Pityrosporum folliculitis in the Philippines: diagnosis, prevalence, and management

Position statement: Recommendations on the diagnosis and treatment of Malassezia folliculitis

Malassezia is a lipophilic yeast that is a part of the human mycobiome. Malassezia folliculitis appears when the benign colonization of the hair follicles, by the Malassezia yeasts, becomes symptomatic with pruritic papules and pustules. Although Malassezia folliculitis is common in hospital departments, diagnosing and treating it varies among dermatologists and countries. The European Academy of Dermatology and Venereology Mycology Task Force Malassezia folliculitis working group has, therefore, sought to develop these recommendations for the diagnosis and management of Malassezia folliculitis. Recommendations comprise methods for diagnosing Malassezia folliculitis, required positive findings before starting therapies and specific treatment algorithms for individuals who are immunocompetent, immunocompromised or who have compromised liver function. In conclusion, this study provides a clinical strategy for diagnosing and managing Malassezia folliculitis.

Truncal Acne and Scarring: A Comprehensive Review of Current Medical and Cosmetic Approaches to Treatment and Patient Management

Acne vulgaris is one of the most common skin disorders worldwide. It typically affects skin areas with a high density of sebaceous glands such as the face, upper arms, chest, and/or back. Historically, the majority of research efforts have focused on facial acne vulgaris, even though approximately half of patients with facial lesions demonstrate truncal involvement. Truncal acne vulgaris is challenging to treat and poses a significant psychosocial burden on patients. Despite these characteristics, studies specifically examining truncal acne vulgaris are limited, with treatment guidelines largely derived from facial protocols. Therefore, truncal acne remains an understudied clinical problem. Here, we provide a clinically focused review on the epidemiology, evaluation, and available treatment options for truncal acne vulgaris. In doing so, we highlight knowledge gaps with the goal of spurring further investigation into the management of truncal acne vulgaris.

Malassezia Folliculitis in the Setting of COVID-19

Purpose of Review

To review recent literature on Malassezia folliculitis and explore its association with COVID-19.

Recent Findings

Reports of Malassezia folliculitis in the setting of COVID-19 are scarce. Shared characteristics between affected individuals include male sex, obesity, intensive care, and administration of systemic antibiotics and systemic steroids. Dexamethasone can potentially stimulate sebum production and therefore lead to Malassezia proliferation. The clinical picture of Malassezia folliculitis accompanying COVID-19 is similar to classic descriptions but tends to spare the face and predominates in occlusion sites.

Summary

Malassezia folliculitis is under-recognized. Fever, sweating, occlusion, immobility, antibiotics, and dexamethasone contribute to COVID-19 patients developing Malassezia folliculitis. Antifungal therapy, together with correcting predisposing factors, is the mainstay of management. Future research should explore the relationship between systemic steroids and other acneiform reactions.

Clinico-Laboratory Findings of Malassezia Folliculitis in Indonesia: a Multicenter Study

BACKGROUND

Malassezia folliculitis (MF) is a humid-favored fungal skin disease caused by Malassezia species. Inaccurate treatments, changes in skin flora, and disease exacerbation are often occurred due to oversights in the diagnosis. Several diagnostic methods are established for MF.

OBJECTIVE

To identify clinico-laboratory findings of Malassezia folliculitis in Indonesia.

METHODS

The study was conducted from January 2014 to December 2018 in seven referral teaching hospitals. Medical records of MF-diagnosed patients were obtained and analyzed using the binomial test, chi-square test, and Cohen's Kappa coefficient in SPSS 26.0.

RESULTS

A total of 353 cases of MF were identified in seven referral teaching hospitals in Indonesia, 66.3% of which were males and 33.7% were females, dominated by the 17-25 years old group (44.5%). Itchy sensation (83.9%) was a major subjective complaint. Lesions were majorly found on the trunk-chest, back, and shoulder (68.3%), while the clinical manifestation are mostly follicular papule-pustular lesions (62.1%). Patients were 87.4% positive by KOH examination (modified Jacinto Jamora's criteria) and 69.1% positive by Wood's lamp. Generally, sex, age, subjective complaint, lesion location, clinical manifestation, and both examinations were statistically significant (p<0.001). A significant relationship between all the clinical criteria of the patients in the KOH; especially the clinical manifestation was significantly related to the Wood's lamp. The Cohen's Kappa assessment suggested that there was an agreement between KOH and Wood's lamp (κ = -0,272, p<0.001).

