Folliculitis Decalvans Has a Heterogeneous Microbiological Signature and Impaired Immunological Response

BACKGROUND

Folliculitis decalvans (FD) is a rare primary neutrophilic scarring alopecia whose etiology has not been completely elucidated yet.

OBJECTIVE

The aim of the study was to determine if the follicular microbiota residing in FD-affected hair follicles had a distinct microbiological signature and if an aberrant immune response was present in the pathogenesis of FD.

METHODS

We conducted a cross-sectional study of 10 patients affected by FD. Trichoscopy-guided follicular biopsies were taken from affected and healthy scalp to identify the follicular microbiome using next-generation sequencing. We searched for microbiological biomarkers of FD-affected follicles using the linear discriminant analysis (LDA) effect size (LEfSe) tool. Additionally, peripheral blood mononuclear cells were obtained, and their cytokine production was quantified after incubation with pathogen-associated molecular patterns isolated from patients' biopsies and compared with healthy controls.

RESULTS

β-diversity analysis showed statistically significant differences regarding bacteria comparing follicular microbiota of healthy and FD-affected hairs. Ruminococcaceae, Agathobacter sp., Tyzzerella sp., and Bacteriodales vadin HA21 family were good predictors of disease status. IL-10, TNF-α, and IL-6 levels were significantly decreased in patients after incubation with various strains of bacteria compared with controls.

CONCLUSION

FD hair follicles have a specific heterogenous follicular bacterial microbiota signature. Additionally, these patients seem to have an impaired immunological response.

Gram-negative infections in patients with folliculitis decalvans: a subset of patients requiring alternative treatment

Background Folliculitis decalvans is a neutrophilic cicatricial alopecia whose etiology remains unknown. It is frequently associated with staphylococcal infections. We aimed to determine the rate of gram-negative infections in patients with folliculitis decalvans. Methods A retrospective chart review was performed of patients with biopsy-proven folliculitis decalvans seen at a tertiary hair referral center. The results of bacterial cultures were evaluated. Subjects were determined to have no infection, gram-positive infections, gram-negative infections, or mixed infections. Results Thirty-nine subjects were included in the study. Ninety-three cultures were performed. The majority of cultures were positive for staphylococci. Eleven patients (28%) had gram-negative infections of the scalp. Gram-negative infections comprised one-third of all cultures (33%). Conclusion We present the largest cohort of folliculitis decalvans patients with gram-negative infections, suggesting the need for routine bacterial cultures in patients who are not responsive to standard anti-staphylococcal antibiotics. Awareness of the incidence of these infections may lead to better therapeutic outcomes.

[Tinea barbae profunda due to Trichophyton mentagrophytes : Case report and review]

Tinea barbae is a rare dermatomycocis, by definition follicular bound in the beard area of adult men. Manifestation usually starts with erythema accompanied by desquamation. Deeper distribution along terminal hairs leads to folliculitis with formation of pustules and nodes as well as abscesses; fixed adherent yellowish crusts may appear. Frequently there is locoregional swelling of the lymph nodes and occasionally a deterioration of general condition with (sub)febrile temperatures. Often this leads to the initial suspected diagnosis of a bacterial folliculitis barbae or impetigo contagiosa. Tinea barbae is mostly induced by species of the genus Trichophyton (T.). The pathogens are diverse and are mostly zoophilic, sometimes anthropophilic and rarely geophilic dermatophytes. With the help of a specific anamnesis and diagnostic procedure, including mycological examinations, histology and molecular detection of dermatophytes via polymerase chain reaction (PCR), tinea barbae-in our patient induced by T. mentagrophytes-can be rapidly diagnosed. Early initiation and adequate treatment duration lead to restitutio ad integrum.

The Prevalence of Malassezia Folliculitis in Patients with Papulopustular/Comedonal Acne, and Their Response to Antifungal Treatment

Because Malassezia folliculitis (MF) may clinically mimic acne vulgaris (AV), patients usually receive unnecessary and prolonged antibiotic treatment. We aimed to determine the prevalence of MF among patients with AV, and to evaluate its response to antifungal treatment. A total of 217 patients with AV underwent cytologic examination for the presence of Malassezia yeasts. Samples were obtained from lesional and nonlesional skin and stained with May-Grünwald-Giemsa. MF was diagnosed if there were more than six spores in one microscopic field (at ×400 magnification). A modified "lesion-counting" method was used to assess the clinical severity of acne. Treatment included oral itraconazole (2×100 mg daily) and topical ketaconazole for 4 weeks. Fifty-five (25.3%) patients were diagnosed with MF; of these, 38 (69.1%) completed the antifungal treatment. The lesions decreased by 50% or more in 26 (68.4%) of the patients who completed the antifungal treatment, which reduced the number of closed comedones/comedolike or molluscoid papules and inflammatory papules. The average number of spores in lesional samples was significantly decreased after treatment (P=<.0005). We observed that MF can present with AV-like lesions, or the two diseases may coexist. Cytology is helpful for making the correct diagnosis and providing proper management of MF.

