):564-6. [Medline].
Fernandes C, Maltez F, Lourenco S, Morgado A, Proenca R. Papulonecrotic tuberculid in a human immunodeficiency virus type-1 patient with multidrug-resistant tuberculosis. J Eur Acad Dermatol Venereol. May 2004;18(3):369-70. [Medline].
Freiman A, Ting P, Miller M, Greenaway C. Papulonecrotic tuberculid: a rare form of cutaneous tuberculosis. Cutis. Jun 2005;75(6):341-6. [Medline].
Morrison JG, Fourie ED. The papulonecrotic tuberculide. From Arthus reaction to lupus vulgaris. Br J Dermatol. Sep 1974;91(3):263-70. [Medline].
Senol M, Ozcan A, Aydin A, Karincaoglu Y, Sasmaz S, Sener S. Disseminated lupus vulgaris and papulonecrotic tuberculid: case report. Pediatr Dermatol. Mar-Apr 2000;17(2):133-5. [Medline].
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. Jan 1990;15(1):21-3. [Medline].
Thappa DM, Karthikeyan K, Jayanthi S. Tuberculid in a child: transformation from papulonecrotic to lichen scrofulosorum. Pediatr Dermatol. Jan-Feb 2003;20(1):91-3. [Medline].
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. Jul 2004;87(7):839-44. [Medline].
[Guideline] Taylor Z, Nolan CM, Blumberg HM. Controlling tuberculosis in the United States. Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR Recomm Rep. Nov 4 2005;54:1-81. [Medline].
[Guideline] Guidelines for the investigation of contacts of persons with infectious tuberculosis. Recommendations from the National Tuberculosis Controllers Association and CDC. MMWR Recomm Rep. Dec 16 2005;54:1-47. [Medline].
Barbagallo J, Tager P, Ingleton R, Hirsch RJ, Weinberg JM. Cutaneous tuberculosis: diagnosis and treatment. Am J Clin Dermatol. 2002;3(5):319-28. [Medline].
Jordaan HF, Van Niekerk DJ, Louw M. Papulonecrotic tuberculid. A clinical, histopathological, and immunohistochemical study of 15 patients. Am J Dermatopathol. Oct 1994;16(5):474-85. [Medline].
Pautrier L-M. Darier J, ed. Tuberculose nodulare dermique á petits nodules. Nouvelle Pratique. Paris: Masson Editeur; 1936.
Victor T, Jordaan HF, Van Niekerk DJ, Louw M, Jordaan A, Van Helden PD. Papulonecrotic tuberculid. Identification of Mycobacterium tuberculosis DNA by polymerase chain reaction. Am J Dermatopathol. Dec 1992;14(6):491-5. [Medline].
Wilson-Jones E, Winkelmann RK. Papulonecrotic tuberculid: a neglected disease in Western countries. J Am Acad Dermatol. May 1986;14(5 Pt 1):815-26. [Medline].
Further Reading
Keywords
papulonecrotic tuberculid, PNT, necrotizing skin papules, tuberculosis hypersensitivity, TB antigens