CONCLUSION

The clinical symptoms of Malassezia folliculitis are dominated by pruritus, papulopustular follicular lesions on the trunk, and the presence of spore load.

Hyperhidrosis and the risk of being treated for skin infections

BACKGROUND

A few studies have described an increased prevalence of skin infections in individuals with hyperhidrosis compared to others. However, it remains uncertain whether hyperhidrosis is an independent risk factor for skin infections.

OBJECTIVE

To compare the risk of skin infections in individuals with and without hyperhidrosis.

METHODS

In this retrospective cohort study, data on hyperhidrosis were collected from the Danish Blood Donor Study. Blood donors included in 2010-2019 were followed from inclusion until December 2019. Data on redeemed prescriptions against skin infections were collected from the National Prescription Register. The intensity of prescription-use by hyperhidrosis status was assessed in Andersen-Gill models.

RESULTS

Overall, 4,176 (9.6%) of 43,477 blood donors had self-reported hyperhidrosis and 437 (0.34%) of 127,823 blood donors had hospital diagnosed hyperhidrosis. Self-reported hyperhidrosis was associated with the use of antibiotic prescriptions (adjusted hazard ratio = 1.21; 95% confidence interval 1.00-1.45, p = 0.047). Hospital diagnosed hyperhidrosis was associated with the use of antibiotic (adjusted hazard ratio = 1.33; 95% confidence interval 1.03-1.68, p = 0.028) and topical antifungal prescriptions (adjusted hazard ratio = 1.43; 95% confidence interval 1.04-1.97, p = 0.027).

CONCLUSIONS

Hyperhidrosis is associated with the use of prescriptions for antibiotics and topical antifungals. This suggests a clinically relevant association between hyperhidrosis and skin infections.

Critical synthesis of available data in Malassezia folliculitis and a systematic review of treatments

Folliculitis is an inflammatory process involving the hair follicle, frequently attributed to infectious causes. Malassezia, an established symbiotic yeast that can evolve to a skin pathogen with opportunistic attributes, is a common source of folliculitis, especially when intrinsic (e.g. immunosuppression) or extrinsic (high ambient temperature and humidity, clothing) impact on the hair follicle and the overlying skin microenvironment. Our aim was to critically review the pathophysiology and clinical characteristics of Malassezia folliculitis, to describe laboratory methods that facilitate diagnosis and to systematically review treatment options. Malassezia folliculitis manifests as a pruritic, follicular papulopustular eruption distributed on the upper trunk. It commonly affects young to middle-aged adults and immunosuppressed individuals. Inclusion into the differential diagnosis of folliculitis is regularly oversighted, and the prerequisite-targeted diagnostic procedures are not always performed. Sampling by tape stripping or comedo extractor and microscopic examination of the sample usually identifies the monopolar budding yeast cells of Malassezia without the presence of hyphae. However, confirmation of the diagnosis with anatomical association with the hair follicle is performed by biopsy. For systematic review of therapies, PubMed was searched using the search string "(malassezia" [MeSH Terms] OR "malassezia" [All Fields] OR pityrosporum [All Fields]) AND "folliculitis" [MeSH Terms] and EMBASE was searched using the search string: 'malassezia folliculitis.mp OR pityrosporum folliculitis.mp'. In total, 28 full-length studies were assessed for eligibility and 21 were selected for inclusion in therapy evaluation. Conclusively Malassezia folliculitis should be considered in the assessment of truncal, follicular skin lesions. Patient's history, comorbidities and clinical presentation are usually indicative, but microscopically and histological examination is needed to confirm the diagnosis. Adequate samples obtained with comedo extractor and serial sections in the histological material are critical for proper diagnosis. Therapy should include systemic or topical measures for the control of the inflammation, as well as the prevention of recurrences.

