Cutaneous tuberculosis (CTB) represents a relatively rare yet crucial manifestation of tuberculosis (TB) within the broader spectrum of TB infections. Although it constitutes a small percentage of TB cases, CTB presents unique and complex challenges to the Indian healthcare system, making its timely diagnosis and effective treatment particularly difficult. The diverse clinical manifestations of CTB, ranging from subtle skin changes to more severe and disfiguring lesions, complicate its recognition and management. This complexity is further exacerbated by systemic barriers within the healthcare system, including limited access to advanced diagnostic tools, a lack of awareness among healthcare providers, and the persistence of socio-cultural stigmas associated with TB. These factors collectively contribute to significant delays in diagnosis and treatment, which, in turn, lead to increased morbidity, a higher potential for disease transmission, and the development of complications. In this review, we will delve into the multifaceted factors contributing to these delays, explore their impact on patient outcomes, and examine the specific challenges encountered in the Indian context. Additionally, we will discuss the comprehensive strategies needed to address these challenges and improve the management of CTB in India.^1-6

CTB, though only accounting for about 1-1.5% of extrapulmonary TB cases, plays a critical role in the overall burden of TB in India. The prevalence of CTB varies significantly across different regions of the country, with higher rates observed in areas where TB is more widespread. These regions are often characterized by lower socioeconomic status, high population density, and inadequate nutritional standards—all factors that create an environment conducive to the spread of TB. CTB can affect individuals across all age groups; however, it is more frequently diagnosed in children and young adults, who may be more vulnerable due to their developing or compromised immune systems. It is important to note that the true prevalence of CTB might be underreported, particularly in rural and underserved areas, where diagnostic facilities are limited and healthcare providers may lack the necessary expertise to identify and diagnose the disease accurately. The underreporting is also influenced by the general lack of awareness about CTB, both among healthcare professionals and the general population, which further complicates the ability to accurately assess the burden of the disease.^6-10

Factors Influencing Prevalence^{[1,2,11,12,13]}

Several factors contribute to the prevalence and clinical course of CTB in India, making the disease more common and severe in certain populations:

• HIV Co-infection: The prevalence of CTB is notably higher among individuals living with HIV. HIV-induced immunosuppression significantly increases susceptibility to TB infections, including its cutaneous forms. In individuals with HIV, the immune system is often compromised to a degree that makes it difficult to mount an effective defense against Mycobacterium tuberculosis, leading to a higher incidence of CTB and other extrapulmonary TB manifestations. The dual burden of HIV and TB complicates both the diagnosis and treatment of CTB, as the clinical presentation may be atypical and the response to therapy may be altered.

• Malnutrition: Widespread malnutrition in many parts of India is a critical factor exacerbating the risk of developing TB, including CTB. Malnutrition impairs the body's immune response, making it more difficult to fight off infections, including TB. In individuals with poor nutritional status, the progression of TB can be more aggressive, and the clinical course more complicated. Malnutrition also hinders the effectiveness of TB treatment, as the body may not be able to adequately absorb and metabolize medications, leading to suboptimal outcomes.

• Diabetes: The rising prevalence of diabetes in India has also been linked to an increased risk of TB, including CTB. Diabetes impairs the immune system's ability to respond to infections, making individuals with diabetes more susceptible to TB. The presence of diabetes not only increases the risk of contracting TB but also complicates its clinical course, leading to a higher likelihood of severe disease and poor treatment outcomes. The interplay between diabetes and TB is of particular concern in India, where both conditions are increasingly common and often coexist in the same patient population.

Clinical Manifestations of Cutaneous Tuberculosis^[14-18]

CTB is characterized by a wide range of clinical manifestations, each presenting its own diagnostic challenges. These manifestations can often mimic other dermatological conditions, making the accurate diagnosis of CTB particularly challenging. The primary clinical forms of CTB include:

• Lupus Vulgaris: This form of CTB is characterized by slowly progressing, reddish-brown plaques that typically affect the face, neck, and sometimes other parts of the body. These plaques are usually well-demarcated and can become more pronounced over time, often leading to severe disfigurement if left untreated. The lesions may persist for years, slowly enlarging and becoming more destructive, particularly in areas of the body with thin skin. The indolent nature of lupus vulgaris often leads to delays in seeking medical attention, as patients may not recognize the seriousness of the condition until significant damage has occurred.