Pityrosporum folliculitis: A retrospective review of 110 cases

BACKGROUND

Pityrosporum folliculitis is an under-recognized eruption of the face and upper portion of the trunk that may be confused with, or occur simultaneously with, acne vulgaris.

OBJECTIVE

We sought to characterize risk factors for Pityrosporum folliculitis, its clinical presentation, and its response to treatment.

METHODS

A retrospective chart review was performed on all patients age 0 to 21 years seen at our facility from 2010 to 2015 with Pityrosporum folliculitis confirmed by a potassium hydroxide preparation.

RESULTS

Of 110 qualifying patients, more than 75% had acne that had recently been treated with antibiotics, and when recorded, 65% reported pruritus. Clinical examination demonstrated numerous 1- to 2-mm monomorphic papules and pustules that were typically on the forehead extending into the hairline and on the upper portion of the back. The most common treatment was ketoconazole shampoo, which led to improvement or resolution in most cases. Some patients required oral azole antifungals.

LIMITATIONS

This study was retrospective and relied on providers describing and interpreting the clinical findings and potassium hydroxide preparations. No standard grading system was used.

CONCLUSION

Unlike classic acne vulgaris, Pityrosporum folliculitis was more common after antibiotic use. It presented as fine monomorphic, pruritic papules and pustules along the hairline and on the upper portion of the back, and it improved with topical or oral azole antifungal therapy.

Dermoscopy: a useful tool for assisting the diagnosis of Pseudomonas folliculitis

This report describes the usefulness of dermoscopy as a supportive diagnostic tool in a pseudomonas folliculitis case.

Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases

Internationally approved guidelines for the diagnosis and management of Malassezia-related skin diseases are lacking. Therefore, a panel of experts consisting of dermatologists and a microbiologist under the auspices of the Danish Society of Dermatology undertook a data review and compiled guidelines for the diagnostic procedures and management of pityriasis versicolor, seborrhoeic dermatitis and Malassezia folliculitis. Main recommendations in most cases of pityriasis versicolor and seborrhoeic dermatitis include topical treatment which has been shown to be sufficient. As first choice, treatment should be based on topical antifungal medication. A short course of topical corticosteroid or topical calcineurin inhibitors has an anti-inflammatory effect in seborrhoeic dermatitis. Systemic antifungal therapy may be indicated for widespread lesions or lesions refractory to topical treatment. Maintenance therapy is often necessary to prevent relapses. In the treatment of Malassezia folliculitis systemic antifungal treatment is probably more effective than topical treatment but a combination may be favourable.

Tinea Barbae (Tinea Sycosis): Experience with Nine Cases

Tinea barbae is a rare dermatophytosis that affects the hair and hair follicles of the beard and mustache. This paper presents 9 cases of tinea barbae observed over an 18-year period of time and classified as follows: 1 was superficial and 8 were deep (6 folliculitis-like and 2 kerion-like). Most of the cases (4) were associated with topical steroid therapy, others with pet contact (3 cases) and one with diabetes. The causal agents isolated were: Trichophyton rubrum in 3; Microsporum canis in 3; Trichophyton mentagrophytes in 2; and Trichophyton tonsurans in one. The involvement of the hair was observed and classified in all cases. The trichophytin skin reaction was positive in all 9 patients. All the patients were treated with systemic antimycotics, 3 cases with griseofulvin, 1 with ketoconazole, 3 with itraconazole, and 2 with terbinafine. Clinical and mycologic cures were achieved at 6 to 8 weeks of treatment at the usual doses.

Infection of the Beard area. Kerion: a review of 2 cases

Folliculitis barbae is a common condition of both infective and non-infectious aetiology. It most frequently presents as a superficial folliculitis, with fine pustules appearing at the opening of hair follicles in the beard area, often associated with shaving; known as Bockhart impetigo and usually due to infection caused by Staphylococcus aureus. If untreated, the infection and inflammation can progress, leading to a more deeply seated infection known as sycosis barbae. Perifollicular nodules, termed furuncles, may appear and when these are multiple and coalesce, a deep-seated, communicating, pustulating plaque called a carbuncle develops, often with associated systemic upset. Such an appearance, which can prompt incision and drainage, should not, however, be assumed to be solely due to staphylococcal infection. Particularly in the context of a history of close animal contact or a lack of response to antibiotic treatment, a diagnosis of tinea barbae should be considered and investigated. Prompt treatment with antifungal agents and often systemic steroids is required once the diagnosis is made. This will help reduce an exacerbation of the pronounced destruction that results from the immune response to the fungal infection, known as a kerion, which would be compounded by surgical intervention. In this article, we review two such cases and review the investigation and management of the disease.