High accuracy of recognition of common forms of folliculitis by dermoscopy: An observational study

BACKGROUND

Clinical differentiation of folliculitis types is challenging. Dermoscopy supports the recognition of folliculitis etiology, but its diagnostic accuracy is not known.

OBJECTIVE

To assess the diagnostic accuracy of dermoscopy for folliculitis.

METHODS

This observational study included patients (N = 240) with folliculitis determined on the basis of clinical and dermoscopic assessments. A dermoscopic image of the most representative lesion was acquired for each patient. Etiology was determined on the basis of cytologic examination, culture, histologic examination, or manual hair removal (when ingrowing hair was detected) by dermatologist A. Dermoscopic images were evaluated according to predefined diagnostic criteria by dermatologist B, who was blinded to the clinical findings. Dermoscopic and definitive diagnoses were compared by dermatologist C.

RESULTS

Of the 240 folliculitis lesions examined, 90% were infections and 10% were noninfectious. Infectious folliculitis was caused by parasites (n = 71), fungi (n = 81), bacteria (n = 57), or 7 viruses (n = 7). Noninfectious folliculitis included pseudofolliculitis (n = 14), folliculitis decalvans (n = 7), and eosinophilic folliculitis (n = 3). The overall accuracy of dermoscopy was 73.7%. Dermoscopy showed good diagnostic accuracy for Demodex (88.1%), scabietic (89.7%), and dermatophytic folliculitis (100%), as well as for pseudofolliculitis (92.8%).

LIMITATIONS

The diagnostic value of dermoscopy was calculated only for common folliculitis. Diagnostic reliability could not be calculated.

CONCLUSION

Dermoscopy is a useful tool for assisting in the diagnosis of some forms of folliculitis.

Comparison between Malassezia Folliculitis and Non-Malassezia Folliculitis

Background

Among the various types of folliculitis, differentiation of Malassezia folliculitis (MF) from other forms of folliculitis is important because it is usually treated with antifungal agents.

Objective

We attempted to find a method to enhance the detection rate of MF, and examined the differences in the clinical manifestation between MF and non-MF (NMF).

Methods

We performed a retrospective study involving patients with folliculitis who were previously diagnosed with MF or NMF on the basis of serial tissue sectioning and diastase-Periodic acid-Schiff (d-PAS) staining findings. The clinical features of MF and NMF were compared.

Results

Among a total of 100 folliculitis patients, 20 were diagnosed with MF and 80 with NMF. Tissues from the 80 patients with NMF were sectioned serially into 10 slices and stained with hematoxylin and eosin stain; among these, 10 had many round-to-oval yeast organisms in the hair follicles that confirmed MF. Finally, d-PAS staining was used to detect the presence of yeast in the NMF slides. Notably, among the 70 d-PAS-stained samples, yeast organisms were found in 6 samples, confirming MF. As a result, the diagnosis of 16 patients changed from NMF to MF. Compared with NMF, MF showed major involvement of the trunk and low involvement of the face and legs as well as male predilection.

Conclusion

Physicians should consider serial sectioning and/or d-PAS staining of folliculitis lesions, particularly of those on the trunk of male patients, even if no yeast organisms are detected initially.

Itraconazole (Sporanox®) in superficial and systemic fungal infections

Itraconazole (Sporanox) is a triazole antifungal agent with a broad activity spectrum and favorable pharmacokinetic and safety profiles. Numerous clinical trials have established the efficacy and safety of itraconazole in the treatment of superficial fungal infections. In this field, full exploitation of its pharmacokinetics in keratinized tissues has led to the development of intermittent (pulse) treatment regimens that allow similar efficacy with lower overall drug exposure as well as a reduction in treatment costs. The additional anti-inflammatory action of itraconazole also makes it suitable for application in difficult-to-treat inflammatory skin disorders, such as seborrheic dermatitis. Recently, a new oral liquid formulation and an intravenous formulation have been developed, extending the therapeutic application of itraconazole to systemic fungal infections. Due to its broad activity spectrum and excellent tolerability, itraconazole is a valuable addition to the antifungal armamentarium used for prophylactic and empiric treatment in immunocompromised hosts.