• Scrofuloderma: Scrofuloderma presents as subcutaneous nodules that eventually ulcerate, commonly in association with underlying lymphadenitis. This form of CTB is particularly challenging to diagnose, as it often coexists with systemic TB, further complicating the clinical picture. The nodules typically form in areas where lymph nodes are present, such as the neck or axilla, and can eventually break down to form ulcers with sinus tracts. The presence of systemic TB symptoms, such as fever, weight loss, and night sweats, can complicate the diagnosis and may lead to delays in recognizing the cutaneous component of the disease.

• Tuberculosis Verrucosa Cutis: Tuberculosis verrucosa cutis (TVC) appears as warty, verrucous lesions, usually on the extremities. These lesions are often the result of direct inoculation of Mycobacterium tuberculosis into the skin of individuals who have been previously sensitized to the bacteria. Healthcare workers and individuals frequently exposed to TB are at higher risk for developing TVC. The lesions are typically slow-growing, well-demarcated, and may resemble other skin conditions such as viral warts or fungal infections, leading to potential misdiagnosis.

• Miliary Tuberculosis of the Skin: This rare form of CTB presents as small, widespread nodules that can ulcerate, typically occurring in severely immunocompromised patients. Miliary TB of the skin is often seen in patients with advanced HIV/AIDS or other conditions that severely compromise the immune system. The widespread nature of the nodules, which can appear anywhere on the body, coupled with the patient's overall poor health, makes this form of CTB particularly difficult to manage and treat.

• Tuberculous Gumma and Metastatic Tuberculous Abscesses: These rare forms of CTB present as soft, fluctuant nodules that may ulcerate. They often occur in individuals with severe immunocompromise, such as those with advanced HIV infection or long-term corticosteroid use. Tuberculous gumma and metastatic abscesses are caused by hematogenous spread of Mycobacterium tuberculosis from a primary site of infection, leading to the formation of abscesses in the skin and subcutaneous tissues. The nodules are typically painless but can become ulcerated, leading to secondary bacterial infections and further complicating the clinical course.

Atypical Presentations^[14-18]

CTB can also present in atypical forms, which further complicate its diagnosis and management:

• Lupoid Reaction: This is a form of hypersensitivity reaction that may mimic lupus vulgaris, complicating the clinical picture. The lupoid reaction is characterized by red, raised plaques that may be indistinguishable from lupus vulgaris on physical examination alone. Histopathological examination is often required to differentiate between the two conditions. Misdiagnosis of a lupoid reaction as lupus vulgaris can lead to inappropriate treatment and delays in addressing the underlying TB infection.

• Sarcoidosis-like Lesions: CTB can sometimes present with lesions that resemble those seen in sarcoidosis, a granulomatous disease of unknown origin. These sarcoidosis-like lesions can lead to potential misdiagnosis, as both conditions can present with similar clinical and histological findings. Differentiating between CTB and sarcoidosis is critical, as the treatment regimens for these two conditions are markedly different.

• Overlap with Other Dermatological Conditions: CTB lesions can closely resemble a variety of other dermatological conditions, including fungal infections, leprosy, and even malignancies. This overlap necessitates a high index of suspicion and a comprehensive diagnostic workup to accurately identify CTB. Failure to recognize CTB can result in inappropriate treatment, such as the use of antifungal medications or corticosteroids, which may exacerbate the condition and delay the initiation of appropriate anti-tuberculous therapy.

Reasons for Delayed Diagnosis^{[1,2,11,19,20,21]}

Clinical Complexity and Misdiagnosis

The clinical presentations of CTB are highly varied and often non-specific, which significantly contributes to misdiagnosis. CTB can present with symptoms that closely resemble other common dermatological conditions, such as fungal infections, eczema, leprosy, psoriasis, and sarcoidosis. These conditions are frequently treated empirically with topical steroids or antifungals, especially in resource-limited settings where diagnostic facilities are scarce. Unfortunately, this empirical approach can exacerbate CTB or obscure its symptoms, leading to further delays in making an accurate diagnosis. Misdiagnosis not only delays the initiation of appropriate treatment but may also lead to the progression of the disease, increasing the risk of complications and transmission.

In many instances, healthcare providers, particularly those in primary care settings, may opt to prescribe general ointments, topical creams, or broad-spectrum antibiotics without conducting a thorough diagnostic workup. This empirical treatment approach, while providing temporary relief from symptoms, can mask the underlying CTB, making it more challenging to correctly identify and diagnose the condition. The temporary alleviation of symptoms often gives both the patient and the healthcare provider a false sense of resolution, leading to significant delays in receiving the appropriate treatment. This can allow the disease to progress, potentially leading to more severe health outcomes.