Pityrosporum folliculitis in an immunocompetent patient: clinical case description

The present report concerns Malassezia-related pityrosporum folliculitis in a patient without any predisposing factor. Once the diagnosis had been confirmed by histopathologic exam, the patient was treated with oral ketoconazole and selenium sulfide shampoo; complete remission of the clinical condition was obtained. Thus it could be concluded that in spite of being routinely associated with immunosuppression, this condition may be present in an immunocompetent patient.

Pseudomonas folliculitis in Arabian baths

A 35-year-old man presented with a painful cutaneous skin eruption that was localized on the upper trunk. He stated that the previous weekend he had attended an Arabian bath. The physical examination revealed multiple hair follicle-centered papulopustules surrounded by an erythematous halo. A clinical diagnosis of pseudomonas folliculitis was made and treatment was prescribed. Afterwards Pseudomonas aeruginosa was isolated from a pustule culture. Pseudomonas folliculitis is a bacterial infection of the hair follicles. The most common reservoirs include facilities with hot water and complex piping systems that are difficult to clean, such as hot tubs and bathtubs. Despite adequate or high chlorine levels, Pseudomonas aeruginosa can grow within a biofilm.

Serratia marcescens folliculitis and concomitant acne vulgaris

We present a unique case of S. marcescens folliculitis of the trunk in a 46-year-old woman with a history of facial acne vulgaris during her teen years. Her eruption occurred at the time of elective ambulatory surgery when she was treated with pre and post-operative antibiotics. The diagnosis of S. marcescens folliculitis was made on the basis of histopathologic features and tissue culture of a skin biopsy specimen of a pustule after her eruption was unresponsive to conventional treatment for inflammatory acne vulgaris. The history and pathophysiology of gram-negative folliculitis in the setting of acne vulgaris is reviewed.

[Pseudomonas folliculitis outbreaks associated with swimming pools or whirlpools in two guest-room sites in the northern region of Israel]

In summer 2010-2011 two outbreaks of Pseudomonas foliculitis occurred among bathers who used the swimming pools or whirlpools in two guest-room sites. The source of the infection was traced to the swimming pools or whirlpools, which had not been chlorinated and monitored routinely. Of 40 bathers, 25 (62.5%) developed Pseudomonas folliculitis 2-4 days after exposure. Typically the rash began as a pruritic erythematous papule on the buttocks, axilla, and extremities, with fever, adenopathy and otitis externa. In the culture of the pustules and bacterial examination grew Pseudomonas aeroginosa. Pseudomonas folliculitis was first described by McCausland and Cox in 1975. To the best of our knowledge, this is the first description of outbreaks in swimming pools or whirlpools in guest-room sites in Israel. This article describes the epidemiological and environmental health investigation of the two outbreaks. With the rising popularity of swimming pools and whirlpools in guest-room sites, physicians in the community and the emergency rooms may encounter this disease. We urge their real time report to the public health offices, in charge of the epidemiological inquires, aiming to prevent the occurrence of new cases or improper treatment of similar cases.

[Pseudomonas folliculitis after spa bath exposure]

Pseudomonas aeruginosa is a rare cause of folliculitis. Pseudomonas folliculitis can develop after contact with contaminated water from swimming pools, hot tubs and spa baths. Systemic therapy may be indicated in patients with widespread lesions, systemic symptoms or in immunosuppressed patients. We describe a 23-year-old healthy woman who developed a pustular rash and general malaise after using a spa bath contaminated with Pseudomonas aeruginosa. Bacterial culture from a pustule confirmed Pseudomonas folliculitis and the patient was treated with ciprofloxacin with rapid good effect.

