Pustular Folliculitis

The patient is a 32 yo man with a 5 year history of an inflammatory process of the mid-upper chest.  He is in good general health and takes no medications by mouth.

The eruption is comprised of discrete papules and pustules.  No areas other than those seen in the photos are involved. Hair growth in the area is unaffected.

Lab:  Culture grew out only Coagulase Negative Staph 1+

Pathology:  The specimens exhibit a dense perifollicular neutrophilic infiltrate forming abscesses and infiltrating follicular epithelium, with admixed lymphocytes, plasma cells, and histiocytes. The histologic differential diagnosis includes both inflammatory and infectious causes of folliculitis. GMS and PAS stains are negative for fungal organisms. Tissue gram stain is negative for bacteria.

Discussion:  This is a healthy young man with a five year history of a localized folliculitis on his chest. If this was fungal, one would expect some hair loss or progression over five years. I found a similar case on PubMed that fit the history, clinical and pathological findings (see below); but still have some questions.  Any suggestions will be appreciated.

Diagnosis: Folliculitis, etiology unclear.  Consider Majocci.

Reference:
Tinea corporis gladiatorum presenting as a majocchi granuloma.

Kurian A1, Haber RM.  ISRN Dermatol. 2011;2011:767589.  Free FullText.

Abstract: Background. Wrestlers are at increased risk of developing cutaneous infections, including fungal infections caused by dermatophytes. Erythematous lesions due to tinea infections can be mistakenly diagnosed as an inflammatory dermatitis and incorrectly treated with potent topical corticosteroid treatments which cause localized skin immunosuppression. This can eventuate in a Majocchi granuloma which then becomes refractory to topical antifungal therapy. To our knowledge, this is the first case of tinea corporis gladiatorum presenting as a Majocchi granuloma. Observations. A 20-year-old wrestler presented with a 4-year history of a large pruritic, scaly erythematous plaque with follicular papules, and pustules on his right forearm. The lesion had the clinical appearance of a Majocchi granuloma. He had been treated with potent topical corticosteroids and topical antifungal therapy. KOH and fungal culture of the lesion were negative. An erythematous scaly lesion in the scalp was cultured and grew Trichophyton tonsurans. Oral Terbinafine therapy was initiated and complete resolution of both lesions occurred within 6 weeks. Conclusion. The purpose of this report is to inform dermatologists that tinea corporis gladiatorum can present as a Majocchi granuloma and needs to be considered in the differential diagnosis of persistent skin lesions in wrestlers.