• Conventional Tests: Traditional diagnostic methods for CTB, such as tuberculin skin tests, histopathology, and mycobacterial culture, have several limitations. While histopathology can be definitive, it often reveals non-specific granulomatous inflammation, which can be misleading and result in a misdiagnosis of conditions such as sarcoidosis or other granulomatous diseases. Mycobacterial culture, although specific, is a slow process, with results taking 4-8 weeks to materialize. Even with MGIT (Mycobacteria Growth Indicator Tube) systems, which are designed to accelerate the growth of Mycobacterium tuberculosis, results can still take 45-60 days, significantly delaying the diagnosis.

• Advanced Diagnostic Tools: Advanced diagnostic tools like PCR (Polymerase Chain Reaction) and other nucleic acid amplification tests (NAATs) offer a more rapid and sensitive diagnosis of CTB. However, these tools are not widely available, especially in rural or under-resourced settings where they are most needed. The lack of accessibility to these advanced tools, coupled with the requirement for significant technical expertise and specialized infrastructure, presents a major barrier to timely diagnosis in many parts of India.

• Biopsy Challenges: The effectiveness of skin biopsies in diagnosing CTB is highly dependent on the quality of the procedure. Inadequate or poorly performed biopsies, where samples are taken from non-representative areas of the lesion, can result in inconclusive or misleading results. This can lead to a missed diagnosis or further delays as additional biopsies or tests may be required to confirm CTB.

Resource Constraints

In many regions across India, healthcare facilities are chronically understaffed and under-resourced, which significantly impacts the timely diagnosis and treatment of CTB. The absence of advanced diagnostic tools, such as PCR machines, in these settings means that patients often have to wait longer for a diagnosis or may not receive one at all. The unavailability of rapid culture facilities further exacerbates delays, as traditional methods are slow and labor-intensive. These resource constraints, coupled with the high patient load in many public health facilities, contribute to prolonged waiting times and delayed access to appropriate care.

A significant barrier to the timely diagnosis of CTB is the lack of awareness and training among healthcare providers, including general practitioners and even some dermatologists. Many healthcare providers may not have sufficient exposure to CTB, particularly its atypical presentations, during their training. This lack of familiarity can lead to delays in ordering the appropriate diagnostic tests, misdiagnosis, and the initiation of incorrect treatment regimens. In areas where TB is less common or where healthcare providers are overburdened with other conditions, CTB may not be considered as a differential diagnosis, further contributing to delays.

Patient Factors

• Socioeconomic Barriers: Patients from lower socioeconomic backgrounds often face significant barriers to accessing timely medical care. Financial constraints, such as the cost of consultations, diagnostic tests, and travel to healthcare facilities, can prevent patients from seeking medical attention promptly. Additionally, the need to prioritize work and other responsibilities over health, particularly in low-income households, can lead to delays in seeking care for CTB.

• Cultural Beliefs: In some communities, traditional beliefs and reliance on alternative medicine play a significant role in healthcare decisions. Patients may initially seek treatment from traditional healers or use home remedies, delaying allopathic treatment. This can lead to a worsening of the condition and further complicates the eventual diagnosis and treatment of CTB.

• Lack of Awareness: Many patients do not recognize the seriousness of their skin lesions, particularly if the symptoms are mild or non-progressive. This lack of awareness often leads them to try over-the-counter medications, home remedies, or to consult non-qualified practitioners, all of which contribute to delays in receiving appropriate medical care.

Stigma and Social Factors

The stigma associated with TB, including CTB, remains a significant barrier to timely diagnosis and treatment. In many rural and conservative communities, misconceptions about TB and its transmission lead to social ostracization of affected individuals, particularly when the disease manifests with visible skin lesions. This stigma often discourages patients from seeking medical help early, as they may fear being labeled or shunned by their community. The social isolation and psychological burden associated with TB can further delay the pursuit of medical care, exacerbating the disease's impact on health and quality of life.

