Derm Dx: Erythematous, indurated, follicular dermatitis on the shin

This patient was diagnosed clinically with Majocchi granuloma, a variant of tinea corporis. Diagnosis was confirmed by fungal culture. The condition, first described more than 60 years ago, is a deep fungal infection that affects hair follicles and the surrounding...

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This patient was diagnosed clinically with Majocchi granuloma, a variant of tinea corporis. Diagnosis was confirmed by fungal culture. The condition, first described more than 60 years ago, is a deep fungal infection that affects hair follicles and the surrounding skin.¹ The most common etiologic agent of Majocchi granuloma is Trichophyton rubrum.

Majocchi granuloma may occur in women who have tinea pedis or onychomycosis and who shave their legs. During shaving, the wall of the hair follicle is disrupted, allowing the fungus to proliferate beneath the epidermis. Trauma, immunosuppression, and prolonged use of topical steroids are factors that promote the condition.^2,3 

Majocchi granuloma characteristically presents as perifollicular papulopustules or granulomatous nodules.¹ Diagnosis can be confirmed with a positive potassium hydroxide test showing hyphae or by fungal culture. Superficial skin scraping may yield negative results, and biopsy is often necessary for definitive diagnosis. Biopsy will reveal hyphae or arthroconidia within hair shafts.¹ Hyphae may also be present in the stratum corneum because keratin is a substrate for the fungus.

First-line treatment for Majocchi granuloma is systemic itraconazole or terbinafine.⁴ Topical monotherapy is not usually successful because of the deep nature of the fungal infection. Case reports document clearing of refractory disease in immunocompromised patients with the azole antifungal agent voriconazole.⁵

Megha D. Patel, BS, is a student at the Commonwealth Medical College, Scranton, Pennsylvania.

Stephen Schleicher, MD, is an associate professor of medicine at the Commonwealth Medical College in Scranton, Pennsylvania, and an adjunct assistant professor of dermatology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. He practices dermatology in Hazleton, Pennsylvania.

References

1. Wilson JW, Plunkett OA, Gregersen A. Nodular granulomatous perifolliculitis of the legs caused by Trichophyton rubrum. AMA Arch Derm Syphilol. 1954;69(3):258-277.
2. Li FQ, Lv S, Xia JX. Majocchi’s granuloma after topical corticosteroids therapy. Case Rep Dermatol Med. 2014;2014:507176.
3. Jacobs PH. Majocchi’s granuloma (due to therapy with steroid and occlusion). Cutis. 1986;38(1):23.
4. Gupta AK, Prussick R, Sibbald RG, Knowles SR. Terbinafine in the treatment of Majocchi’s granuloma. Int J Dermatol. 1995;34(7):489.
5. Liu HB, Liu F, Kong QT, et al. Successful treatment of refractory Majocchi’s granuloma with voriconazole and review of published literature. Mycopathologia. 2015;180(3-4):237-243.