Fungal folliculitis

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Majocchi's granuloma
Majocchi granuloma new image in 2019.jpg
Specialty Dermatology

Majocchi's granuloma is a skin condition characterized by deep, pustular plaques, and is a form of tinea corporis. It is a localized form of fungal folliculitis. Lesions often have a pink and scaly central component with pustules or folliculocentric papules at the periphery. [1] The name comes from Domenico Majocchi, who discovered the disorder in 1883. [2] Majocchi was a professor of dermatology at the University of Parma and later the University of Bologna. [2] This disease is most commonly caused by filamentous fungi in the genus Trichophyton .

Contents

Symptoms and signs

Majocchi's granuloma often presents as pink scaly patches with pustules at the periphery. It is most common on skin exposed to mechanical abuse—wear and tear—such as the upper and lower extremities. Patients experience papules, pustules, or even plaques and nodules at the infection site. [3] The white to red papules and pustules often have a perifollicular location. Hair shafts can be easily removed from the pustules and papules. [3] Itching is common.

Firm or fluctuant subcutaneous nodules or abscesses represent a second form of MG that is generally observed in immunosuppressed hosts. Nodules may develop in any hair-bearing part of the body, but are most often observed on the forearms, hands, and legs of infected individuals. Involvement of the scalp and face is rarely observed. Lesions start as solitary or multiple well-circumscribed perifollicular papulopustules and nodules with or without background erythema and scaling. In rare circumstances, the lesions may have keloidal features. [4]

Causes

Majocchi's granuloma is caused by a common group of fungi called dermatophytes. Unlike traditional tinea corporis (commonly known as ringworm) that resides in the top layer of the skin, Majocchi's granuloma contains dermatophytes that invade the hair follicle and/or dermis. The invasion of the hair follicule leads to the clinically evident papules and pustules at the periphery. The most common form, the superficial perifollicular form, occurs predominately on the legs of otherwise healthy young women who repeatedly shave their legs and develop hair follicle occlusions that directly or indirectly disrupt the follicle and allow for passive introduction of the organism into the dermis. [5] Hence, the physical barrier of the skin is important because it prevents the penetration of microorganisms. Physical factors that play a major role in inhibiting dermal invasion include the interaction among keratin production, the rate of epidermal turnover, the degree of hydration and lipid composition of the stratum corneum, CO2 levels, and the presence or absence of hair. [4] Keratin and/or necrotic material can be introduced into the dermis with an infectious organism to exacerbate the problem. Majocchi granuloma also can occur as a result of the use of potent topical steroids on unsuspected tinea. [2]

Mechanisms

Historically, many types of dermatophytes were known to cause the condition. Trichophyton violaceum used to be one of the most common species of dermatophytes to cause this disease. Today, however, Trichophyton rubrum is the main culprit in most cases. These fungi are keratinophilic and colonize or infect the superficial keratinized tissues (the skin, nails, and hair) of humans and animals. The organisms are usually restricted to the non-living cornified layer of the epidermis and do not invade beyond the epidermis. The fungi are usually unable to penetrate into viable tissues in an immunocompetent host and therefore the infection incidence is higher in immune compromised individuals. The two forms of MG are: [6]

Diagnosis

Primary diagnosis starts with a thorough physical exam and evaluation of medical history. Often, the condition is readily apparent to a medical practitioner and no further testing is required. If not readily apparent, a skin biopsy test or fungal culture may be ordered. This pathological examination of the skin biopsy helps to arrive at the correct diagnosis via a fungal culture (mycology). In severe or recurrent cases, further workup may be required.[ citation needed ]

This disease commonly affects both immunocompetent and immunocompromised hosts. However, immunocompromised individuals have a higher risk.[ citation needed ]

Treatment

Oral antifungal medications are the standard of care. Due to the location of the dermatophytes within the hair follicle, treatment with topical antifungals is often unsatisfactory. In patients with tinea pedis or onychomycosis, re-inoculation and recurrence is common. In individuals with recurrent outbreaks, inoculation sources should be identified and treated appropriately. Historical therapies include oral potassium iodide, mildly filtered local X-radiation, and topical applications of Asterol as a fungicide in both tincture and ointment forms. [4] In modern medicine, systemic antifungals, such as griseofulvin and itraconazole, are the standard. Therapy extends over at least 4–8 weeks, and treatment continues until all lesions are cleared. [4] Currently, no data about relapse rates or the complications of not treating Majocchi granuloma exist. [5]

