Nodular granulomatous perifolliculitis B35.8

Perifollicular granuloma formation in chronic dermatophytosis, which usually develops after trauma (e.g. shaving, e.g. shaving of the lower legs)

Trichophyton rubrum (by far the most common pathogen) and also Trichophyton violaceum are frequently found in the classical form.

In the classic (cutaneous or dermal) form of nodular granulomatous perifolliculitis, fungal elements (in the case of a possibly pre-existing tinea faciei) penetrate the dermis via a ruptured follicle after banal injuries (e.g. when shaving). Displaced keratin serves as substrate for the pathogen. From this, a therapy-resistant (only systemically treatable!), chronic, perifollicular granuloma develops.

In the deep dermal-subcutaneous (nodular) form of nodular granulomatous perifolliculitis (granuloma trichophyticum), which occurs mainly in immunocompromised patients, a banal follicular injury with pre-existing tinea is followed by chronic, deep suppurative folliculitis and perifolliculitis (boils), which is often still bacterially superimposed (Gupta S et al. 2000). Local factors such as long-term use of glucocorticoid externa favour the penetration of the pathogens. Such pre-treatments can lead to a concealment of the classic signs of infection and thus to the picture of incognito tinea.

Especially beard area, extremity extensor sides (shaving of the legs!), inguinal, scrotal and glutaeal area. Accordingly, the clinical picture is also characterized by topographical peculiarities.

Painless or only slightly pressure-painful reddish-brown papules, nodules or extensive inflammatory, scaly plaques with a reddened surface.

Bacterial folliculitis

Erythema nodosum (higher acuteity and painfulness)

Erythema induratum Bazin (nodular vasculitis): Inflammatory, in interval phases only moderately, in recurrent phases clearly painful, red to brown-red, solid, cutaneous or subcutaneous nodules and plaques. Size: 2.5 cm, rarely up to 10 cm. Frequently, but not always, with mostly deep-reaching central necrotic melting and subsequent roundish, poorly healing ulceration. Extremely chronic or chronically recurrent course over several years possible.

Internally (a systemic therapy is always to be aimed at) and externally antimycotic (e.g. Terbinafine p.o. - Rallis E et al. 2016), see below. Mycoses, dermatomycoses.

Since an increasing incidence of nodular granulomatous perifolliculitis in immunocompromised persons is detectable, consistent antifungal prevention and therapy should be carried out.

1. Coelho WS et al (2009) Case for diagnosis. Granuloma trichophyticum (Majocchi's granuloma. On Bras Dermatol 84:85-86
2. Gupta S et al (2000) Majocchi's granuloma trichophyticum in an immunocompromised patient. Int J Dermatol 39:140-141
3. Meinhof W (1977) Granuloma trichophyticum. dermatologist 28:214-215
4. Nishiyama C et al (1985) Studies on the parasitic forms of Trichophyton rubrum isolated from patients with granuloma trichophyticum using the "agar-implantation method". J Dermatol 12:325-328
5. Rallis E et al (2016) Pubic Majocchi's Granuloma Unresponsive to Itraconazole Successfully Treated withOral
   Terbinafine. Skin Appendage Disord 1(3):111-113.