Healthcare System Challenges

• Inadequate Training: The training of healthcare providers, particularly those working in rural and underserved areas, often does not include sufficient focus on recognizing and managing CTB. This lack of specialized training can result in healthcare providers misdiagnosing CTB or opting for inappropriate initial management strategies, such as the use of general antibiotics or steroids. While these treatments may offer temporary symptom relief, they do not address the underlying TB infection, leading to delays in proper treatment and increasing the risk of complications.

• Referral Delays: The referral process to specialists, such as dermatologists or infectious disease experts, is often fraught with delays, particularly in rural areas where specialists may not be readily available. The absence of clear referral pathways and the geographical barriers to accessing specialist care can significantly prolong the time it takes for patients to receive an accurate diagnosis and appropriate treatment for CTB.

• Diagnostic Delays: Even when a diagnosis of CTB is made, there can be considerable delays in initiating treatment due to the time required for confirmatory test results, such as culture or PCR, which can take weeks to months. These delays are particularly pronounced in resource-limited settings where logistical challenges, such as the unavailability of medications or inadequate follow-up mechanisms, further hinder the timely initiation of treatment.

Patient Factors

• Socioeconomic Barriers: Financial constraints are a major obstacle for many patients in completing the full course of CTB treatment or maintaining regular follow-up with healthcare providers. The costs associated with medications, travel to healthcare facilities, and the loss of income due to illness are significant deterrents that can lead to interruptions in treatment, ultimately compromising the effectiveness of therapy and increasing the risk of drug resistance.

• Non-Adherence to Treatment: CTB treatment typically involves a prolonged course of multidrug therapy, often lasting several months. Non-adherence to this treatment regimen is a major challenge, especially among patients who experience adverse side effects or those who see early improvements in their symptoms and prematurely discontinue treatment. Non-adherence can lead to incomplete treatment, disease recurrence, and the development of drug-resistant TB strains.

• Traditional Medicine: In some cases, patients may discontinue allopathic treatment in favor of traditional or alternative therapies. This decision is often influenced by cultural beliefs or dissatisfaction with the side effects of conventional treatment. However, the use of traditional medicine can lead to disease progression, complications, and further delays in achieving a cure.

Stigma and Social Factors

The stigma associated with TB, particularly when it manifests as visible skin lesions, plays a significant role in delayed treatment. Patients who fear social rejection or who are burdened by the psychological impact of a chronic disease may discontinue treatment prematurely or avoid seeking follow-up care. This stigma, combined with the fear of being ostracized, can lead to poor adherence to treatment regimens and ultimately worsen health outcomes.

Impact of Delayed Diagnosis and Treatment

Disease Progression and Complications

Delays in the diagnosis and treatment of CTB can have severe consequences, leading to significant disease progression and complications. As the disease advances, patients may experience extensive skin damage, disfigurement, and scarring. In more severe cases, CTB can extend beyond the skin to affect deeper tissues or even disseminate to other organs, resulting in life-threatening complications. The longer the delay in receiving appropriate treatment, the greater the risk of irreversible damage and the more challenging it becomes to manage the disease effectively.

Development of Drug Resistance

Incomplete or delayed treatment of CTB significantly increases the risk of developing drug-resistant TB strains, including multidrug-resistant TB (MDR-TB). The emergence of drug-resistant TB complicates treatment, as it requires the use of more toxic and expensive medications, extends the duration of therapy, and diminishes the chances of a successful outcome. The development of drug-resistant strains also poses a public health threat, as these strains can be transmitted to others, further complicating TB control efforts.

Psychosocial and Economic Impact

The visible nature of CTB lesions can have profound psychosocial effects on affected individuals, leading to feelings of depression, anxiety, and social isolation. The stigma associated with visible TB lesions can exacerbate these psychological burdens, resulting in decreased self-esteem and a diminished quality of life. Additionally, the economic impact of long-term treatment, combined with the loss of income due to illness, can place a significant financial strain on patients and their families. This combination of psychosocial and economic challenges can further complicate the management of CTB and reduce the likelihood of successful treatment outcomes.

Patient-Level Delays

• Ignorance of Disease Severity: Many patients may not perceive cutaneous tuberculosis (CTB) as a serious health condition, particularly if the initial symptoms are mild, non-progressive, or mistaken for a more common and less severe skin condition. This lack of awareness often leads to significant delays in seeking medical attention. Patients may dismiss the early signs of CTB, assuming they will resolve on their own or can be managed with simple home remedies, thereby allowing the disease to progress unchecked. The subtlety of the initial symptoms can be misleading, causing patients to underestimate the potential severity of their condition, which in turn delays the initiation of appropriate medical care.

