Histopathologic examination showed pseudoepitheliomatous hyperplasia of the epidermis and multiple granulomas in the dermis, with a surrounding mixed cell infiltrate. Thick-walled spherules with endospore formation and several of the multinucleate giant cells were present within the granulomas. Complement fixation tests were strongly positive for fungal antibodies, with a Coccidioides titer of 1:16. There was no evidence of lung involvement on chest x-ray films. Fungal cultures of the skin yielded Coccidioides immitis. After the biopsy results were received, fluconazole therapy (400 mg/d) was initiated, resulting in flattening of the nodules over a period of 5 months.