Malassezia folliculitis in an infant

Malassezia folliculitis commonly affects the adolescents and the young adults. We describe an unusual case of Malassezia folliculitis which is particular in age of patient and scare evolution of lesions. The patient was a three-month-old immuno-competent boy. On clinical examination, 1- to 2-mm superficial follicular pustules were observed on his face, neck and upper trunk. Direct microscopy of pustule scrapings and hair follicles showed numerous Malassezia yeast cells. Based on the clinical and mycological data, the diagnosis of Malassezia folliculitis was made. The possible predisposing factors in our patient were heat and sweating, caused by the excessive heat of the summer season in Tunisia. Treatment with topical ketoconazole promoted cure with depressed varioliform scars.

The Malassezia genus in skin and systemic diseases

In the last 15 years, the genus Malassezia has been a topic of intense basic research on taxonomy, physiology, biochemistry, ecology, immunology, and metabolomics. Currently, the genus encompasses 14 species. The 1996 revision of the genus resulted in seven accepted taxa: M. furfur, M. pachydermatis, M. sympodialis, M. globosa, M. obtusa, M. restricta, and M. slooffiae. In the last decade, seven new taxa isolated from healthy and lesional human and animal skin have been accepted: M. dermatis, M. japonica, M. yamatoensis, M. nana, M. caprae, M. equina, and M. cuniculi. However, forthcoming multidisciplinary research is expected to show the etiopathological relationships between these new species and skin diseases. Hitherto, basic and clinical research has established etiological links between Malassezia yeasts, pityriasis versicolor, and sepsis of neonates and immunocompromised individuals. Their role in aggravating seborrheic dermatitis, dandruff, folliculitis, and onychomycosis, though often supported by histopathological evidence and favorable antifungal therapeutic outcomes, remains under investigation. A close association between skin and Malassezia IgE binding allergens in atopic eczema has been shown, while laboratory data support a role in psoriasis exacerbations. Finally, metabolomic research resulted in the proposal of a hypothesis on the contribution of Malassezia-synthesized aryl hydrocarbon receptor (AhR) ligands to basal cell carcinoma through UV radiation-induced carcinogenesis.

Epidemiologic Study of Malassezia Yeasts in Acne Patients by Analysis of 26S rDNA PCR-RFLP

Background

Although acne is a common follicular inflammatory dermatosis, studies of the relationship between Malassezia yeasts and acne have rarely been conducted.

Objective

We sought to identify Malassezia yeasts from acne patients and establish a relationship between specific types of species of Malassezia and acne.

Methods

Sixty acne patients were enrolled. Each strain obtained was identified as one of eleven species by 26S rDNA PCR-RFLP. We then compared these data with those of age- and sex-matched healthy subjects.

Results

Growth of Malassezia was evident in fewer patients with acne (50%) in comparison to controls (70.6%). M. restricta was dominant in patients with acne (23.9%), whereas M. globosa was most common (26.7%) in healthy controls. In the patients group, the rate was the highest (71.7%) in the twenties and, in terms of body site, the rate was the highest (60%) in the chest. In the control group, the rate was the highest (75.0%) in the thirties and in the forehead (85.0%).

Conclusion

The detection rate of Malassezia yeasts was conspicuously low in the acne patients group. Statistically significant differences were observed between the patient and the control groups in the twenties and thirties, and in terms of body site, in the forehead and chest.

[Malassezia folliculitis: characteristics and therapeutic response in 26 patients]

BACKGROUND

Malassezia folliculitis is most often described in patients living in hot and humid countries or in immunocompromised patients. Its frequency in France is unknown. We report 26 cases diagnosed at Saint-Louis Hospital between May 2002 and April 2004. The clinical features, the contributing factors, the results of direct mycological examination and/or histology and the efficacy of antifungal treatments were compared to the literature.