• Economic Constraints: Financial hardships pose a major barrier to timely diagnosis and treatment of CTB. For many patients, especially those from lower socioeconomic backgrounds, the costs associated with medical consultations, diagnostic tests, and subsequent treatments can be prohibitively expensive. These economic barriers can prevent patients from accessing healthcare services altogether, or they may opt for less costly, less effective alternatives, such as visiting unqualified practitioners or relying on over-the-counter medications. The financial burden is further compounded by the potential loss of income due to illness, as patients may prioritize their economic survival over their health, delaying medical consultation until the disease has significantly progressed.

• Reliance on Self-Medication: Many patients resort to self-medication as an initial response to the symptoms of CTB. This often involves the use of over-the-counter treatments, such as topical creams or herbal remedies, which may provide temporary relief but do not address the underlying infection. The reliance on self-medication is often fueled by a combination of factors, including financial constraints, limited access to healthcare services, and a lack of awareness about the seriousness of CTB. As a result, proper medical intervention is delayed, allowing the disease to advance and increasing the risk of complications.

Doctor-Level Delays

• Misinterpretation of Symptoms: Healthcare providers, particularly those working in primary care settings, may not recognize the symptoms of CTB due to its varied and often non-specific clinical presentations. The symptoms of CTB can easily be mistaken for more common skin conditions such as fungal infections, eczema, or psoriasis. Without a high index of suspicion, doctors may misinterpret these symptoms, leading to misdiagnosis and the prescription of inappropriate treatments. This misdiagnosis not only delays the initiation of proper treatment but may also worsen the patient’s condition, as the underlying TB infection remains unaddressed.

• Lack of Access to Diagnostic Tools: In many parts of India, especially in rural or under-resourced healthcare settings, doctors face significant challenges due to the lack of access to advanced diagnostic tools. Without these tools, such as PCR machines or rapid culture facilities, doctors may find it difficult to confirm a diagnosis of CTB, leading to delays in starting appropriate treatment. The unavailability of these diagnostic tools often forces healthcare providers to rely on less accurate or slower methods, prolonging the diagnostic process and increasing the likelihood of treatment delays.

• Inappropriate Initial Treatment: Some doctors may prescribe general ointments, topical steroids, or broad-spectrum antibiotics without considering CTB in their differential diagnosis. This empirical treatment approach, while it may provide temporary symptom relief, can mask the symptoms of CTB, leading to further delays in proper diagnosis and treatment. In some cases, the use of inappropriate treatments can exacerbate the condition, causing the disease to progress and increasing the risk of more severe complications.

Challenges in the Management of Cutaneous Tuberculosis^{[1,2,14,22.23,24,25]}

Multifaceted Clinical Presentation

The varied clinical presentations of CTB present a significant challenge for accurate diagnosis, particularly in primary care settings where specialized dermatological services are often unavailable. CTB can mimic a wide range of other skin conditions, making it difficult for healthcare providers to correctly identify the disease without specialized training or access to advanced diagnostic tools. This multifaceted presentation requires a high degree of clinical suspicion and expertise, which is often lacking in resource-limited settings. The complexity of CTB’s clinical manifestations underscores the need for improved training and diagnostic capabilities in primary care to ensure timely and accurate diagnosis.

The management of CTB in India is further complicated by the lack of comprehensive epidemiological data on the disease. This scarcity of data hampers efforts to understand the true burden of CTB, identify high-risk populations, and develop targeted interventions. Without reliable data, it is challenging to assess the effectiveness of current treatment protocols or to implement evidence-based public health strategies. More research is needed to explore the epidemiology, risk factors, and best practices for managing CTB in diverse settings across India. Increased focus on data collection and research can help bridge the knowledge gaps and inform better clinical and public health practices.

Integration of Care

Effective management of CTB requires coordinated care involving multiple disciplines, including dermatologists, infectious disease specialists, and public health professionals. However, healthcare services in many parts of India are fragmented, leading to gaps in care and suboptimal treatment outcomes. The lack of integration between different levels of the healthcare system often results in patients receiving incomplete or inconsistent care, which can lead to delays in diagnosis, treatment, and follow-up. Integrating care across various healthcare providers and systems is essential to ensure that patients receive timely and appropriate treatment, improving overall outcomes and reducing the burden of CTB.

