Pustular Painful Rash On Face

Pustules and Infection Of The Skin Under The Beard

 

74 yo male comes in with his wife. He has every diagnosis imaginable. CHF, COPD (on home O2), HTN, DM2, Renal Disease, Hx of Prostate CA. He started out 1.5 months ago with 2-3 pustules on the face that he got seen in the urgent care for and they were thought to be MRSA infection for which he got clindamycin. He had no improvement at all, the pustules got larger and more painful. He stopped shaving due to the pain. He came back to his primary care doctor who took a culture and did a fungal scraping and since KOH revealed no fungal organism patient was starting on doxycyline along with cephalexin. He has completed the antibiotics for about 5 days now and reports no improvement.

No new facial products.
No history of this in the past.
Hasn’t tried anything at home for it.
No history of staph or MRSA infections.

 

Crusty, pustular, tender, erythematous nodules.
Crusty, pustular, tender, erythematous nodules.
Notice the small pustules, crusty lesions and diffuse erythema.
Notice the small pustules, crusty lesions and diffuse erythema.

 

On exam, patient has normal vitals.
Has diffuse indurated and erythematous skin on the chin and neck where his beard is.
Has multiple brown crusted over raised nodules.
Has multiple smaller pustule in various stages in the bear line.
Some lymphadenopathy noted in the anterior cervical column.

 

After consulting Uptodate with a high enough suspicion of Tinea Barbae I learned that they best way to collect a sample was to deroof one of the pustules and remove an infected hair follicle and send that in for confirmation of hyphae. The result came back positive. The previous clinician may have just sent a puss sample to the lab or skin scraping which may not be adequate for diagnosis in this condition.

Diagnosis: Tinea Barbae.
Treatment: Griseofulvan.
Outcome: Drastic improvement after 1 week.

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