Successful treatment of cutaneous botryomycosis with a combination of minocycline and topical heat therapy.

Abstract

Cutaneous botryomycosis is a chronic focal infection characterized by a granulomatous inflammatory response to bacterial pathogens such as Staphylococcus aureus. Treatment requires antibiotic therapy and may also require surgical debridement. We employed topical heat therapy and oral minocycline. The lesions became flattened and pigmented after 1 month. We consider that this simple treatment can be an effective and harmless complementary therapy for cutaneous botryomycosis.

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Case Rep Dermatol 2012;4:114–118
DOI: 10.1159/000338798
Published online:
May 10, 2012
© 2012 S. Karger AG, Basel
ISSN 1662–6567
www.karger.com/cde
This is an Open Access article licensed under the terms of the Creative Commons
Attribution-NonCommercial-NoDerivs 3.0 License (www.karger.com/OA-license), applicable
to the online version of the article only. Distribution for non-commercial purposes only.



Masaya Ishibashi, MD




Department of Dermatology
Tohoku University Hospital
1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574 (Japan)
Tel. +81 22 717 7271, E-Mail mishibas @ m.tohoku.ac.jp

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Successful Treatment of
Cutaneous Botryomycosis with
a Combination of Minocycline
and Topical Heat Therapy
Masaya Ishibashia Yukikazu Numatab Hachiro Tagamib
Setsuya Aibab
aDepartment of Dermatology, Tohoku University Hospital, and bDepartment of
Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan


Key Words
Botryomycosis · Minocycline · Topical heat therapy


Abstract
Cutaneous botryomycosis is a chronic focal infection characterized by a granulomatous
inflammatory response to bacterial pathogens such as Staphylococcus aureus. Treatment
requires antibiotic therapy and may also require surgical debridement. We employed topical
heat therapy and oral minocycline. The lesions became flattened and pigmented after 1
month. We consider that this simple treatment can be an effective and harmless
complementary therapy for cutaneous botryomycosis.

Introduction
Skin staphylococcal infections usually show acute inflammatory skin changes such as
impetigo and furuncles. However, certain individuals, possibly those with an
immunodeficiency, may show a unique, chronic focal granulomatous lesion that is
noted clinically as botryomycosis. To treat such a case, we employed topical heat
therapy together with oral antibiotics to cure botryomycosis without using any surgical
measures.
Case Report
A 53-year-old Japanese woman with a 6-year history of bronchial asthmatic attacks for which she
occasionally used budesonide inhalation presented with a 3-month history of asymptomatic,
scattered, red papules on the dorsum of the right foot (fig. 1). She denied any preceding trauma or

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Case Rep Dermatol 2012;4:114–118
DOI: 10.1159/000338798
Published online:
May 10, 2012
© 2012 S. Karger AG, Basel
ISSN 1662–6567
www.karger.com/cde


surgical procedures at this site. The lesions gradually increased in size despite the tentative
application of a topical corticosteroid. Thus, suspecting infectious granulomatous lesions, in addition
to bacterial and fungal cultures we surgically removed one of the red papules for histopathological
studies. Histopathologically, the papule showed the presence of basophilic bacterial granules
surrounded by eosinophilic amorphous materials, constituting a typical Splendore-Hoeppli
phenomenon in the mid-dermis [1] (fig. 2). The bacteriological culture of a part of the biopsy
specimen yielded a colony of Staphylococcus aureus, whereas no other growth for fungi or
actinomycetes could be observed. The results of the laboratory investigations excluded any risk
factors such as diabetes mellitus, collagen disease or HIV infection. There was also no history of
alcoholism. Despite the prolonged budesonide inhalation for bronchial asthma in the past, her
neutrophil phagocytotic function and immunological parameters such as IgG levels and CD4 count
were found to be all within normal limits. Based on these results, we made a diagnosis of cutaneous
botryomycosis caused by S. aureus. Since the patient was allergic to a variety of drugs containing
β-lactam antibiotics, we started oral administration of minocycline at a dose of 200 mg/day together
with topical heat therapy, using a commercially available, disposable pocket warmer. She applied the
pack daily as long as possible, taking care not to cause a burn injury. With this treatment, we noticed
substantial clinical improvement of the lesions after 1 month, and the treatment was continued for
another 4 months until all lesions became flattened and pigmented (fig. 3). There was no subsequent
relapse in the following 8 months.

