History:

 A 23-year old male suffered for more than one and a half year of painless mildly itchy redness and swelling of the nose and nearby areas. He was diagnosed on clinical background only as cutaneous leishmaniasis and treated with 4 sessions of sodium stibogluconate intralesionally (?!) with no response. Then a biopsy was taken from the tip of the nose (?!) which left a very ugly rounded depressed scar. The result of biopsy was non specific granulomatous pathology with no Leishman Donvan bodies could be detected. Then treated as granulomatous rosacea for 4 months (Doxycycline 100 mg per day for two months and Isotretinoin 10 mg per day for another two months) with non significant response! In last month, a reddish plaque appeared on the thigh? The photos associated with this case were taken in last month in which the rash slightly differs from that seen in earlier visits. In last presentation, the rash was well-demarcated especially in its upper part. There was no doubt that in earlier visits the rash was so consistent with “granulomatous rosacea” with rhinophymatous nose in addition to the supportive evidence from histological report (that report didn’t indicate presence of hyphae and or sports in the stratum cornermen)! It might be that the histological report was read by an inexperienced pathologist who could followed the clinical suspected differential diagnosis!). Anyhow, in the last visit, we didn’t arrange KOH scrapings or repeated the biopsy! We followed our clinical acumen and stopped previous treatment and started treating the case as tinea faciei with Griseofulvin tablet 500 mg bd with topical Clotrimazole cream only. Four weeks later, excellent result was obtained with only residual erythema remained (see last “post treatment” photo). The suffering of the patient was ended after another two weeks on same treatment. Still, I am annoyed from the rounded depressed scar, the result of bad selection of biopsy site by inexperienced dermatologist.

Please, re-read the history of the case with the present finalizing comment as I denoted history more than once! Thanks ??