Research

The review article, "Majocchi’s granuloma: a symptom complex caused by fungal pathogens" [8] concludes that the Tzanck smear method is a rapid and easy diagnostic test. In addition, histopathologic examinations reveal granulomatous folliculitis in patients with MG. It found that systemic antifungals given at an adequate dose and for an appropriate duration are the drugs of choice; in general, topical antifungals alone do not clear the fungal infections. [4]

In "Majocchi's granumloma - Case report", [7] the authors discuss the case of a three-year-old child who presented with lesions around her jaw. It was reported that she had been using a combination of topical corticoids, anti-fungals and antibiotics during this period. The use of these products was ineffective. Drugs were suspended after 15 days of use and followed by cutaneous biopsy and histopathological examination. Mycological examination showed the presence of hyphae and spores compatible with MG. The patient was treated with griseofulvin for 8 weeks and went into remission.[ citation needed ]

The article "Tinea Corporis Gladiatorum Presenting as a Majocchi Granuloma" [9] discussed the importance of differential diagnosis. It includes a case report involving a 20-year-old male H who had been a part of schools wrestling team for the past six years. H presented with a 4-year history of follicular papules and pustules on his right forearm. This lesion had the typical clinical appearance. A skin biopsy showed an acute deep folliculitis compatible with a Majocchi granuloma, but fungal stainings with a Grocott stain was negative. This was the first reported case that showed that tinea corporis gladiatorum can present as a Majocchi granuloma. Thus, dermatologists must consider a Majocchi granuloma in the differential diagnosis of persistent skin lesions in wrestlers.

See also

Related Research Articles

<span class="mw-page-title-main">Tinea cruris</span> Fungal infection

Tinea cruris (TC), also known as jock itch, is a common type of contagious, superficial fungal infection of the groin and buttocks region, which occurs predominantly but not exclusively in men and in hot-humid climates.

<span class="mw-page-title-main">Folliculitis</span> Human and animal disease of follicles

Folliculitis is the infection and inflammation of one or more hair follicles. The condition may occur anywhere on hair-covered skin. The rash may appear as pimples that come to white tips on the face, chest, back, arms, legs, buttocks, or head.

<span class="mw-page-title-main">Athlete's foot</span> Skin infection caused by fungus

Athlete's foot, known medically as tinea pedis, is a common skin infection of the feet caused by a fungus. Signs and symptoms often include itching, scaling, cracking and redness. In rare cases the skin may blister. Athlete's foot fungus may infect any part of the foot, but most often grows between the toes. The next most common area is the bottom of the foot. The same fungus may also affect the nails or the hands. It is a member of the group of diseases known as tinea.

Dermatophyte is a common label for a group of fungus of Arthrodermataceae that commonly causes skin disease in animals and humans. Traditionally, these anamorphic mold genera are: Microsporum, Epidermophyton and Trichophyton. There are about 40 species in these three genera. Species capable of reproducing sexually belong in the teleomorphic genus Arthroderma, of the Ascomycota. As of 2019 a total of nine genera are identified and new phylogenetic taxonomy has been proposed.

<span class="mw-page-title-main">Tinea corporis</span> Medical condition

Tinea corporis is a fungal infection of the body, similar to other forms of tinea. Specifically, it is a type of dermatophytosis that appears on the arms and legs, especially on glabrous skin; however, it may occur on any superficial part of the body.

<span class="mw-page-title-main">Tinea capitis</span> Cutaneous fungal infection of the scalp

Tinea capitis is a cutaneous fungal infection (dermatophytosis) of the scalp. The disease is primarily caused by dermatophytes in the genera Trichophyton and Microsporum that invade the hair shaft. The clinical presentation is typically single or multiple patches of hair loss, sometimes with a 'black dot' pattern, that may be accompanied by inflammation, scaling, pustules, and itching. Uncommon in adults, tinea capitis is predominantly seen in pre-pubertal children, more often boys than girls.

<span class="mw-page-title-main">Dermatophytosis</span> Fungal infection of the skin

Dermatophytosis, also known as tinea and ringworm, is a fungal infection of the skin, that may affect skin, hair, and nails. Typically it results in a red, itchy, scaly, circular rash. Hair loss may occur in the area affected. Symptoms begin four to fourteen days after exposure. The types of dermatophytosis are typically named for area of the body that they affect. Multiple areas can be affected at a given time.