Tufted hair folliculitis in a patient affected by pachydermoperiostosis: case report and videodermoscopic features

A 25-year-old man presented with Touraine-Solente-Golé syndrome (primary pachydermoperiostosis), with an area of inflammatory dermatosis (12-month evolution) of the scalp at the cranial vertex. The patient presented with arthropathy, clubbing of the digits, diffuse periostosis, pachydermia of the hands and feet, and periosteal hyperostosis of the knee. Facial seborrhea and sebaceous gland hyperplasia were evident (Figure 1A and 1B and Figure 2A and 2B). Examination of the scalp revealed an erythematous pruritic plaque with erosions, crusts, and pustules, on which multiple tufts of 10 to 20 normal-looking hairs emerged from single follicular openings (Figure 3A). Slight pressure on the perifollicular areas resulted in the discharge of purulent material through the dilated follicular openings. Cervical and occipital lymph nodes were not enlarged, and the patient was in generally good health. Routine laboratory findings were normal. Immunologic studies, including a screening for antinuclear antibody, complement, and immunoglobulins, were normal. Both potassium hydroxide staining and fungal culture were negative. Bacteriologic culture of purulent material taken from the affected area was positive for Staphylococcus aureus. Videodermoscopy of the lesion showed rarefied interfollicular twisted red loops centered around actively affected follicles and white dots with absence of normal vascular pattern (Figure 3B). These dermoscopy patterns are markers for folliculitis decalvans, of which tufted hair folliculitis (THF) is a clinical variant. Histologic examination showed hair plugging, a dense perifollicular infiltrate of plasma cells, lymphocytes, neutrophils, and large areas of scarring and fibrosis, which would confirm suspected THE THF was diagnosed on the grounds of clinical, microbiologic, histologic, and videodermoscopy data. The patient was treated with amoxicillin 875 mg plus clavulanic acid 125 mg twice daily and topical nadifloxacin 1% twice daily for 20 days, achieving substantial clinical improvement. One month after antimicrobial therapy, a single area of cicatricial alopecia with a few hair tufts emerging from single orifices was observed, and no new lesions or symptoms had appeared.

Follicular variant of seborrheic dermatitis: is it identical to Malassezia folliculitis?

Follicular accentuation in some patients with seborrheic dermatitis of the back and chest has been recognized for more than a century. The recognition of Malassezia folliculitis in recent decades has led to some confusion regarding categorization of these cases. The author proposes that there is sufficient clinical variation between the typical case of Malassezia folliculitis and patients with follicular seborrheic dermatitis to justify continued separation of these entities until further study provides more clarification.

Tufted hair folliculitis: complete enduring response after treatment with rifampicin

BACKGROUND

A 47-year-old woman presented with erythematous lesions with papules and pustules on her parieto-occipital region that had been present for 8 months. Areas of sclero-atrophic alopecia were evident, whereas at different points tufted hair shafts were coming out from single dilatated follicular ostia. Before our observation, an antibiotic oral therapy with tetracyclines and local with erythromycin had been administered to the patient, with partial improvement and relapse on its suspension.

METHODS

Bacterial culture from pustules showed the development of Staphylococcus aureus. A skin biopsy was done. According to clinical and histopathological findings a diagnosis of tufted hair folliculitis was made and a treatment with oral rifampicin was started at the dosage of 450 mg twice per day.

RESULTS

After 3 weeks of therapy, the pustular lesions regressed completely and after a follow-up of 1 year no relapse was observed.

CONCLUSIONS

Rifampicin is one of the best active antibiotics against S. aureus, which seems to play a role in the pathogenesis of tufted hair folliculitis. Our results, if further confirmed, may suggest a role for rifampicin either for the control of the pustular phase of this rare disorder or to prevent its relapses for a long time.

[Traction folliculitis: 6 cases caused by different types of hairstyle that pull on the hair]

Excessive hair traction caused by hairstyles that pull the hair too tightly may cause noninfectious mechanical and irritant folliculitis known as traction folliculitis. We present a series of 6 cases of traction folliculitis caused by different hairstyles. All patients were women aged between 12 and 26 years old. Their hairstyles were braids, ponytails, pigtails, cornrows, and hair extensions in 2 patients. The lesions consisted of small, slightly painful, follicular pustules confined to the sites of maximum hair traction and surrounded by erythema. Only in 1 case were the lesions associated with traction alopecia. In 2 cases in which bacterial cultures were done, Staphylococcus aureus was isolated. All patients improved after undoing their hairstyle and treatment with oral flucloxacillin. We assume that the role of S aureus is secondary and opportunistic, given that only follicles subject to traction and not the adjacent ones were affected.

Beyond spaghetti and meatballs: skin diseases associated with the Malassezia yeasts

Malassezia are common lipid-dependent fungi that grow on the sebaceous areas of human skin, including the face, scalp, and upper trunk. Although Malassezia are a part of the normal human skin flora, they may also cause or exacerbate several skin diseases, including tinea versicolor, Pityrosporum folliculitis, and seborrheic dermatitis. Topical antifungals are the mainstay of treating Malassezia-related diseases. Chronic prophylaxis is often required to prevent recurrences.

