Cutaneous Tuberculosis in the Modern Era: A Case of Lupus Vulgaris with Surgical Management and a Review of Clinical Spectrum, Diagnostic Challenges, and Malignant Potential

<b>Background/Objectives</b>: Cutaneous tuberculosis (CTB) represents a rare extrapulmonary manifestation of <i>Mycobacterium tuberculosis</i> infection, accounting for approximately 1-2% of all tuberculosis cases. Despite its low incidence, CTB remains diagnostically challenging due to its clinical polymorphism and resemblance to other granulomatous or neoplastic dermatoses. Among its variants, lupus vulgaris (LV) constitutes the most common and indolent form in regions of moderate tuberculosis endemicity. The present study aims to highlight the diagnostic complexity, management, and long-term outcomes of LV, emphasizing its potential for malignant transformation into squamous cell carcinoma (SCC). <b>Methods</b>: We present a detailed case of lupus vulgaris in a male patient with a prolonged disease course, refractory to initial empiric therapy, successfully managed through anti-tubercular therapy (ATT) followed by surgical excision. A review of the literature was conducted to contextualize this case within the broader clinical spectrum of CTB, with particular attention to epidemiology, histopathology, and complications, including SCC development. <b>Results</b>: The patient demonstrated significant clinical improvement following standard six-month ATT; however, residual fibrotic lesions required excision for definitive management. Literature review revealed that chronic LV lesions persisting for decades may undergo malignant transformation. Analysis of reported cases underscores the importance of vigilance and early surgical intervention in long-standing or atypical LV. <b>Conclusions</b>: Lupus vulgaris remains a clinically deceptive entity requiring multidisciplinary management. Early recognition, appropriate ATT, and surgical excision of residual or recalcitrant lesions are crucial to prevent complications, including carcinogenesis. Greater clinician awareness of CTB's diverse presentations may reduce diagnostic delays and improve outcomes.