What Is Majocchi's Granuloma?
Majocchi’s granuloma is a rare deep folliculitis caused by a fungal infection. It is an infection that affects the dermis and subcutaneous tissue. According to condition and clinical manifestation, this condition is divided into two types. It is also known as nodular granulomatous perifolliculitis or granuloma trichophyticum. Dermatophyte fungal infection is the reason behind this condition. It infects different body parts such as hair, skin, and nails.
What Are the Types of Majocchi's Granuloma?
Following are the two types of Majocchi’s granuloma:
Perifolliculitis: This type usually appears as perifollicular papules or bumps. It mainly affects the lower part of the body due to penetrating trauma.
Subcutaneous Nodules: This type of Majocchi’s granuloma usually affects immunocompromised patients. This type mainly affects the upper part of the body. It is clinically represented as a group of nodules.
What Is the Source of Infection and Possible Predisposing Factors of Majocchi’s Granuloma?
People with weakened immune systems due to conditions such as HIV/AIDS, organ transplantation, or immunosuppressive therapy are more susceptible. Majocchi's granuloma can develop at sites of skin trauma, like shaving, scratching, or other disruptions that compromise the skin's integrity. Long-term application of corticosteroid creams or ointments can weaken the skin's natural defenses, making it easier for fungal infections to take hold. Patients with pre-existing skin diseases, such as eczema or psoriasis, might be more prone to developing Majocchi's granuloma. Exposure to the dermatophyte fungus (Trichophyton species) in environments like gyms, swimming pools, or through contact with contaminated objects can contribute to infection.
What Are the Causes of Majocchi's Granuloma?
Majocchi’s granuloma is caused by infected hair follicles, where the fungi enter through the dermis and subcutaneous tissue, causing the infection. The following are the etiological factors associated with Majocchi’s granuloma:
Fungi that cause this infection are:
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Trichophyton rubrum.
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Trichophyton mentagrophytes.
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Trichophyton tonsurans.
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Trichophyton violaceum.
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Epidermophyton floccosum.
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Non-dermatophyte molds.
If a person has a longstanding or recurrent infection in the body. For instance, preexisting dermatophytosis puts a person at a greater risk of developing this condition.
If a person lives in a place with a tropical climate.
If there is a cutaneous trauma on the skin, for example, a cut from shaving.
If a person is on topical steroids or antineoplastic therapy.
If a person had chemotherapy or an organ transplant and is on immunosuppressant drugs, such as alpha inhibitors.
Animals are the carriers of pathogenic fungi. The following are the most common carriers of the diseases:
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Cats.
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Guinea pigs.
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Mice.
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Rats.
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Hamsters.
As the condition is contagious, sexual activity or contact with the other person might spread it. Moreover, touching an infected person’s hair or nail fragments can also cause this infection to spread.
What Are the Signs and Symptoms of Majocchi's Granuloma?
It manifests as red or violaceous papules, nodules, or plaques, usually on the legs, but it can occur elsewhere in the body. Hair follicles are often affected, leading to pustules or nodules centered around hair shafts. Lesions can be solitary or multiple and may spread across the affected area. Patients may experience itching, pain, or tenderness at the site of the lesions. The condition can persist for an extended period if not properly treated, potentially leading to scarring or pigmentary changes in the affected skin. In individuals with compromised immune systems, the lesions might be more extensive and challenging to treat.
Following are the signs and symptoms associated with Majocchi’s granuloma:
Irregular Patches: This condition shows redness and irregular patches on the affected site.
Scaly Plaque: During this type of condition, there is an erythematous plaque with crusts seen at the site.
Pustules: They are small, swollen pus-filled blisters or bumps on the skin. They are usually sized four to six millimeters and red.
Nodules: It is an abnormal growth of the tissue that develops under the skin layers. This abnormality can be developed under the deeper layer of the skin or on the internal organs. They are at least one centimeter in size.
Scaling: At the foot's sole, this symptom is seen.