PATIENTS AND METHODS

The inclusion criteria were the presence of folliculitis on the trunk confirmed by direct microscopy and/or histopathology showing abundant yeast cells in the follicles.

RESULTS

Patients comprised 22 men and 4 women (M/F sex ratio: 5: 5) with a mean age of 46 years. Five patients (19%) were immunocompromised. In normal patients, the duration of folliculitis was long with a mean of 61 months. The eruption was typical, with follicular papules and superficial pustules distributed predominantly on the trunk. Itching was frequent (70%). Direct microscopy was more often positive than histology (89% vs 33%). Some sixty-five percent of the patients had been previously treated by topical or systemic antibiotics or anti-acne drugs, which was ineffective in all cases. Cure with topical ketoconazole, oral ketoconazole alone or in combination with topical ketoconazole occurred respectively in 12%, 75% and 75% of patients, but with consistent recurrence within 3 to 4 months after cessation of treatment.

DISCUSSION

Malassezia folliculitis is probably misdiagnosed, as suggested by the long time between onset and diagnosis and the high frequency of non-antifungal treatments prescribed. In our study, direct mycological examination provided more effective diagnosis than histology. Treatment is difficult especially because of the high frequency of relapses.

CONCLUSION

A diagnosis of Malassezia folliculitis should be considered in young adults or immunocompromised patients with an itching follicular eruption. Further therapeutic trials are needed due to the frequency of relapse.

Profile of acne patients in the Philippines requiring a second course of oral isotretinoin

BACKGROUND

Oral isotretinoin (OI) is currently the gold standard in the treatment of moderately severe to severe acne vulgaris. Approximately 50-85% of patients achieve permanent cure with one course based on 1.0-2.0 mg/kg/body weight. It has been shown that a dosage of less than 1 mg/kg/body weight predisposed to noncure and required a second course for a permanent cure.

OBJECTIVE

Purpose of this study was to describe the profile of acne patients in the Philippines requiring a second course of OI.

METHODS

Charts of acne vulgaris patients given OI in a private dermatology clinic (SSJ) over a period of 10 years were reviewed and analyzed. All patients were given a total dose of 1 mg/kg/body weight (cumulative total dose of 120 mg/kg/body weight).

RESULT

Of 240 patients taking OI included in the study, 193 completed the entire course. One hundred and 43 (59.6%) were cured after one course and required no further therapy (control group: CG), 42 (17.5%) experienced relapse and were treated with topical therapy, and eight (3.3%) relapsed and required oral antibiotic plus topical therapy. Only 47 patients (19.6%) required a second course of OI therapy (study group: SG). There was no difference between the two groups in age, sex, severity, and location of lesions. Two factors were found to be of statistically significant difference: Total dose actually taken with 103.5 mg/kg/body weight for the SG vs. 118.55 mg/kg/body weight for the CG. Median duration of treatment was 6.7 months for the SG vs. 7.41 months for the CG, respectively.

CONCLUSION

The profile of acne patients in the Philippines requiring a second course of OI is seen in those taking a mean cumulative dose (actual total dose) less than 120 mg/kg/body weight, with a mean actual duration of 6.7 months.

Skin diseases associated with Malassezia species

The yeasts of the genus Malassezia have been associated with a number of diseases affecting the human skin, such as pityriasis versicolor, Malassezia (Pityrosporum) folliculitis, seborrheic dermatitis and dandruff, atopic dermatitis, psoriasis, and--less commonly--with other dermatologic disorders such as confluent and reticulated papillomatosis, onychomycosis, and transient acantholytic dermatosis. Although Malassezia yeasts are a part of the normal microflora, under certain conditions they can cause superficial skin infection. The study of the clinical role of Malassezia species has been surrounded by controversy because of their fastidious nature in vitro, and relative difficulty in isolation, cultivation, and identification. Many studies have been published in the past few years after the taxonomic revision carried out in 1996 in which 7 species were recognized. Two new species have been recently described, one of which has been isolated from patients with atopic dermatitis. This review focuses on the clinical, mycologic, and immunologic aspects of the various skin diseases associated with Malassezia. It also highlights the importance of individual Malassezia species in the different dermatologic disorders related to these yeasts.