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Discussion
Botryomycosis is a unique, chronic bacterial granulomatous disease that often
involves the skin, subcutaneous tissues and, rarely, the viscera [2]. Its treatment
requires antibiotic therapy and, in most cases, surgical debridement. The selection of
antibiotics should be tailored to the results of bacterial cultures [3]. Even though such
patients may not show any signs of immunodeficiency, it sometimes happens that
antibiotic therapy alone may be insufficient [4, 5].
The present patient did not show any laboratory-proven abnormalities in her
immune system such as T cell defects, neutrophil function or a previous
immunosuppressive condition associated with the history of other opportunistic
infections. However, it was reported that T cell defects and impaired neutrophil,
monocyte and/or macrophage function play a significant role in the development of
botryomycosis [6]; therefore, we cannot exclude the possibility that her past 6-year
history of occasional corticosteroid inhalation for the control of bronchial asthma might
have influenced her immune system. In fact, botryomycosis occurs most commonly
among immunocompromised patients [7]. Thus, besides antibiotic therapy, we also
started topical heat therapy based on the findings that it was a safe and effective
method for treating sporotrichosis and chromoblastomycosis when antifungal agents
were not available in Japan [8]. The temperature of the commonly used heating packs,
which are available as body warmers in Japan, rises up to 63°C and lasts 12 h, with an
average temperature of 53°C in wintertime. Being a source of heat, any device that
emits constant heat to keep the skin surface temperature at 40–43°C should be
wrapped with a piece of cloth because the skin cannot tolerate persistent heat higher
than that [8, 9]. Therefore, a temperature-dependent germicidal effect for S. aureus
cannot be expected since the highest temperature limit for its growth is 48°C after 7
days of incubation [10].
Although the precise mechanisms underlying the effectiveness of topical heat
therapy are not completely clear, we think that heat exerts at least a cytostatic effect on
the organisms, which facilitates the phagocytic function of the host defense

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Case Rep Dermatol 2012;4:114–118
DOI: 10.1159/000338798
Published online:
May 10, 2012
© 2012 S. Karger AG, Basel
ISSN 1662–6567
www.karger.com/cde


mechanisms in addition to its possible effect on host immunity. The skin surface
temperature of the ankle is about 30°C [11]. An increase of the skin surface
temperature from 30 to 43°C can lead to an increased blood flow, which would result in
the increased activation of antibacterial defense. We consider that this simple
treatment can be an effective and harmless complementary therapy for cutaneous
botryomycosis. To our knowledge, this is the first report of botryomycosis successfully
treated by minocycline combined with topical heat therapy.

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Fig. 1. Dark red papuloerythematous lesions on the dorsal and lateral side of the right foot.

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Case Rep Dermatol 2012;4:114–118
DOI: 10.1159/000338798
Published online:
May 10, 2012
© 2012 S. Karger AG, Basel
ISSN 1662–6567
www.karger.com/cde



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Fig. 2. a Basophilic granules surrounded by mixed cell granuloma in the lower dermis (original
magnification ×50). b Magnified feature of bacterial clumps. Grain surrounded by an eosinophilic
material (the Splendore-Hoeppli phenomenon; original magnification ×200).

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Case Rep Dermatol 2012;4:114–118
DOI: 10.1159/000338798
Published online:
May 10, 2012
© 2012 S. Karger AG, Basel
ISSN 1662–6567
www.karger.com/cde



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Fig. 3. Four months after the initial therapy.

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