Skin diseases associated with Malassezia species in humans. Clinical features and diagnostic criteria

Malassezia yeasts not only cause the well known pityriasis versicolor and folliculitis, but also play an important role in other skin diseases, including seborrheic dermatitis and atopic dermatitis. The presence of Malassezia yeasts may be confirmed by direct microscopic examination and cultures of skin scrapings. In pityriasis versicolor the direct microscopic examination is the rapidest and surest test for confirming the clinical diagnosis. The preparation will show a cluster of globose budding spores with thick or double wall and short hyphae. For detecting Malassezia in the other diseases the cultures is preferable. Culture is useful both for confirming the clinical diagnosis and for epidemiological investigations. The identification of the Malassezia species is not easy. The microscopic observation of the colony direct towards the identification of Malassezia species, but it is not enough to identify the colonies definitely. Several biochemical tests are necessary for a precise identification, such as catalase reaction, growth on media without lipid sources, ability to utilize hydrophilic emulsifiers as sole lipid source, esculin test, tryptophan test.

Hot tub folliculitis or hot hand–foot syndrome caused by Pseudomonas aeruginosa

Pseudomonas aeruginosa is a ubiquitous gram-negative rod that can cause a well-recognized, acquired skin infection from bacterial colonization of contaminated water called "hot tub folliculitis." We report an outbreak of pseudomonas skin infection associated with the use of a hot tub at a pool party in 33 children. In particular, 2 of the children were admitted to our hospital; both presented with high leukocyte counts, intermittent low grade fevers, and painful, erythematous nodules and papules on their palms and soles. One of the 2 children also presented with small erythematous pustular lesions on the face and trunk, which led to the diagnosis. Cultures from these pustules grew P aeruginosa. Thirty two other children at this pool/hot tub party developed similar lesions of varying severity 6 to 48 hours after the party. These findings were most consistent with the diagnosis of pseudomonas folliculitis/hot hand.

Pulsed-field gel electrophoresis patterns and antimicrobial susceptibility phenotypes for coagulase-positive staphylococcal isolates from pustules and carriage sites in dogs with superficial bacterial folliculitis

OBJECTIVE

To determine whether coagulase-positive staphylococcal isolates that are genotypically the same strain obtained from pustules and carriage sites of individual dogs with superficial bacterial folliculitis have the same antimicrobial susceptibility phenotype.

ANIMALS

40 dogs with superficial bacterial folliculitis.

PROCEDURES

Samples were obtained from 3 pustules and 3 carriage sites (ie, anus, nonlesional axillary skin, and nasal mucosa) for bacterial culture, morphologic identification, Gram staining, catalase and coagulase testing, antimicrobial susceptibility testing, speciation, and pulsed-field gel electrophoresis (PFGE).

RESULTS

223 isolates from pustules and carriage sites were included. Seventeen susceptibility phenotypes were found among isolates. One hundred twenty-eight (100%) isolates from pustules and 95 (100%) isolates from carriage sites were susceptible to cephalothin; 128 (100%) isolates from pustules and 94 (98.9%) isolates from carriage sites were susceptible to amoxicillin-clavulanic acid; 114 (89.1%) isolates from pustules and 82 (86.3%) isolates from carriage sites were susceptible to erythromycin and lincomycin hydrochloride; and 103 (80.5%) isolates from pustules and 70 (73.7%) isolates from carriage sites were susceptible to trimethoprim-sulfamethoxazole. In 37 of 39 (94.9%) dogs, isolates with the same PFGE pattern from multiple pustules had the same susceptibility phenotype. In 21 of 33 (63.6%) dogs, isolates from multiple carriage sites with the same PFGE pattern had the same susceptibility phenotype.

CONCLUSIONS AND CLINICAL RELEVANCE

In dogs with superficial bacterial folliculitis, most coagulase-positive staphylococcal isolates from pustules that are genotypically the same strain will have the same susceptibility phenotype and treatment may be based on empiric antimicrobial selection or susceptibility testing of 1 lesional isolate.

Folliculitis decalvans of the scalp: response to triple therapy with isotretinoin, clindamycin, and prednisolone

Folliculitis decalvans of the scalp is a recurrent, purulent follicular inflammation leading to scarring alopecia. We report on a 27-year-old man with folliculitis decalvans successfully treated with a combination of isotretinoin, corticosteroids, and clindamycin.

Industrial Pseudomonas folliculitis

INTRODUCTION

Complaints of poor water quality and skin rashes among workers at a US cardboard manufacturing facility were investigated to determine potential causes.

METHODS

Employees were interviewed regarding work duties and health symptoms. Areas of dermatitis in affected employees were visually examined. Collected water samples were tested for potential chemical and microbial contaminants.