Logistical Challenges

In resource-limited settings, logistical challenges such as the unavailability of drugs, long waiting times for diagnostic results, and poor follow-up mechanisms severely hinder the management of CTB. Patients may experience delays in receiving their medications due to supply chain issues or may have to wait weeks or even months for diagnostic results, which can delay the start of appropriate treatment. Additionally, the lack of robust follow-up protocols means that many patients do not receive the continuous care needed to monitor their progress and adjust treatment as necessary. Addressing these logistical challenges is critical for improving the management of CTB and ensuring better patient outcomes.

Strategies for Improvement^{,[1,2,13,14,24,25]}

Enhancing Diagnostic Capacity

Expanding access to rapid diagnostic tools such as PCR in resource-limited settings is crucial for improving the timely diagnosis of CTB. By making these tools more widely available, particularly in rural and underserved areas, healthcare providers can more quickly and accurately diagnose CTB, leading to earlier and more effective treatment. Additionally, investing in the development of new diagnostic methods with higher sensitivity and specificity for CTB is essential. This includes research into novel biomarkers or imaging techniques that can complement existing diagnostic tools and improve overall diagnostic accuracy.

Training Healthcare Providers

Improving the training of healthcare providers, particularly those in primary care settings, is vital for enhancing the recognition and management of CTB. Continuing medical education programs that focus on the clinical presentations, diagnosis, and treatment of CTB can help bridge the knowledge gap and ensure that healthcare providers are better equipped to identify and treat the disease. These programs should emphasize the importance of considering CTB in the differential diagnosis of skin conditions and provide practical guidance on how to manage the disease effectively within the constraints of resource-limited settings.

Public Health Campaigns

Public health campaigns aimed at raising awareness about CTB among both the general public and healthcare providers can play a key role in reducing the stigma associated with the disease and encouraging timely medical consultation. These campaigns should focus on educating communities about the signs and symptoms of CTB, the importance of early diagnosis and treatment, and the availability of effective treatments. By increasing public awareness and reducing stigma, these campaigns can help ensure that more patients seek medical attention early, leading to better outcomes.

Strengthening Healthcare Infrastructure

Investing in healthcare infrastructure, particularly in rural and underserved areas, is critical for improving access to quality care for CTB patients. This includes upgrading diagnostic facilities to ensure that advanced diagnostic tools, such as PCR machines, are available in more healthcare settings. Ensuring the consistent availability of essential drugs and improving referral systems to facilitate timely and appropriate care are also important components of strengthening healthcare infrastructure. By addressing these infrastructure challenges, the healthcare system can become more responsive to the needs of CTB patients, leading to improved diagnosis, treatment, and follow-up care.

Encouraging Research and Development

Increased funding for research into the epidemiology, pathogenesis, and treatment of CTB is essential for developing targeted interventions that can effectively manage the disease. Collaborative research efforts between government institutions, academic centers, and international organizations can help fill the knowledge gaps and provide the evidence base needed to improve clinical and public health practices. By fostering a research environment that encourages innovation and collaboration, new and more effective strategies for managing CTB can be developed and implemented, leading to better patient outcomes.

Policy and Programmatic Support

National and state-level health policies must prioritize TB control, including the specific challenges posed by CTB. Strengthening the integration of CTB management into the broader National Tuberculosis Elimination Program (NTEP) can help ensure that patients receive comprehensive care that addresses all aspects of their condition. Additionally, policies should focus on improving access to diagnostic tools, expanding training programs for healthcare providers, and enhancing patient education to reduce delays in diagnosis and treatment. By providing robust policy and programmatic support, the healthcare system can become better equipped to manage CTB and reduce its impact on patients and communities.

Cutaneous tuberculosis presents a significant challenge in India due to delayed diagnosis and treatment, which often result in severe disease progression, complications, and psychosocial impacts. The multifactorial nature of these delays, driven by clinical complexity, resource constraints, lack of awareness, and social stigma, underscores the need for a comprehensive approach to improve patient outcomes. By enhancing diagnostic capabilities, training healthcare providers, raising public awareness, and strengthening healthcare infrastructure, India can make significant strides in reducing the burden of CTB and improving the quality of life for affected patients. Addressing these challenges will require coordinated efforts across all levels of the healthcare system, supported by robust policy frameworks and continued research to ensure that patients receive the timely and effective care they need.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Indira Gandhi Medical College, Shimla, Himachal Pradesh.

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