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.

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• Folliculitis (Dermatology)
• Tinea Corporis (Dermatology)