RESULTS

A total of 27 employees were identified with complaints of recent skin rashes affecting primarily the upper and lower extremities. Dermatitis complaints were associated with water contact and work in areas with poor water quality. Water testing showed high levels of Pseudomonas aeruginosa. Other tested substances were not at levels of concern.

CONCLUSIONS

Overgrowth of P. aeruginosa occurred in the water system shortly after the facility switched to a closed-loop water recycling system and was the most likely cause of the observed dermatitis. To our knowledge, this is the first reported outbreak of Pseudomonas folliculitis in an industrial setting.

Genotypic relatedness of staphylococcal strains isolated from pustules and carriage sites in dogs with superficial bacterial folliculitis

OBJECTIVE

To determine whether staphylococcal isolates cultured from pustules and carriage sites in dogs with superficial bacterial folliculitis were genotypically the same strain by use of pulsed-field gel electrophoresis (PFGE).

ANIMALS

40 dogs with superficial bacterial folliculitis.

PROCEDURES

Samples were obtained from 3 pustules and 3 carriage sites (anus, axillary skin, and nasal mucosa). Bacterial culture, morphologic identification, Gram staining, catalase and coagulase tests, speciation, and PFGE were performed.

RESULTS

Of 246 isolates, 203 were Staphylococcus intermedius, 5 were Staphylococcus aureus, 15 were Staphylococcusspp, and 22 were coagulase-negative staphylococcal isolates. No dog had an isolate with the same PFGE pattern as an isolate from another dog. Coagulase-positive isolates from multiple pustules and multiple carriage sites had the same PFGE pattern in 37 of 39 (94.9%) and 22 of 39 (56.4%) dogs, respectively. Coagulase-positive staphylococcal isolates from at least 1 pustule had the same PFGE pattern as an isolate from at least 1 carriage site in 34 of 36 (94.4%) dogs. Ninety-seven of 116 (83.6%) coagulase-positive staphylococcal isolates from pustules had the same PFGE pattern as an isolate from at least 1 carriage site. Sixty-nine of 91 (75.8%) coagulase-positive staphylococcal isolates from carriage sites had the same PFGE pattern as an isolate from at least 1 pustule.

CONCLUSIONS AND CLINICAL RELEVANCE

Coagulasepositive staphylococcal strains were heterogeneous among dogs with superficial bacterial folliculitis. In individual dogs, strains from multiple pustules were genotypically the same, and strains from pustules were genotypically the same as strains from carriage sites.

Community-acquired methicillin-resistant Staphylococcus aureus skin infection presenting as a periumbilical folliculitis

Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) infection is a clinical problem of increasing global incidence. CAMRSA most commonly presents as abscess and cellulitis of the skin and soft tissue. However, the lesions of cutaneous CAMRSA infection are pleomorphic and may appear as erythematous pustules of superficial folliculitis. This report presents the cases of 2 patients with CAMRSA skin infection that presented as a superficial folliculitis. The distribution of CAMRSA-related, erythematous, folliculocentric pustules was periumbilical, in contrast to the lesional location of methicillin-susceptible S. aureus (MSSA)-associated folliculitis, which typically appears on the axillae, bearded area, buttocks, and extremities. CAMRSA should be considered in the diagnosis of periumbilical folliculitis or superficial folliculitis arising in areas not typically affected by MSSA-related folliculitis, such as the chest, flanks, and scrotum.

[The use of calcofluor white for studying Malassezia species by direct microscopy]

Fungi of Malassezia genus are known as normal flora in human beings. However, different pathologies due to Malassezia, have been described. Traditionally, early diagnosis was delayed because of the difficulties in culture isolation of these organisms. The aim of this work, is to evaluate the technique of observation microscopy with calcofluor, for identification of Malassezia in both, clinical samples and isolates. In comparison to traditional method of direct examination with lactophenol-blue, calcofluor method offers an advantage because it turns easier the observation of fungal elements and its budding pattern. This technique contributes then, to identify species of Malassezia. The analysis of clinical specimens with calcofluor followed by observation under fluorescence microscopy is a simple and rapid method for the identification, and contribute therefore to the early diagnosis.

[Malassezia. Current knowledge and study perspectives]

The study of Malassezia has been postponed for many years due to its nutritional requirements and its morphological variability. Molecular biology methods led to a taxonomic revision of this genus and to a new interest for its clinical importance. Nowadays, 11 Malassezia species are known, 10 are lipophilic, having similar morphological, physiological and biochemical characteristics, therefore, conventional techniques are not useful to differentiating them. Molecular methods are an accurate tool in the identification and they lead to a better knowledge of the ecology and epidemiology of this genus. Noteworthy antifungal susceptibility variations have been observed in some species, although there is not a standard method for these yeasts. There are few data about their biochemical characteristics, and the enzymes they produce might be important virulence factors, favouring host tissue invasion. Malassezia has been recognised as a member of the normal human and animal skin. Its implication in pathologic processes, including skin diseases to systemic infections, is the main issue in current investigations in order to determine the real pathogenic role of these yeasts.