A case of infantile acne due to pityrosporum

We report a case of infantile acne. The lesion on the forehead resembled infantile acne clinically, but histologically it contained yeasts of Pityrosporum. The lesion was treated with topical ketoconazole cream and improved. We suggest that Pityrosporum is associated with infantile acne.

Immunology of diseases associated with Malassezia species

Malassezia species are members of the human cutaneous commensal flora, in addition to causing a wide range of cutaneous and systemic diseases in suitably predisposed individuals. Studies examining cellular and humoral immune responses specific to Malassezia species in patients with Malassezia-associated diseases and healthy controls have generally been unable to define significant differences in their immune response. The use of varied antigenic preparations and strains from different Malassezia classifications may partly be responsible for this, although these problems can now be overcome by using techniques based on recent work defining some important antigens and also a new taxonomy for the genus. The finding that the genus Malassezia is immunomodulatory is important in understanding its ability to cause disease. Stimulation of the reticuloendothelial system and activation of the complement cascade contrasts with its ability to suppress cytokine release and downregulate phagocytic uptake and killing. The lipid-rich layer around the yeast appears to be pivotal in this alteration of phenotype. Defining the nonspecific immune response to Malassezia species and the way in which the organisms modulate it may well be the key to understanding how Malassezia species can exist as both commensals and pathogens.

Pityrosporum folliculitis: renal transplantation case report

Pityrosporum folliculitis is caused by the fungus Pityrosporum ovale. It is characterized by the presence of pruriginous follicular papulae and papulae-pustules in face, upper part of the trunk, and upper limb root. It is more prevailing in places with hot and humid climates. Its incidence can be associated with either immunosuppressive or chemotherapy states secondary to pathologies. We report herewith a case of pityrosporum folliculitis in a patient who had previously underwent kidney transplantation and these result of the itraconazol therapeutics given.

An epidemic outbreak of Malassezia folliculitis in three adult patients in an intensive care unit: a previously unrecognized nosocomial infection

BACKGROUND

Malassezia is a lipophilic fungus commonly found in normal human skin. Infection of the hair follicle by Malassezia furfur occurs in patients with predisposing factors such as diabetes or immunosuppression, or who are undergoing antibiotic treatment. Malassezia furfur folliculitis is an infrequent nosocomial infection which may be associated with fomite transmission.

METHODS

We reviewed the clinical files of three adult patients from an intensive care unit (ICU) who simultaneously developed folliculitis through Malassezia infection. We specifically analysed predisposing factors, possible transmission modes, characteristics of skin lesions, results of biopsies and cultures, treatment, and patient outcome.

RESULTS

The three male patients were in neighboring beds and they all had factors that predisposed them to underlying immunosupression. Simultaneously, and within hours of each other, they developed erythematous follicular papules and pustules on the face and chest. The skin biopsies revealed an acute folliculitis with abundant round to oval yeasts of up to 5 microm in diameter. Stains for fungi (Schiff's peryodic acid, Grocott and silver methenamine) revealed numerous unipolar budding yeasts without hyphae, consistent with M. furfur. Conventional cultures were negative. The diagnosis of folliculitis by M. furfur was established and antifinigal treatment initiated, with adequate outcome of the dermatosis. After this outbreak, the aseptic and hygienic measures of the health care personnel of the ICU were reviewed and corrected.

CONCLUSIONS

The simultaneous emergence of this superficial infection by M. furfur suggests fomite participation. This dermatomycosis is an infrequent nosocomial infection in adults, which to our knowledge has not been previously reported.

