Lupus vulgaris is caused by Mycobacterium tuberculosis invading the skin from the outside. It is the most common form of cutaneous tuberculosis. The formation of this disease is mostly caused by physical weakness, insufficient Qi and Yin, exogenous wind evil, and stagnant dampness and phlegm. Blood vessels cause millet-sized nodules to appear on the skin, which will fester over time and leave contracture scars after healing. Pathology Pathology is tuberculous infiltration or tuberculous infiltration, that is, tuberculous granuloma, which is a granuloma composed of epithelioid cells, lymphocytes and giant cells. The tissue in the center of tuberculosis often shows caseous necrosis. Pathophysiology Traditional Chinese Medicine Diagnostic Criteria Traditional Chinese Medicine diagnoses physical weakness, lung and kidney yin deficiency, yin deficiency generates internal heat, which transforms fire, and burnt fluid turns into phlegm. Qi stagnation blocks the skin, resulting in insufficient qi and blood, and phlegm accumulates and dampness blocks, which does not disappear over time. Lingering is hard to heal. 1. Yin deficiency and phlegm accumulation Syndrome: bright red or brownish-red patches or nodules with obvious infiltration on the face, accompanied by low-grade fever, night sweats, fatigue, thin white fur, red tongue, and thready pulse. Analysis: ① Syndrome differentiation: This syndrome is mostly seen in the early stages of lupus vulgaris, and infiltrated plaques or nodules are the main features. ②Pathogenesis: Yin deficiency generates internal heat, and deficiency fire causes inflammation and burns body fluid to form phlegm, which will lead to various symptoms. 2. Qi deficiency and phlegm accumulation. Syndrome: Dark red infiltration on the face, plaques and nodules forming ulcers and pus, fatigue, low fever, night sweats, anorexia, reddish tongue, thin white coating, and deep and thready pulse. Analysis: ① Syndrome differentiation: Physical weakness, lack of Qi and blood over time, nodules, ulcers, pus, etc. are the characteristics of this type. ②Pathogenesis: Insufficient Qi and blood, phlegm and dampness will cause various symptoms. Western Medicine Diagnostic Criteria Diagnostic Criteria for Lupus Vulgaris: 1. It is more common in children and young people, and is more likely to occur on the face (especially the nasal isthmus). It can also be seen on the buttocks, limbs and mucous membranes, and can destroy cartilage. 2. Chronic disease course. The rash consists of small applesauce-colored or yellow-brown nodules that enlarge, multiply and merge into sheets. After breaking, they become ulcers, leaving atrophic or hypertrophic scars, which can cause deformity. A new rash may appear on the scar. "Lupus nodules" can be seen on slide pressure examination. Some patients have visceral tuberculosis. 3. Histopathology shows tuberculosis nodules or tuberculosis-like nodules in the dermis. The tuberculin test was positive. Western medicine diagnosis basis Clinical diagnosis 1. The skin lesions are nodules the size of millet to pea, which are applesauce-like. After ulceration, scars form, and new nodules can regenerate on the scars, destroying and healing at the same time. 2. It usually occurs on the face, followed by the limbs, buttocks, trunk, etc. 3. Some patients often develop various deformities due to scar shrinkage, such as eyelid ectropion, rabbit eyes, etc. The onset often starts in childhood, and can persist for many years or even decades, with recurring attacks. Medical History Personal or family history of tuberculosis. Symptoms and signs: The lesions are small applesauce-colored nodules known as "lupus nodules". After ulceration, they form atrophic scars. New nodules can regenerate on the scars. The skin is very destructive and often forms ulcers. More than 50% of the disease occurs on the face, followed by the limbs, buttocks and neck. (1) Symptoms 1. At first, there are a few bright red or brown nodules, ranging from millet to pea-sized nodules (called lupus nodules). Afterwards, the nodules gradually enlarge, the number increases, the infiltration is obvious, the boundary is obvious, and it can expand to the surroundings, which is diffuse infiltration. 2. The nodule is soft, and it is easy to penetrate and bleed when the probe is inserted with a little force (probe penetration phenomenon). If viewed with a glass slide, the nodules are more obvious and appear light yellow or tan, like the color of applesauce, so they are called "applesauce nodules". 3. In the long-term process, some nodules rupture and form ulcers. The ulcers are mostly superficial, round or shapeless, with reddish-brown granulations and a small amount of thin pus or light brown scabs on the surface. Ulcers can heal on their own, forming atrophic scars after healing, and new nodules can still recur on the scars. 