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| Fig. 32.3 Chromomycosis. Cauliflower-like nodules and tumors on the foot and ankle with edema. (Courtesy of James E. Fitzpatrick, MD.) |
Chromomycosis is a chronic cutaneous and subcutaneous infection that is usually present for years with minimal discomfort. The inciting injury is often not remembered. The infection is most common on the lower extremity and 95% of cases occur in males. The typical patient is a barefoot, rural agricultural worker in the tropics. At the site of inoculation, red papules develop that eventually coalesce into a plaque. The plaque slowly enlarges and acquires a verrucous or warty surface. Satellite lesions can develop from extension of the infection through scratching. There may also be secondary bacterial infections of the lesion. If the lesion is not treated, it can evolve into a cauliflower-like mass, leading to lymphatic obstruction and elephantiasis-like edema of the lower extremity (Fig. 32-3). Neoplastic transformation to squamous cell carcinoma can occur. Diagnosis is made through potassium hydroxide (KOH) mounts from scrapings, biopsies of the lesions showing the organism and suppurative and granulomatous inflammation, and culture. Rare reports of hematogenous dissemination to the brain have been made. Chromomycosis is typically resistant to treatment. The treatment of choice for small lesions is surgical excision with a wide margin of normal skin. Chronic or extensive lesions should be treated with a combination of itraconazole therapy and surgical excision. Combination therapy with terbinafine, posaconazole, cryotherapy and local heat therapy also appear to be effective. Treatment is continued for months.
