Skin fungus on my leg?

[thea]

Six months ago my lower right leg (in the area in front of the shin bone)itched.  After scratching it slightly I noticed 3 tiny red spots which I assumed were caused by some kind of insect bite.  A few days later the area itched again and I automatically scratched it, having forgotten about the so-called bites. Within days more red spots appeared and the whole area became red and inflamed, despite my not having ever scratched it again. It soon became circular in shape and about 1/2" in dia.  I saw my doctor and since no infection was evident a 3 week treatment of Diprolene AF 0.05% was prescibed to breakup the inflamation.  The inflamation cleared up but and the skin was left shiny and tan in color.  However, within a week the condition returned and a 2nd three-week treatment failed. A skin fungus was now suspected and a biopsy performed.  The pathology report noted:  Multiple tissue levels are examined.  There is superficial epidermal erosion with assoc. acute inflammatory inflitrated.  The epidermis adjacent to this region shows mild to moderate acanthosis, slight spongiosis and inflamed serum crust.  There is also prominent red blood cells extravasation in the superficial dermis along with a mixed inflammatory inflitrates.  The histologic features are not entirely specific although may be seen in the setting of a non-healing ulcer. An underlaying eczematous dermatitis could be considered.  A PAS-D stain is negative for fungi. Despite the report's findings the dermatologist I saw a month ago felt the problem was caused by fungi and exacerbated by the steroid cream I had used, which allowed the fungus to penetrate deeper by tracking down the follicle shaft.  He recommended that Lamisil cream be applied twice daily and the area covered with a large band-aid at all times for 3 weeks. The idea was to force as much of the cream down the follicle shaft as possible.  I am now at the end of this treatment and it too has not worked.  The area involved has slowing expanded to approx 3" in dia. About a 3rd of the surface (especially toward the center) is glazed over with a shiny transparent gray colored skin while the remaining areas have small red crater-like eruptions from which a white substance oozes. This area is raw and tender and ofter bleeds slightly when I clean it.  The dermatologist is now recommending that I take an oral form of the Lamisil for another 3 weeks and if that doesn't work to do a 2nd biopsy.  I have never been prone to skin eruptions of any kind and I usually heal quickly.  After 6 months I'm getting worried that this is not healing and getting worse!  Is what I have described typical of a skin fungus and the course of treatment correct or should other causes be suspected?

[tcc]

I had a very similar problem, always thought it to be an insect bite, but doctors don't think so... "Just eczema"...  one perscribed a steroid cream and seemed to have no effect, until it started getting really red, then dark in the center... real infected.  Now another doctor says steroid creams make these areas prone to infection...  turned out to be MRSA and I was hospitalized for 3 days.  After getting it cut open to drain and a month of "healing", the same thing happened on my opposite leg.  This was also near an "old" itchy area (like 15 years old), with a lump from healed over scratching, that I was also applying steroid cream to.  I knew what it was and started anti-biotics right away, and has almost healed now.

I find when I take a shower or work outside and get hot (for a very short period of time), these areas get real red and some other areas on my leg (and groin area) get red/splotchy looking, and a spot on my upper forhead gets real red.  After cooldown, most of the redness goes away.  I'm just real paranoid that something else is going to get infected.  Doc says just keep putting lotion on it... and don't get hot.  I live in Texas... good luck!  I am "healthy" other that this problem and have had all the blood tests run....  any clue what is really causing this, or diet or treatment that migh make it go away eventually?

[Alan Rockoff, MD]

It could indeed be fungus, despite all the evidence not confirming it so far.  (Sometimes this is referred to as Majocchi's granuloma.) Your dermatologist's explanation and plan are sensible.  Fungus of the follicle shafts is tougher to treat, harder to culture, and may indeed require an oral form of therapy.  Oral antifungal treatment (usually Lamisil) is easy and safe.  

This is an annoying rather than serious condition.  It should be curable completely, even after 6 months, and the skin color changes from the rash are likely to go away completely, even after all this time.  

Best.

Dr. Rockoff

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