eMedicine Specialties > Dermatology > Fungal Infections

Majocchi Granuloma

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Coauthor(s): Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Contributor Information and Disclosures

Updated: Nov 20, 2009

Introduction

Background

Majocchi granuloma can be defined as a deep folliculitis due to a cutaneous dermatophyte infection.1 Majocchi granuloma is most commonly due to Trichophyton rubrum infection. Majocchi granuloma tends to occur in young women who frequently shave their legs, although Majocchi granuloma also is seen in men.2 Majocchi granuloma also commonly occurs as a result of the use of potent topical steroids on unsuspected tinea. Majocchi granuloma is also known as granuloma trichophyticum.

Many species of dermatophytes can cause Majocchi granuloma. Today, Majocchi granuloma is usually due to T rubrum; however, Trichophyton violaceum was the most common organism identified historically. Other causes of Majocchi granuloma include Trichophyton mentagrophytes and Epidermophyton floccosum.

In 1883, Professor Domenico Majocchi (1849-1929) first described this disorder, he called granuloma tricofitico.3 He is also credited with describing a type of chronic pigmented purpura: purpura annularis telangiectodes, which is commonly known as Majocchi disease. Majocchi, an important figure in Italian academic dermatology, was a professor of dermatology first at the University of Parma and later at the University of Bologna.

Also see the eMedicine article Tinea Corporis.

Pathophysiology

The pathophysiology of the fungal infection and defense mechanisms against superficial dermatomycosis has been studied.4 Two series of experimental infections of T mentagrophytes were made on the forearm of a male volunteer with topical steroid ointment and vehicle alone. Steroid ointment suppressed the immune reactions locally to produce little inflammatory reaction with abundant fungal elements (so-called atypical tinea) and a mixed cell granuloma.

While inflammatory tinea capitis or kerion is the result of a hypersensitivity reaction to a dermatophytic infection, Majocchi granuloma usually begins as a suppurative folliculitis and may culminate in a granulomatous reaction.5 Nineteen cases of kerion of the scalp in children were evaluated. Histopathological findings demonstrated a spectrum from suppurative folliculitis to dense granulomatous infiltrates without a clear relationship with the clinical features.

Widespread trichophytic granulomas may occur in patients receiving immunosuppressive therapy for leukemia or lymphoma, autoimmune diseases, and post–organ transplantation. However, these dermatophyte infections may also occur in patients with atopic dermatitis, probably because of their immunological susceptibility.6

Frequency

United States

To the authors' knowledge, no specific data on the incidence and prevalence of Majocchi granuloma exist.

International

To the authors' knowledge, no specific data on the incidence and prevalence of Majocchi granuloma exist. A patient was recently described in Brazil.2

Clinical

History

  • Patients may complain of nonpruritic solitary or multiple persistent papulopustules or plaques.
    • The legs are common sites for Majocchi granuloma in young women who frequently shave.
    • Patients may also complain of onychomycosis or tinea pedis.
  • Two clinical forms of Majocchi granuloma exist.
    • The follicular type is secondary to trauma or topical corticosteroid use. It commonly occurs in young women who repeatedly shave their legs. Long-standing immunosuppression with steroids certainly predisposes individuals to widespread dermatophytosis, a component of which may be follicular papules consistent with Majocchi granuloma.
    • The subcutaneous nodular type occurs in immunocompromised hosts such as persons with graft versus host disease, those who undergo bone marrow and organ transplantation, and those receiving long-term immunosuppressive medication for lymphoma, leukemia, and autoimmune diseases. Whether trichophytic abscesses in neutropenic bone marrow transplant recipients are Majocchi granulomas is debatable because these patients lack specific cellular immunity. These granulomas may be widespread.6
  • Antibiotic use does not result in Majocchi granuloma because Majocchi granuloma is an atypical course of a fungal disease that may result from a modified local and/or systemic immune response or a damaged skin barrier.
  • The use of potent topical steroids, especially under occlusion or on preexistent tinea, may predispose the patient to Majocchi granuloma.

