Majocchi’s granuloma was first described by Domenico Majocchi in 1883, as a deep chronic dermatophyte infection of hair follicles, in which dermatophytes penetrate the dermis through hair canals, forming granulomatous changes in the dermis and/or hypodermis. Majocchi’s granuloma has two different clinical variants: the first is a small perifollicular papular type, seen in otherwise healthy individuals, that occurs secondary to trauma (e.g. in women with chronic tinea pedis that extends to the legs and who shave their legs); the second is a type with deep plaques or nodular lesions in immunocompromised hosts. The diagnosis is primarily made using direct microscopy of unstained specimens and fungal cultures, while additional diagnostics (histology, PCR) are generally not necessary. It is most commonly caused by Trichophyton rubrum.
We present a 26-year-old otherwise healthy man exhibiting blue erythematous patches over the skin of his abdomen on clinical examination, which agglomerated to form slightly raised plaques with irregular ovoid contours, spreading from umbilicus to the pubic region; they were covered with multiple red-blue, erythematous partly coalescing scales, eroded, firm papules and nodules. On pressure, some nodules excreted viscid and turbid sero-purulent content. The lesions were slightly itchy. The patient was previously unsuccessfully treated during at least 4 weeks with a topical steroid cream prescribed by his physician. Direct microscopy for fungi of skin scrapings and pus mounted in potassium hydroxide was negative. Cultures of the contents and scrapings were performed on Sabouraud’s glucose agar and Trichophyton rubrum was isolated. The diagnosis of Majocchi’s granuloma was made, and the patient was treated with itraconazole (200 mg daily) for eight weeks, when all lesions resolved and fungal culture was negative.
Misapplication of topical corticosteroids over a long period, as in our case, can produce Majocchi’s granuloma. When assessing skin lesions of unusual appearance, especially if aggravated by corticosteroids, dermatologists and general practitioners should consider tinea incognito, which may appear in its invasive form of Majocchi’s granuloma. The available world literature shows that Majocchi’s granuloma presenting as tinea incognito caused by topical corticosteroids has been reported extremely rarely.
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