Majocchi's granuloma trichophyticum in an immunocompromised patient

A 40-year-old man with alcoholic liver disease was referred to the dermatology clinic for asymptomatic papulonodular lesions over the face of 15 days' duration. Cutaneous examination revealed multiple, dusky red to yellow, follicular as well as perifollicular papulonodular lesions, varying in size from 0.5 to 2 cm (Fig. 1). They were distributed over the forehead, cheeks, eyelids, nose, chin, beard area, retroauricular area, and neck. Careful examination revealed well-defined scaly margins on the back of the pinna (Fig. 2). KOH examination of a scraping from the neck revealed nonpigmented septate hyphae. Histopathologic examination of the excised nodule revealed epitheloid cell granulomas with neutrophilic microabscesses surrounding the hair follicles. Periodic acid-Schiff stain was noncontributory. Culture of an excised nodule on Sabouraud's agar showed growth of Trichophyton rubrum. Considering his liver disease, the patient was initially treated with topical terbinafine. Because of a lack of a satisfactory response this was changed to oral terbinafine 250 mg/day. There was marked regression of the lesions by the sixth day. Unfortunately, the patient succumbed to complications relating to his liver disease.