4. During the development process, the nodule in the center or one side of the ulcer heals, but the edge or the other side continues to expand outward, forming large areas of damage. Deformity or dysfunction often occurs due to scar shrinkage. 5. The damage is mostly on the face, especially the nose, mouth, cheeks and ears. This is followed by the mucous membranes, buttocks, limbs and trunk. 6. Generally lack of subjective symptoms. It is easy to relapse, and if not treated in time, the condition may linger for decades without recovery. (2) Signs "lupus nodules", "probe penetration phenomenon" and "applesauce phenomenon" are the clinical characteristics of this disease. (3) Clinical classification 1. Flat lupus vulgaris: The surface of the lesions is smooth, with some scales, flaky infiltrative patches, lupus nodules, and relatively flat atrophic scars after recovery. 2. Proliferative lupus: including nodular lupus, tumorous lupus, verrucous lupus, papillary lupus, etc. This type of lupus nodules are densely fused with each other and appear as obvious infiltrative masses or papillary proliferations of varying sizes above the skin surface. 3. Ulcerative lupus: Large-area ulcers often form, which may occur from the ulcerated surface of lupus nodules, or may be secondary to tuberculosis infection of lymph nodes, bones or other tissues under the skin. 4. Disseminated lupus: It is caused by the blood spread of tuberculosis bacteria in tuberculosis lesions inside the body. This disease can be seen in children after acute infectious diseases such as measles or scarlet fever. Small patches composed of scattered lupus nodules suddenly appear on the skin and do not merge with each other. Physical examination, electrodiagnosis, imaging diagnosis, laboratory diagnosis, blood, urine, feces, cerebrospinal fluid, other diagnosis, immunology, histological examination, Western medicine differential diagnosis 1. Sarcoidosis: The nodules of sarcoidosis are firmer than lupus nodules, are infiltrative, and generally do not break. Tuberculin test was negative. 2. Nodular syphilis: Syphilitic nodules develop quickly and can be arranged in staggered rows. They are as hard as cartilage, copper-red in color, and often ulcerate. The ulcers are hole-shaped and scar after healing. Syphilis serology was positive.

Its pathological changes are mainly plasma cell infiltration and vascular changes. 3. Discoid lupus erythematosus: The erythematosus is butterfly-shaped and often symmetrically distributed on the nose and cheeks. There are no lupus nodules and ulcers. There are fixed scales on the erythematosus, and hair follicle keratin plugs are attached to the bottom surface. 4. Deep fungal part: The nodules are often ulcerated and scarred, and the fungal culture is positive. Pathogenic bacteria can be detected by histopathology. 5. Tuberculous leprosy: The nodules are harder than lupus nodules and are characterized by sensory disturbance in the affected area, enlarged peripheral nerves, numbness and deformity of the limbs, and nutritional ulcers may occur. Identification of TCM syndromes and efficacy evaluation standards 1. Cure: the rash subsides, leaving only atrophic scars. 2. Improvement: The rash shrank and became flat, with no new rash. Prognosis Complications Western Medicine Treatment 1. Systemic treatment 1. Supportive therapy: appropriate arrangements for rest, activities and labor, reasonable nutrition, etc. 2. Anti-tuberculosis drugs: ① Streptomycin, daily intramuscular injection of 1.0K for adults. Use continuously for 1 to 3 months. ② Isoniazid, 3 to 6 mg/kg daily, 300 mg daily intramuscular injection for adults until 2 months after clinical recovery. ③ For ammonia salicylic acid, adults should take 8 to 12g per day, divided into 4 times, and the total dosage for one course of treatment is 600 to 1000g. ④ Rifampicin, 600mg orally taken daily, should not be used by patients with liver and gallbladder diseases. ⑤Ethambutol, 15mg/kg daily. ⑥Isoniazid is a derivative of isoniazid. For adults, 0.25-0.5g is given 3 times a day. The total dosage for one course of treatment is 150-200g. Streptomycin and isoniazid are first-line drugs, often combined with rifampicin and ethambutol, which can shorten the course of the disease and delay drug resistance. 3. Vitamins: Take vitamin B6, vitamin B1, etc. orally. 2. Local treatment 1. Topical anti-tuberculosis drugs: Apply isoniazid powder or 0.5% to 1.0% isoniazid ointment, or 15% to 20% para-aminosalicylic acid ointment, 1% streptomycin for external application, etc. 2. Drug corrosion: For example, 5% to 20% pyrogallic acid ointment has a destructive effect on tuberculosis lesions. Start with 5% and gradually increase the concentration. In addition, pure carbonic acid, trichloroacetic acid, lactic acid, silver nitrate rods, etc. can be used to prevent corrosion and burning. 