Physical

  • Majocchi granuloma or granuloma trichophyticum may develop on any hair-bearing area, but most often, the scalp, face, forearms, hands, and legs are involved. A superficial perifollicular form of Majocchi granuloma on the scrotum, caused by T rubrum, has been described.7  
  • Majocchi granuloma may begin as solitary or multiple well-circumscribed oval patches or as indistinct scaling ones. Majocchi granuloma evolves into perifollicular papulopustules and nodules with or without background erythema and scaling.
  • A plaque may demonstrate keloidal features, but these findings are unusual.
  • Nodules are often clustered, but they can be solitary as well.
  • Pressure does not result in pus exudation.
  • Unlike a kerion, granuloma trichophyticum does not become clinically suppurative until late in its course, unless secondarily impetigo develops.
  • If the cutaneous features of Majocchi granuloma are associated with the use of topical steroids, they may be affected by the complications of topical steroid therapy, including poikiloderma with atrophy and telangiectasia, papular rosacea, or a hypopigmented patch suggestive of indeterminate leprosy.
  • Majocchi granuloma may rarely resemble Kaposi sarcoma, as it does in patients with AIDS or lymphocytoma cutis. In such cases, Majocchi granulomas are painful and appear as blue-red papules and nodules on an erythematous base.8

Causes

  • Majocchi granuloma is a foreign body granuloma most commonly caused by T rubrum. T violaceum was the most common organism identified historically.
  • Other causes of Majocchi granuloma include T mentagrophytes and E floccosum.9
  • The fungal infections may be due to or linked with a widespread contiguous dermatophytosis, immunosuppression, and/or the use of topical steroids.

More on Majocchi Granuloma

Overview: Majocchi Granuloma
Differential Diagnoses & Workup: Majocchi Granuloma
Treatment & Medication: Majocchi Granuloma
Follow-up: Majocchi Granuloma
References

References

  1. Wilson JW, Plunkett OA, Gregersen A. Nodular granulomatous perifolliculitis of the legs caused by Trichophyton rubrum. AMA Arch Derm Syphilol. Mar 1954;63(3):258-77. [Medline].

  2. Coelho WS, Diniz LM, Sousa Filho JB, Castro CM. [Case for diagnosis. Granuloma trichophyticum (Majocchi's granuloma)]. An Bras Dermatol. Jan-Feb 2009;84(1):85-6. [Medline].

  3. Majocchi D. Sopra una nuova trichofizia (granuloma tricofitico): Studi clinici e micologici. [A new trichophyton granuloma: Clinical and mycological studies]. Bull R Acad Med Roma. 1883.

  4. Nakajima H. [The pathophysiology and defense mechanism against superficial and subcutaneous fungal infection]. Nippon Ishinkin Gakkai Zasshi. 2005;46(1):5-9. [Medline].

  5. Arenas R, Toussaint S, Isa-Isa R. Kerion and dermatophytic granuloma. Mycological and histopathological findings in 19 children with inflammatory tinea capitis of the scalp. Int J Dermatol. Mar 2006;45(3):215-9. [Medline].

  6. Tateishi Y, Sato H, Akiyama M, et al. Severe generalized deep dermatophytosis due to Trichophyton rubrum (trichophytic granuloma) in a patient with atopic dermatitis. Arch Dermatol. May 2004;140(5):624-5. [Medline].

  7. Cho HR, Lee MH, Haw CR. Majocchi's granuloma of the scrotum. Mycoses. Nov 2007;50(6):520-2. [Medline].

  8. Brod C, Benedix F, Rocken M, Schaller M. Trichophytic Majocchi granuloma mimicking Kaposi sarcoma. J Dtsch Dermatol Ges. Jul 2007;5(7):591-3. [Medline].

  9. Sanchez-Castellanos ME, Mayorga-Rodriguez JA, Sandoval-Tress C, Hernandez-Torres M. Tinea incognito due to Trichophyton mentagrophytes. Mycoses. Jan 2007;50(1):85-7. [Medline].

  10. Akiba H, Motoki Y, Satoh M, Iwatsuki K, Kaneko F. Recalcitrant trichophytic granuloma associated with NK-cell deficiency in a SLE patient treated with corticosteroid. Eur J Dermatol. Jan-Feb 2001;11(1):58-62. [Medline].

  11. Alteras I, Feuerman EJ, David M, Shvili D. Unusual aspects of granulomatous dermatophytosis. Mycopathologia. May 30 1984;86(2):93-7. [Medline].