Steroid acne vs. Pityrosporum folliculitis: the incidence of Pityrosporum ovale and the effect of antifungal drugs in steroid acne

BACKGROUND

Steroid acne is a folliculitis that can result from systemic or topical administration of steroid, and has been described as showing a similar clinical picture to Pityrosporum folliculitis, but there have been few reports about the incidence of Pityrosporum ovale and the effect of antimycotic drugs in steroid acne and other acneiform eruptions. Our purpose was to describe the association between steroid acne and P. ovale, and to confirm the superior efficacy of oral antifungal drugs over anti-acne drugs in the treatment of steroid acne.

METHODS

The history, clinical features direct microscopy, histopathologic analysis, and therapeutic results of 125 cases with steroid acne or other acneiform eruptions were described and compared.

RESULTS

Over 80% of patients with acneiform eruption receiving systemic steroid revealed significant numbers of P. ovale in the lesional follicle. Furthermore, oral antifungal drug (itraconazole) showed significantly better clinical and mycologic effects than any other group of medications used in this study.

CONCLUSIONS

Steroid acne and other acneiform eruptions showing discrete follicular papules and/or pustules localized to the upper trunk and acneiform facial skin lesions associated with multiple acneiform lesions on the body in the summer period should be suspected as Pityrosporum folliculitis. In addition, oral antifungal drugs recommended for Pityrosporum folliculitis; however, it will require a larger case-control study to confirm the superiority of antifungal therapy over anti-acne treatment.

The superficial mycoses

The various agents of the superficial mycoses have been recognized for more than a century as causes of mild diseases affecting humankind. Two of these, Malassezia furfur and Trichosporon beigelii, are ubiquitous organisms now known to be opportunistic pathogens in susceptible patient populations. The clinical manifestation, pathogenesis, and treatment of the common skin presentation of these and the other superficial mycoses are reviewed.

Pityrosporum (Malassezia) folliculitis in Saudi Arabia--diagnosis and therapeutic trials

Pityrosporum folliculitis (PF) is frequently misdiagnosed as acne vulgaris, resulting in unnecessary and prolonged treatment. Sixty-two patients with PF seen in the Dermatology Clinic, King Gahad Hofuf Hospital, Saudi Arabia were evaluated clinically. The diagnosis was confirmed by routine histology with haemotoxylineosin staining and Periodic acid-Schiff staining. Scrapings of the lesions, especially the molluscum-like papules, were mounted in KOH/Parker blue ink and examined under the microscope. Patients, divided into three groups as follows, were given treatment for 4 weeks: (1) 20 were treated with ketoconazole, 200 mg orally in addition to ketoconazole shampoo 2% daily; (2) 20 were given only ketoconazole, 200 mg daily, orally; (3) 12 used econazole nitrate 1% solution applied twice daily; and (4) 10 used miconazole nitrate 2% cream twice daily. Cases in groups 3 and 4, who did not respond, were given the same treatment as for group 1. All who responded were kept on ketoconazole shampoo 2% twice weekly. PF was commoner in young adult females as the female to male ratio was 2:1 while the mean age was 21.5 years. The most common site involved was the trunk (95%) in the form of papules, pustules and molluscoid lesions. The latter type of lesion yielded the highest number of spores using KOH/Parker blue ink. Biopsy was positive in 87% of the patients but is usually not necessary. Combined topical and systemic ketoconazole produced clearance of the lesions in 20 patients (100%), while systemic therapy only resulted in 75% clearance (15 of 20). Topical econazole and miconazole failed in 20 of 22 (90%) and improved only two patients. There were no significant side-effects from the drugs.

Pityrosporum infections

Pityrosporum ovale is a lipophilic yeast that is part of the normal human adult cutaneous flora. It is both a saprophyte and an opportunistic pathogen associated with pityriasis versicolor, Pityrosporum folliculitis, seborrheic dermatitis, and some forms of atopic dermatitis. Systemic infections have also been described. In this article the diagnosis and management of pityriasis versicolor, Pityrosporum folliculitis, seborrheic dermatitis, and atopic dermatitis will be discussed.