Photo Quiz

Pruritic Rash on the Hand of a Home Gardener


Am Fam Physician. 2020 Oct 15;102(8):497-498.

A 61-year-old patient presented with a pruritic rash on the palm of the hand. The patient first noticed the rash one month earlier after working in the garden and described the initial rash as scratches and bumps. The pruritus progressively worsened, and the rash did not improve with hydrocortisone ointment.

Physical examination revealed crusted papular lesions on a mildly erythematous base located on the palm of the left hand (Figure 1). The lesion was approximately 2 × 2 cm in size. No lymphadenopathy was present. The patient had no joint swelling or tenderness. Examination findings were otherwise normal.




Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

  • A. Actinomycosis.

  • B. Cellulitis.

  • C. Cutaneous anthrax.

  • D. Cutaneous nocardiosis.

  • E. Sporotrichosis.


Answer is E: sporotrichosis, which is caused by the Sporothrix schenckii fungus. Sporotrichosis is a subacute to chronic infection associated with activities in which skin comes in contact with soil, such as landscaping and gardening.1 The most common clinical feature of lymphocutaneous sporotrichosis is a small ulcerated and indurated primary lesion accompanied by erythema and nodularity.2 Similar lesions appear proximal to the primary lesion, along the lymphatic channels. On initial presentation, pain is usually mild and systemic symptoms absent. Biopsy and fungal culture are the diagnostic standards for sporotrichosis.3

Actinomycosis is a rare disease caused by Actinomyces, an anaerobic gram-positive species found in the normal oral flora

Address correspondence to Courtney Humphrey, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Mahajan VK. Sporotrichosis: an overview and therapeutic options. Dermatol Res Pract. 2014;2014:272376....

2. de Lima Barros MB, de Almeida Paes R, Schubach AO. Sporothrix schenckii and Sporotrichosis. Clin Microbiol Rev. 2011;24(4):633–654.

3. Ramos-e-Silva M, Vasconcelos C, Carneiro S, et al. Sporotrichosis. Clin Dermatol. 2007;25(2):181–187.

4. Valour F, Sénéchal A, Dupieux C, et al. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist. 2014;7:183–197.

5. Raff AB, Kroshinsky D. Cellulitis: a review. JAMA. 2016;316(3):325–337.

6. Doganay M, Metan G, Alp E. A review of cutaneous anthrax and its outcome. J Infect Public Health. 2010;3(3):98–105.

7. Wilson JW. Nocardiosis: updates and clinical overview. Mayo Clin Proc. 2012;87(4):403–407.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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