Shape of the Toenails: Irregular or abnormally yellow toenails.
How to Diagnose Majocchi's Granuloma?
The following are the diagnostic methods used for Majocchi’s granuloma:
Physical Examination: The condition represents the skin's non-tender, unilateral purple nodules or erythematous (red rashes) lesions. Doctors check for these signs on the body and move to the next diagnostic option to confirm the condition.
Hair Samples: During this step, the doctor scrapes the hair from the affected area and checks for any infection trace to confirm the diagnosis.
Mycology: During this step, the fungal cultures are microscopically tested and evaluated to confirm the diagnosis.
Biopsy: During this diagnostic step, from the affected area, the tissue or skin biopsy sample is collected and sent for testing. All the biopsy sections are examined under polarized light and checked for abnormalities.
What Is the Prognosis of Majocchi's Granuloma?
As the condition is contagious, there are high chances of recurrence and spread. In addition, the study shows that the condition remains uncured in areas such as nails, feet, or other sites. Moreover, after giving antifungal therapy, there are high chances of developing post-inflammatory pigments, atrophic scarring, and alopecia.
How to Manage Majocchi's Granuloma?
The following management options are available for Majocchi’s granuloma:
Pharmacological Therapy: In the cases of Majocchi’s granuloma, the infection is penetrated to the deeper layer of the skin. Due to this reason, topical antifungal medications are not effective. However, systemic prescription of antifungal drugs is effective. The drug therapy should be continued until the wound is closed, which takes four to eight weeks. The following are the medications that can be prescribed:
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Terbinafine - 250 milligrams/day for four to six weeks.
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Griseofulvin - 0.5 to 1 gram/day for four to six weeks.
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Itraconazole - 100 to 200 milligrams twice daily for 20 to 30 days.
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Voriconazole - 200 milligrams twice daily for four months.
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Ketoconazole - 200 milligrams/day for 30 to 90 days.
Traditional Therapy: The traditional therapy for this condition includes oral potassium iodide, filtered radiation, and topical administration of dimethylamino-6-Benzothiazole.
Nitrogen Therapy: This next step can be used after antifungal systemic medication therapy. This therapy is used for the drainage of toxins and cell healing.
Surgical Approach: During this mode of treatment, surgical incision, drainage, and excision are used. Each option is recommended depending on the site and the severity of the condition. For instance, in the case of deep fungal infections in immunosuppressed patients, excision is recommended along with other drug therapy.
Multi-Therapy Approach: In the case of severe conditions, this mode of treatment is used. It is a combination of surgical therapy and pharmaceutical therapy. The combination of surgery and Fluconazole, surgery and Griseofulvin, or Amphotericin B and Terbinafine was used.
What Is the Differential Diagnosis of Majocchi's Granuloma?
According to the type of lesion, the following are differential diagnoses associated with Majocchi’s granuloma:
Papule:
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Folliculitis.
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Acne vulgaris.
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Lupus miliaris disseminatus faciei.
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Insect bite.
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Cutaneous leishmaniasis.
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Granulomatous rosacea.
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Disseminated toxoplasmosis.
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Kaposi sarcoma.
Nodule:
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Erythema nodosum.
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Erythema induratum Bazin.
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Furunculosis.
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Sarcoidosis.
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Cutaneous leishmaniasis.
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Kaposi sarcoma.
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Foreign body granuloma.
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Lymphocytoma cutis.
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Thrombophlebitis.
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Squamous cell carcinoma.
Plaque:
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Bacterial cellulitis.
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Eosinophilic cellulitis.
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Chemical cellulitis.
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Sarcoidosis.
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Lupus vulgaris.
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Cutaneous leishmaniasis.
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Stasis dermatitis.
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Psoriasis.
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Contact dermatitis.
Conclusion
Majocchi’s granuloma is a condition that affects a deeper layer of the skin. Due to the complications and severity of the condition, it is highly recommended to check with the doctor at the first sign of the condition. Moreover, along with the therapy, regular follow-up visits are highly recommended.
