Majocci's Granuloma (presumptive)

The patient is a 67 yo man with a three month history of a dermatitis on the left wrist.  It began under his watch.  Initially treated with "a steroid cream" prescribed by his PCP.  The rash cleared but recurred shortly after he stopped the cream.  He'd moved his watch to his right arm which has developed no rash after three months.  Patient has two cats at home which occasionally scratch and bite.

O/E:  2.5 c.m. annular, scsaly plaque l. wrist.  Borders are erythematous and indurated.  No other similar lesions.

KOH scraping was negative.

Dx: Presumptive diagnosis is Majocci Granuloma.

Plan:
Fungal culture taken.
Started on betamethasome disproprionate/clotrimazole cream b.i.d. for two weeks only.
Follow-up visit scheduled for two weeks.
Low threshold for biopsy if culture negative and if he is not doing well.
Switch to ketoconazole 2% cream; consider oral terbinafine.

Reference:

Treatment-Resistant Plaque on the Thigh  (Free Full Text)

Collins MA, Lloyd R. Am Fam Physician. 2011 Mar 15;83(6):753-754.