<span class="mw-page-title-main">Onychomycosis</span> Medical condition

Onychomycosis, also known as tinea unguium, is a fungal infection of the nail. Symptoms may include white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed. Fingernails may be affected, but it is more common for toenails. Complications may include cellulitis of the lower leg. A number of different types of fungus can cause onychomycosis, including dermatophytes and Fusarium. Risk factors include athlete's foot, other nail diseases, exposure to someone with the condition, peripheral vascular disease, and poor immune function. The diagnosis is generally suspected based on the appearance and confirmed by laboratory testing.

<span class="mw-page-title-main">Kerion</span> Medical condition

Kerion or kerion celsi is an acute inflammatory process which is the result of the host's response to a fungal ringworm infection of the hair follicles of the scalp that can be accompanied by secondary bacterial infection(s). It usually appears as raised, spongy lesions, and typically occurs in children. This honeycomb is a painful inflammatory reaction with deep suppurative lesions on the scalp. Follicles may be seen discharging pus. There may be sinus formation and rarely mycetoma-like grains are produced. It is usually caused by dermatophytes such as Trichophyton verrucosum, T. mentagrophytes, and Microsporum canis. Treatment with oral griseofulvin common.

<i>Trichophyton rubrum</i> Species of fungus

Trichophyton rubrum is a dermatophytic fungus in the phylum Ascomycota. It is an exclusively clonal, anthropophilic saprotroph that colonizes the upper layers of dead skin, and is the most common cause of athlete's foot, fungal infection of nail, jock itch, and ringworm worldwide. Trichophyton rubrum was first described by Malmsten in 1845 and is currently considered to be a complex of species that comprises multiple, geographically patterned morphotypes, several of which have been formally described as distinct taxa, including T. raubitschekii, T. gourvilii, T. megninii and T. soudanense.

<i>Trichophyton</i> Genus of Fungi

Trichophyton is a genus of fungi, which includes the parasitic varieties that cause tinea, including athlete's foot, ringworm, jock itch, and similar infections of the nail, beard, skin and scalp. Trichophyton fungi are molds characterized by the development of both smooth-walled macro- and microconidia. Macroconidia are mostly borne laterally directly on the hyphae or on short pedicels, and are thin- or thick-walled, clavate to fusiform, and range from 4 to 8 by 8 to 50 μm in size. Macroconidia are few or absent in many species. Microconidia are spherical, pyriform to clavate or of irregular shape, and range from 2 to 3 by 2 to 4 μm in size.

<i>Piedraia hortae</i> Species of fungus

Piedraia hortae is a superficial fungus that exists in the soils of tropical and subtropical environments and affects both sexes of all ages. The fungus grows very slowly, forming dark hyphae, which contain chlamydoconidia cells and black colonies when grown on agar. Piedraia hortae is a dermatophyte and causes a superficial fungal infection known as black piedra, which causes the formation of black nodules on the hair shaft and leads to progressive weakening of the hair. The infection usually infects hairs on the scalp and beard, but other varieties tend to grow on pubic hairs. The infection is usually treated with cutting or shaving of the hair and followed by the application of anti-fungal and topical agents. The fungus is used for cosmetic purposes to darken hair in some societies as a symbol of attractiveness.

<i>Trichophyton tonsurans</i> Species of fungus

Trichophyton tonsurans is a fungus in the family Arthrodermataceae that causes ringworm infection of the scalp. It was first recognized by David Gruby in 1844. Isolates are characterized as the "–" or negative mating type of the Arthroderma vanbreuseghemii complex. This species is thought to be conspecific with T. equinum, although the latter represents the "+" mating strain of the same biological species Despite their biological conspecificity, clones of the two mating types appear to have undergone evolutionary divergence with isolates of the T. tonsurans-type consistently associated with Tinea capitis whereas the T. equinum-type, as its name implies, is associated with horses as a regular host. Phylogenetic relationships were established in isolates from Northern Brazil, through fingerprinting polymorphic RAPD and M13 markers. There seems to be lower genomic variability in the T. tonsurans species due to allopatric divergence. Any phenotypic density is likely due to environmental factors, not genetic characteristics of the fungus.

<span class="mw-page-title-main">Domenico Majocchi</span>

Domenico Majocchi (1849–1929) was an Italian dermatologist, an histologist and anatomo-pathologist of great value and an extremely expert clinician, who discovered some pathologies such as the purpura annularis telangiectodes and the Fungal folliculitis.

