What it is

➝ Majocchi granuloma is a deep fungal infection of the skin and hair follicles, most often caused by dermatophytes such as Trichophyton rubrum.

➝ Unlike superficial ringworm, the fungus penetrates the dermis and hair follicles, leading to red, inflamed nodules, papules, and pustules, often on the legs, arms, or face.

➝ It commonly occurs in immunosuppressed individuals, people with chronic steroid use, or after trauma/shaving that allows fungus to invade deeper layers.

➝ Because the infection is deep-seated, topical antifungals are insufficient. Systemic antifungal therapy is the mainstay of treatment.

Why it’s done

→ To eradicate the deep fungal infection and prevent spread.

→ To avoid chronic or recurrent disease, as untreated Majocchi granuloma does not resolve spontaneously.

→ To reduce pain, swelling, and discomfort, since lesions may mimic bacterial folliculitis or abscesses.

→ To prevent scarring and pigmentation changes that can result from prolonged inflammation.

→ In Korea, therapy is focused on systemic antifungal treatment combined with supportive skin care, with careful diagnosis to distinguish it from bacterial infections.

Alternatives

→ Topical antifungals: Helpful as adjunct therapy but not effective alone due to the depth of infection.

→ Systemic antifungals (mainstay):

• Terbinafine: First-line, excellent activity against dermatophytes.
• Itraconazole: Commonly used, especially if terbinafine is not tolerated.
• Fluconazole: Alternative option.
• Griseofulvin: Less common now but still effective in some cases.

→ Antibiotics: Only used if secondary bacterial infection is confirmed, not as primary therapy.

→ Steroid withdrawal: If triggered by inappropriate topical corticosteroid use, discontinuing steroids is essential.

Preparation

→ Dermatologist performs skin scraping, fungal culture, or biopsy to confirm diagnosis, since it can resemble bacterial folliculitis.

→ Baseline tests may include liver function and kidney function if systemic antifungals are planned.

→ Patients are advised to:

• Stop using topical corticosteroids on affected areas.
• Maintain proper hygiene and skin care.
• Avoid shaving over active lesions until cleared.

→ In Korea, diagnosis is usually confirmed with direct microscopy (KOH test) and, if needed, histopathology.

How it’s Done

→ Terbinafine: 250 mg daily for 4–6 weeks.

→ Itraconazole: 100–200 mg daily for 4–6 weeks, or pulse dosing (200 mg twice daily for 1 week/month).

→ Fluconazole: 150–300 mg once weekly for several weeks in selected cases.

→ Topical antifungal cream may be added to reduce surface fungal load.

→ Supportive care includes gentle cleansing, avoiding occlusive ointments, and using soothing moisturizers.

→ In Korea, systemic therapy is often combined with adjunctive laser or light-based therapies to speed healing and reduce pigmentation changes.

Recovery

→ Improvement in redness, swelling, and pustules is often seen within 2–3 weeks of therapy.

→ Complete clearance usually requires 4–8 weeks of treatment, depending on severity.

→ Recurrence risk is minimized with full treatment completion and preventive hygiene.

→ Patients typically regain normal skin texture, though post-inflammatory pigmentation may take months to fade.

Complications

→ If untreated: Infection may persist for months, leading to scarring and chronic inflammation.

→ Medication-related risks:

• Terbinafine: Rare liver toxicity, taste changes.
• Itraconazole: Drug interactions, liver function changes.
• Fluconazole: Gastrointestinal upset, rare liver issues.

→ Misdiagnosis: Treated as bacterial folliculitis instead of fungal infection, leading to worsening with antibiotics or steroids.

Treatment Options in Korea

→ Korean dermatologists are highly experienced in diagnosing atypical fungal infections like Majocchi granuloma.

→ Standard therapy includes oral terbinafine or itraconazole, often guided by culture results.

→ Topical antifungals are used alongside systemic drugs to reduce recurrence.

→ Clinics provide regular follow-up with blood tests for patients on systemic antifungals.

→ Some dermatology centers in Korea integrate laser treatments or chemical peels after infection clearance to address pigmentation or scarring.

→ Patient education focuses on avoiding corticosteroid misuse, proper shaving techniques, and antifungal hygiene practices to prevent recurrence.