The wound healed well until approximately 4 to 5 weeks after surgery when she noticed increasing erythema of her reexcisional scar. The wound began to dehisce and a culture grew methicillin-sensitive Staphylococcus aureus. Despite appropriate antibiotics, she had only slight improvement of her wound. A second biopsy once again demonstrated granulomatous inflammation, and mycobacterial and fungal cultures were taken on these tissue biopsies. No acid-fast bacilli were isolated; fungal culture grew Candida parapsilosis. She did not improve after a course of fluconazole, however. Additional laboratory workup showed negative or normal results.
Approximately 8 weeks after reexcision of the biopsy scar, she had a 5.2×3.2-cm ulcerated erythematous plaque with a pink rim on her right temple with granulation tissue at the bed (Fig 1). A third biopsy specimen was obtained from the reexcised lesion. This biopsy demonstrated reactive epidermal hyperplasia with neutrophil-rich inflammation, focal granuloma formation, and granulation tissue (Fig 2). There were no fungal, bacterial, or mycobacterial organisms identified with appropriate stains and culture.
Tissue biopsy specimen showing reactive epidermal hyperplasia with neutrophil-rich inflammation and focal granuloma formation (hematoxylin-eosin, original magnification ×10).
The diagnosis of SGP was subsequently made on the basis of the clinical and histopathologic characteristics of her presentation. Treatment was initiated with oral prednisone 50 mg daily and mupirocin 2% ointment. At 1-month follow-up, substantial improvement was noted with significant reepithelialization from her prior evaluation (Fig 3).
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