++
++
A chronic, principally tropical skin and subcutaneous infection
Usually affects older men who are agricultural workers
Caused by several species of closely related black molds
Organisms from the genera Fonsecaea, Cladiophialophora, Exophiala, Phialophora, Rhinocladiella, and Veronaea are most common etiologic agents
++
Lesions usually follow implantation wounds
Over months to years, papules enlarge to become vegetating, papillomatous, verrucous, elevated nodules along with scarring
Lesions may vary in appearance and have been classified into five categories
Secondary bacterial infection may occur
Elephantiasis as well as squamous cell cancers may result
++
Potassium hydroxide preparations of pus or skin scrapings are helpful, showing brown, thick-walled, spherical, sometimes septate cells
Punch or excisional biopsy specimens are also sensitive for diagnosis
++
Itraconazole, 200–400 mg orally once daily for 6–18 months, achieves response rate of 65%
Terbinafine (500–1000 mg/d orally) may be equivalent to itraconazole; the two may be useful in combination
5-fluorocytosine (50–150 mg/kg/d orally) along with one of the above drugs also has been shown to be active, but patients require careful monitoring for adverse events
Adding immunomodulating drugs, eg, topical imiquimod or oral acitretin (0.25 mg/kg/d), to conventional antifungal therapy may be beneficial
Surgery or photodynamic therapy combined with antifungal drugs has also been used successfully