Majocchi’s Granuloma (Granuloma trichophyticum)

Are You Confident of the Diagnosis?

Majocchi’s granuloma is a rare clinical variant of tinea corporis. Tinea corporis is a dermatophyte infection of the skin and is generally restricted to the stratum corneum. Majocchi’s granuloma is a follicular and perifollicular dermatophyte infection of the deep dermis, and may be found in immunocompetent and immunocompromised people.

• What you should be alert for in the history

In general, the patient will be an immunocompetent person with a history of chronic use of high-potency topical corticosteroids in a nondiagnosed dermatophyte infection. Another key to the diagnosis is to ask about previous shaving or waxing leading to the dissemination of the lesions. This occurs because the infected hair shafts facilitate the dermatophyte to penetrate the follicular wall.

• Characteristic findings on physical examination

Patients will complain about papules, pustules, or even plaques and nodules at the infection site (Figure 1). The papules will be pink-red, and, along with the pustules, will be located in a perifollicular location. Hair shafts can be easily removed from the pustules and papules. Classically, patients will complain about many treatment attempts with poor results. Itching is very common.

Figure 1.

Plaques, nodules, or abscesses are seen more often on the face, scalp, hands, or forearms of immunocompromised hosts. In these cases, it’s important to ask about associated diseases, such as lymphoma, AIDS, lymphopenia, and others, and dialysis, high doses of oral corticosteroids, and other immunosuppressive medications.

• Expected results of diagnostic studies

The diagnosis of Majocchi’s granuloma can only be made in confidence by the demonstration of the fungus on potassium hydroxide (KOH) examination, histopathological examinations, or by culture. Histopathology demonstrates hyphae or arthrospores within expanded hair follicles, among keratin from the fragmentized hair. In the perifollicular area there will be a dermal infiltrate consisting of lymphoplasmacytic cells, and focal collections of epithelioid giant cells, neutrophils, and mild interstitial edema.

Afterwards, it’s mandatory to try to identify the agent. Direct smear exams (KOH) are often negative, but in many cases the culture in a Sabouraud agar can be enlightening (Figure 2, Figure 3). Evaluating the hair that is removed from the center of a papule or pustule with a KOH examination may be more sensitive.

Figure 2.

Figure 3.

• Diagnosis confirmation.

We should differentiate this infection from bacterial folliculitis and other fungal infections with nodules and plaques such as chromoblastomycosis and sporotrichosis and even leishmaniasis. Other diagnoses that should be excluded are nontuberculous mycobacterial infections.

Who is at Risk for Developing this Disease?

Majocchi’s granuloma is more prevalent in tropical regions. It is related to occlusion, chronic use of high-potency topical corticosteroids, and to superficial trauma, and it is found in people who have chronic dermatophytosis, including onychomycosis or tinea pedis. Usually this variant can be detected in people who shave or wax their legs or other parts of the body.

What is the Cause of the Disease?

Any dermatophyte can cause Majocchi’s granuloma; however, the most common agent is Trichophyton rubrum (Figure 4). Rarely, other agents such as Trichophyton mentagrophytes, Trichophyton epilans, Trichophyton violaceum, Trichophyton tonsurans, Microsporum canis, Microsporum audouinii, Microsporum gypseum and Microsporum ferrugineum can cause the disease.

Figure 4.

Other nondermatophytic fungi may cause infection in immunocompromised hosts. Majocchi’s granuloma results from the rupture of a dermatophyte-infected infundibulum, as a result of trauma.

Recently, a case of Majocchi’s granuloma related to the use of adalimumab (tumor necrosis factor alpha [TNF-alpha] inhibitor) was described.

Systemic Implications and Complications

When plaques, nodules, or abscesses are widespread and seen on the face, scalp, hands, or forearms in patients proven to have Majocchi’s granuloma, the possibility of an immunocompromised state should be considered. In such cases, it is important to ask about associated diseases, such as lymphomas, AIDS, lymphopenia, and others, and dialysis and high doses of oral corticosteroids.

Treatment Options

Treatment options are summarized in Table I.