Malassezia Baillon, emerging clinical yeasts

The human and animal pathogenic yeast genus Malassezia has received considerable attention in recent years from dermatologists, other clinicians, veterinarians and mycologists. Some points highlighted in this review include recent advances in the technological developments related to detection, identification, and classification of Malassezia species. The clinical association of Malassezia species with a number of mammalian dermatological diseases including dandruff, seborrhoeic dermatitis, pityriasis versicolor, psoriasis, folliculitis and otitis is also discussed.

Acinetobacter baumanii folliculitis in a patient with AIDS

Gram-negative folliculitis usually involves the face and develops in patients with acne or rosacea during long-term antibiotic therapy. Numerous pathogens have been found, but not, until now, Acinetobacter baumanii which has previously been recognized as an important cause of nosocomial infections and hospital outbreaks. We report here a case of A. baumanii folliculitis of the face, neck, arms and upper part of trunk in a patient with AIDS responding to intravenous treatment with ticarcillin-clavulanic acid. The bacterium was not found on healthy skin and the source of the infection remained unknown.

Malassezia folliculitis on the scalp of a 12-year-old healthy child

Malassezia folliculitis is a condition chracterized by itchy follicular papules and pustules with erythema. Malassezia yeasts are the pathogens in this condition. It is mainly located on the back, shoulders, and chest. Presented here is a 12-year-old boy with malassezia folliculitis on the scalp. The case was found to be worthy of presentation because it rarely occurs in childhood and is rarely located on the scalp.

Pityrosporum folliculitis: diagnosis and management in 6 female adolescents with acne vulgaris

BACKGROUND

Pityrosporum folliculitis is a common inflammatory skin disorder that may mimic acne vulgaris. Some adolescents with recalcitrant follicular pustules or papules may have acne and Pityrosporum folliculitis simultaneously. Clinical response is dependent on treating both conditions.

OBJECTIVES

To demonstrate the similarity in clinical manifestation between acne vulgaris and Pityrosporum folliculitis, the benefit of potassium hydroxide preparation, and the benefit of appropriate antifungal therapy.

PATIENTS

We describe 6 female adolescents with concurrent Pityrosporum folliculitis infection and acne vulgaris.

INTERVENTION

A potassium hydroxide examination was performed on all 6 patients from the exudate of follicular pustules exhibiting spores consistent with yeast. All patients were treated with oral antifungals, and 5 of the 6 patients were also treated with topical antifungals.

RESULTS

Six of 6 patients improved with antifungal treatment. All patients also required some ongoing therapy for their acne.

CONCLUSIONS

These patients demonstrate that follicular papulopustular inflammation of the face, back, and chest may be due to a combination of acne vulgaris and Pityrosporum folliculitis, a common yet less frequently identified disorder. Symptoms often wax and wane depending on the patient's activities, time of the year, current treatment regimens, and other factors. Pityrosporum folliculitis will often worsen with traditional acne therapy and dramatically respond to antifungal therapy.

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.

Involvement of granulysin-producing T cells in the development of superficial microbial folliculitis

BACKGROUND

Granulysin is a recently identified antimicrobial protein expressed on cytotoxic T cells, natural killer (NK) cells and NKT cells. It has been shown that granulysin contributes to the defence mechanisms against mycobacterial infection. Superficial microbial folliculitis is a common skin disease. In a previous report, we showed that, as a first line of defence, alpha-defensin, a human neutrophil peptide, and beta-defensin (human beta-defensin-2) were expressed in infiltrating neutrophils and in lesional epidermal keratinocytes, respectively, in superficial folliculitis. As we also observed many infiltrating lymphocytes in lesional dermis, we hypothesized that infiltrating lymphocytes may possess antimicrobial substances, such as granulysin, and play a role in the defence mechanism as a second line of defence.

OBJECTIVES

Seven specimens of superficial microbial folliculitis diagnosed clinically and histologically were examined by means of immunohistochemistry. To identify the phenotype of cells expressing granulysin, confocal laser microscopic examination was performed.

RESULTS

A dense lymphoid cell infiltrate was observed in pustules, in the perivascular regions. A large number of these lymphoid cells were positive for granulysin. Phenotypically, cells consisted of CD3+ T cells, CD8+ T cells and UCHL-1+ T cells. CD20+ cells and CD56+ cells were not observed. Microscopic examination with a confocal laser showed that the lymphocytes producing granulysin were CD3+ and CD4+ T cells but not CD8+ T cells.