3. Local lesion injection: Streptomycin (0.2-0.4g each time) plus 2% lidocaine solution is used for local lesion injection, once every 4-6 days. 2% lidocaine plus isoniazid is also useful for local lesion injection. Peripheral injections are effective. 4. Surgical therapy: used for smaller localized isolated lesions. Surgery can be used to completely remove the damage to prevent recurrence. However, it must be noted that the incision must be made at 0.5cm of normal skin outside the lesion, and the depth should be as deep as the muscle membrane. 3. Physical therapy 1. X-ray irradiation: It can promote the absorption of tuberculosis tissue, flatten hypertrophic and proliferative lesions, promote ulcer healing, and soften scars. 2. Ultraviolet light treatment: Ultraviolet light and sunbathing can increase the body's resistance, reduce susceptibility to tuberculosis bacteria, promote blood circulation in local skin, enhance the function of the nervous system and change the metabolic process, thereby promoting the absorption of tuberculosis tissue. 3. Use zinc ions or streptomycin to introduce direct current drugs and electrolyze them to destroy lupus nodules. Route of infection. BCG vaccination enhances the body's immunity. TCM treatment 1. Syndrome differentiation and prescription selection 1. Yin deficiency and phlegm knots Treatment method: Nourish yin, clear away heat and detoxify, harmonize nutrients, dissolve phlegm and soften hardness. Recipe: 20g of Rehmannia glutinosa, 15g of Scrophulariaceae, 15g of Asparagus, 12g of Scutellaria baicalensis, 12g of Phellodendron cypress, 15g of Salvia miltiorrhiza, 12g of Radix Rhizoma Root, 10g of Prunella vulgaris, 12g of seaweed, 10g of Hedyotis diffusa, and 6g of licorice. For those who have restless sleep at night, add Nocturna japonica and Zhu Fuling. 2. Treatment of qi deficiency and phlegm knots: Replenish qi and nourish blood, soften hardness and resolve phlegm. Recipe: Buzhong Yiqi Decoction. 15g of raw astragalus, 15g of Codonopsis pilosula, 10g of Angelica sinensis, 10g of Atractylodes macrocephala, 10g of Poria cocos, 15g of Spatholobus, 10g of safflower, 15g of Prunella vulgaris, 10g of Fritillaria grandis, 10g of Forsythia suspensa, 5g of tangerine peel and 10g of licorice. If you have bone steam, hot flashes or night sweats, add tortoise shell, turtle shell, Digu skin, etc. 2. External treatment: Purple swelling ointment can be used for those who have not ulcerated. When ulcers form, apply red oil ointment mixed with Qisandan, or use gallnut ointment. Traditional Chinese medicines include Neixiao Suohuan Pills, Prunella Vulgaris Ointment, Sanjieling, Ginseng Yangrong Pills, Bazhen Pills, Neixiao Forsythia Pills, and Xiaojindan. Acupuncture, massage, and combined Chinese and Western medicine are used to treat cutaneous tuberculosis, which is a systemic disease. Anti-tuberculosis drugs are often prone to drug resistance. Therefore, systemic and local treatments should be used in treatment. Only a comprehensive treatment method that combines Chinese and Western medicine can completely cure the disease. Cure diseases. 1. Pay attention to the following points during treatment: (1) Treat other tuberculosis diseases as early as possible and eliminate the source of infection. (2) When inoculating the BCG vaccine, remember not to mistakenly inject the intradermal BCG vaccine subcutaneously, otherwise it will be complicated by lupus vulgaris. (3) Early diagnosis and early treatment can shorten the disease period to prevent secondary canceration over time. Squamous cell carcinoma secondary to lupus vulgaris has been reported. 2. Western medicine for external use combined with oral administration of traditional Chinese medicine: When the condition is stable, traditional Chinese medicine such as Buzhong Yiqi Decoction, Shiquan Dabu Decoction plus Xiaojin Tablets, 4 tablets each time, twice a day, can be taken orally to increase the body's immunity. Topical anti-tuberculosis drugs. Such as: rifampicin ointment, isoniazid powder, etc. for external application. 3. External use of traditional Chinese medicine combined with oral administration of Western medicine: When the condition is more serious, anti-tuberculosis drugs such as isoniazid, streptomycin, rifampicin, para-aminosalicylic acid, etc. can be taken orally in combination to increase the efficacy and control the development of the disease. Topically apply traditional Chinese medicine gallnut ointment, purple swelling ointment, purple carbuncle ointment, etc. Nursing, rehabilitation, prevention, proper rest, increased nutrition, and improvement of the patient's resistance. Early diagnosis, early treatment, elimination of sources of infection, and elimination of infection routes.

BCG vaccination enhances the body's immunity.

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