  12. Carter RL. Majocchi's granuloma. J Am Acad Dermatol. Jan 1980;2(1):75. [Medline].

  13. Chen HH, Chiu HC. Facial Majocchi's granuloma caused by Trichophyton tonsurans in an immunocompetent patient. Acta Derm Venereol. 2003;83(1):65-6. [Medline].

  14. Elgart ML. Tinea incognito: an update on Majocchi granuloma. Dermatol Clin. Jan 1996;14(1):51-55. [Medline].

  15. Gill M, Sachdeva B, Gill PS, Arora B, Deep A, Karan J. Majocchi's granuloma of the face in an immunocompetent patient. J Dermatol. Oct 2007;34(10):702-4. [Medline].

  16. Gupta AK, Prussick R, Sibbald RG, Knowles SR. Terbinafine in the treatment of Majocchi's granuloma. Int J Dermatol. Jul 1995;34(7):489. [Medline].

  17. Gupta S, Kumar B, Radotra BD, Rai R. Majocchi's granuloma trichophyticum in an immunocompromised patient. Int J Dermatol. Feb 2000;39(2):140-1. [Medline].

  18. Hirschmann JV, Raugi GJ. Pustular tinea pedis. J Am Acad Dermatol. Jan 2000;42(1 Pt 1):132-3. [Medline].

  19. Ive FA, Marks R. Tinea incognito. Br Med J. Jul 20 1968;3(5611):149-52. [Medline].

  20. Jacobs PH. Majocchi's granuloma (due to therapy with steroid and occlusion). Cutis. Jul 1986;38(1):23. [Medline].

  21. Janniger CK. Majocchi's granuloma. Cutis. Oct 1992;50(4):267-8. [Medline].

  22. Lepage JC. Source of Majocchi's granuloma. J Am Acad Dermatol. Feb 1983;8(2):260. [Medline].

  23. Liao YH, Chu SH, Hsiao GH, Chou NK, Wang SS, Chiu HC. Majocchi's granuloma caused by Trichophyton tonsurans in a cardiac transplant recipient. Br J Dermatol. Jun 1999;140(6):1194-6. [Medline].

  24. Meinhof W, Hornstein OP, Scheiffarth F. [Multiple subcutaneous Trichophyton rubrum abscesses. Pathomorphosis of a generalized superficial tinea due to impaired immunological resistance]. Hautarzt. Jul 1976;27(7):318-27. [Medline].

  25. Nolting C, Vennewald I, Seebacher C. [Tinea follicularis presenting as trichophytic Majocchi granuloma]. Mycoses. 1997;40 Suppl 1:73-5. [Medline].

  26. Radentz WH, Yanase DJ. Papular lesions in an immunocompromised patient. Trichophyton rubrum granulomas (Majocchi's granuloma). Arch Dermatol. Sep 1993;129(9):1189-90, 1192-3. [Medline].

  27. Reynolds RD, Boiko S, Lucky AW. Exacerbation of tinea corporis during treatment with 1% clotrimazole/0.05% betamethasone diproprionate (Lotrisone). Am J Dis Child. Nov 1991;145(11):1224-5. [Medline].

  28. Sequeira M, Burdick AE, Elgart GW, Berman B. New-onset Majocchi's granuloma in two kidney transplant recipients under tacrolimus treatment. J Am Acad Dermatol. Mar 1998;38(3):486-8. [Medline].

  29. Smith KJ, Neafie RC, Skelton HG 3rd, Barrett TL, Graham JH, Lupton GP. Majocchi's granuloma. J Cutan Pathol. Feb 1991;18(1):28-35. [Medline].

Further Reading

Keywords

Majocchi granuloma, MG, granuloma trichophyticum, granuloma tricofitico, dermatophytes

Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Medical Editor

David P Fivenson, MD, Associate Director, St Joseph Mercy Hospital Dermatology Program, Ann Arbor, Michigan
David P Fivenson, MD is a member of the following medical societies: American Academy of Dermatology, Medical Dermatology Society, Michigan Dermatological Society, Michigan State Medical Society, Photomedicine Society, Society for Investigative Dermatology, and Wound Healing Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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