CONCLUSIONS

We showed that many granulysin-bearing T cells infiltrated affected follicles and perilesional dermis in superficial microbial folliculitis. However, few granulysin-positive lymphoid cells were observed in sterile pustular lesions. Our observations indicated that adaptive immunity such as granulysin, a lymphocyte-produced antimicrobial protein, may play an important role in the cutaneous defence mechanism.

Treatment of gram-negative folliculitis in patients with acne

Gram-negative folliculitis may be the result of long-term antibacterial treatment in acne patients. It is caused by bacterial interference and replacement of the Gram-positive flora of the facial skin and the mucous membranes of the nose and infestation with Gram-negative bacteria. These Gram-negative bacteria include Escherischia coli, Pseudomonas aeruginosa, Serratia marescens, Klebsiella and Proteus mirabilis. The occurrence of Gram-negative folliculitis should be considered in acne patients in whom oral treatment with tetracyclines has not resulted in a significant improvement of acne lesions after 3-6 months' treatment. The occurrence of Gram-negative folliculitis in acne patients is believed to be generally underestimated, since correct sampling and bacteriology is rarely performed by clinicians. Gram-negative folliculitis in acne and rosacea patients is best treated with isotretinoin (0.5-1 mg/kg daily for 4-5 months).

[Malassezia species isolated from skin diseases in a care center in the city of Buenos Aires, Argentina]

The epidemiology of Malassezia genus is poorly understood; geographical and population factors might have influence on the species distribution. The aim of this work was to determine the frequency of Malassezia species involved in skin diseases in a diagnostic center at Buenos Aires City. From 02/01/1999 to 10/31/2001, 456 skin specimens from 447 patients diagnosed as pityriasis versicolor, seborrheic dermatitis, foliculitis and atopic dermatitis, were analyzed by microscopic examination and culture. Malassezia spp was evidenced in 255 skin samples (55.9%) by microscopic analysis but it could be recovered from only 99 (38.8%) specimens. Malassezia species were isolated from 10 (3.9%) scarring lesions that were negative by microscopy. Among 109 isolates, M. sympodialis (58.7%) was the most frequent, followed by M. globosa and M. furfur (18.3% and 9.2%). Unique isolates (0.9%) of M. obtusa, M. slooffiae and M. restricta were recovered. Eleven isolates (10.1%) could not be identified because they had lost viability in the culture. This is the first study on Malassezia species associated to skin diseases in Argentina; further screening including other geographic regions of the country is necessary in order to confirm these results.

Presumed Pseudomonas folliculitis outbreak in children following an outdoor games event

In early summer 2001, an outbreak of atypical rash occurred among children from 24 junior schools who attended an outdoor games event. The event comprised a series of five water games including a water slide, and within 24 hours of attending the event 151/593 (26%) children developed a papulopustular rash. The rash had a characteristic distribution, predominantly over the lower trunk and buttocks, with some involvement of the arms and legs. Pseudomonas aeruginosa was isolated from a water butt used to draw water for the games, and from the tank of a fire engine that supplied the water. Similar outbreaks, due to Pseudomonas folliculitis, have been previously described and in immunocompromised people this can be associated with serious illness. We recommend that superchlorinated water be used for water play events and that care be taken to avoid abrasive surfaces.

Folliculitis decalvans--a retrospective study in a tertiary referred centre, over five years

Folliculitis decalvans is a rare condition affecting mainly the scalp leading to scarring alopecia. Aetiology of the condition is still unknown, abnormal host response to Staphylococcus aureus has been postulated. We present a retrospective analysis of six cases of folliculitis decalvans presented to National Skin Centre (NSC), Singapore for the past five years, 1995-2000. The mean age of presentation was 39 years and ages ranged from 17 to 62 years. There were five male patients and one female patient. Duration of symptoms at presentation varied from six months to seven years. Occipital and vertex areas of the scalp were the only regions involved. Staphylococcus aureus was isolated in three patients; in one patient culture yielded negative results and no culture was done in the other two patients. All our patients were treated with several separate courses of systemic antibiotics which include doxycycline, erythromycin, minocycline, co-trimoxazole, cloxacillin, erythromycin, rifampicin and clindamycin. In addition one patient was treated with fucidic acid and zinc sulphate. The disease ran a protracted course with temporary improvement while on antibiotic and flare up of disease when antibiotics were stopped. The effectiveness of early treatment with rifampicin has been highlighted in some case reports in the past. We did use rifampicin in one of our patients. Our concern over emergence of antibiotic resistance, if used widely, may not permit us to use rifampicin on a wide scale.