<i>Aphanoascus fulvescens</i> Species of fungus

Aphanoascus fulvescens is a mould fungus that behaves as a keratinophilic saprotroph and belongs to the Ascomycota. It is readily isolated from soil and dung containing keratin-rich tissues that have been separated from their animal hosts. This organism, distributed worldwide, is most commonly found in areas of temperate climate, in keeping with its optimal growth temperature of 28 °C (82 °F). While A. fulvescens is recognized as a geophilic fungal species, it is also a facultative opportunistic pathogen. Although it is not a dermatophyte, A. fulvescens has occasionally been shown to cause onychomycosis infections in humans. Its recognition in the laboratory is clinically important for correct diagnosis and treatment of human dermal infections.

<i>Microsporum gallinae</i> Species of fungus

Microsporum gallinae is a fungus of the genus Microsporum that causes dermatophytosis, commonly known as ringworm. Chickens represent the host population of Microsporum gallinae but its opportunistic nature allows it to enter other populations of fowl, mice, squirrels, cats, dogs and monkeys. Human cases of M. gallinae are rare, and usually mild, non-life-threatening superficial infections.

<span class="mw-page-title-main">Favus</span> Medical condition

Favus or tinea favosa is the severe form of tinea capitis, a skin infectious disease caused by the dermatophyte fungus Trichophyton schoenleinii. Typically the species affects the scalp, but occasionally occurs as onychomycosis, tinea barbae, or tinea corporis.

<i>Trichophyton verrucosum</i> Species of fungus

Trichophyton verrucosum, commonly known as the cattle ringworm fungus, is a dermatophyte largely responsible for fungal skin disease in cattle, but is also a common cause of ringworm in donkeys, dogs, goat, sheep, and horses. It has a worldwide distribution, however human infection is more common in rural areas where contact with animals is more frequent, and can cause severe inflammation of the afflicted region. Trichophyton verrucosum was first described by Emile Bodin in 1902.

<i>Epidermophyton floccosum</i> Species of fungus

Epidermophyton floccosum is a filamentous fungus that causes skin and nail infections in humans. This anthropophilic dermatophyte can lead to diseases such as tinea pedis, tinea cruris, tinea corporis and onychomycosis. Diagnostic approaches of the fungal infection include physical examination, culture testing, and molecular detection. Topical antifungal treatment, such as the use of terbinafine, itraconazole, voriconazole, and ketoconazole, is often effective.

References

  1. ↑ Bolognia, Jean.; Jorizzo, Joseph L.Schaffer.; Julie V. (Eds.); et al. (2012). Dermatology. Elsevier Saunders. ISBN   978-0723435716.
  2. 1 2 3 "Majocchi Granuloma: Background, Pathophysiology, Epidemiology". 2017-07-14.
  3. 1 2 "Majocchi's Granuloma (Granuloma trichophyticum)". www.mdedge.com. Archived from the original on 2017-12-13. Retrieved 2017-12-11.
  4. 1 2 3 4 5 İLkit, Macit; Durdu, Murat; Karakaş, Mehmet (2012-07-01). "Majocchi's granuloma: a symptom complex caused by fungal pathogens". Medical Mycology. 50 (5): 449–457. doi: 10.3109/13693786.2012.669503 . ISSN   1369-3786. PMID   22435879.
  5. 1 2 "Majocchi Granuloma: Background, Pathophysiology, Epidemiology". 2017-11-17.
  6. ↑ Fu-qiu, Li (2014). "Majocchi's Granuloma after Topical Corticosteroids Therapy". Case Reports in Dermatological Medicine. 2014: 1–3. doi: 10.1155/2014/507176 . PMC   4227411 . PMID   25405039.
  7. 1 2 Soligo Kanaan, Izabel Cristina (2015). "Majocchi's granuloma- Case report". Anais Brasileiros de Dermatologia. 90 (2): 251–253. doi:10.1590/abd1806-4841.20153115. PMC   4371678 . PMID   25830999.
  8. ↑ Ilkit, M (2012). "Majocchi's granuloma: a symptom complex caused by fungal pathogens". Medical Mycology. 50 (5): 449–457. doi: 10.3109/13693786.2012.669503 . PMID   22435879.
  9. ↑ Kurian, Anil (2011). "Tinea Corporis Gladiatorum Presenting as a Majocchi Granuloma". ISRN Dermatology. 2011: 767589. doi: 10.5402/2011/767589 . PMC   3262549 . PMID   22363858.
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