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Successful Treatment of Protracted Malassezia Folliculitis Initially Misdiagnosed as Pityriasis Versicolor
Case Report
Successful Treatment of Protracted Malassezia Folliculitis Initially Misdiagnosed as Pityriasis Versicolor Edward J. Bottone, Ph.D.,1,2 and Christopher M. Marro, B.A.,2 1Division of Infectious Diseases, Mount Sinai School of Medicine, New York, New York and 2Division of Infectious Diseases, New York Medical College, Valhalla, New York
Introduction Malassezia species are part of the normal human cutaneous flora, occurring mainly on the trunk and head, with the highest densities in post-pubertal adolescents (1). Except for Malassezia pachydermatis, the remaining six species require an exogenous source of lipid for growth, because they are unable to synthesize C14 to C16 fatty acids (1). Clinically, Malassezia species cause a variety of recurrent cutaneous infections, i.e., pityriasis versicolor, folliculitis, seborrheic dermatitis, and a spectrum of other dermatologic Mailing address: Edward J. Bottone, Ph.D., Division of Infectious Diseases, Box 1090, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029. Tel.: 212-241-6741. Fax: 212-5343240. E-mail: [email protected]
Clinical Microbiology Newsletter 33:6,2011
disorders (2). Catheter-related fungemia associated with administration of total parenteral nutrition through central venous catheters has also been documented, especially in premature neonates (3). In regard to cutaneous infections, we report here the occurrence of a protracted case of Malassezia folliculitis in a college student, which was cured by the application of topical cream containing 2.5% selenium sulfide after the correct diagnosis of folliculitis was made rather than a diagnosis of pityriasis versicolor.
Case Report In July 2009, a 21-year-old college student began to notice small round lesions appearing only on her chest. She had no prior history of such an eruption, which began shortly after she completed a course of azithromycin for an upper © 2011 Elsevier
respiratory tract infection. Initially, the student was not alarmed by the eruption, which she attributed to an acneform outbreak. After 3 months without resolution, the papules became more pronounced and moderately pruritic, especially after an intensive, sweat-inducing 1- to 2-hour workout in the non-air-conditioned college gymnasium. Because of the persistence of the lesions, the student consulted a dermatologist, who superficially scraped her chest with a scalpel and subjected the specimen to a KOH test, which was interpreted as negative because of the absence of yeast forms and hyphae. Nevertheless, her eruption was diagnosed as tinea (pityriasis) versicolor, and she was instructed to wash the area with an antidandruff shampoo containing 1% zinc pyrithione. Two months of once-daily 3-minute washings with the 0196-4399/00 (see frontmatter)
45
shampoo resulted in partial resolution of the lesions. At this juncture, because of the persistence of the lesions, a microbiologic consultation was undertaken, during which small, dome-shaped erythematous papular lesions with a central “dell,” representing the follicle, were noted scattered over the patient’s chest. With use of a sterile scalpel, two lesions were individually unroofed, and the bases of the lesions were scraped. The tissue fragments collected were smeared onto glass slides. Fragments from the second scraping were directly inoculated onto 5% sheep blood agar that was overlaid with sterile olive oil and incubated at 35oC after the stained smears were reviewed.
Microbiology The two slides were stained by the Diff-Quick (IMEB Inc, San Marco, CA) method and examined microscopically. Numerous yeast cells with unipolar budding and collarettes at the sites of budding were seen (Fig. 1). Hyphae were not observed in either of the stained preparations. Dry white colonies developed on the inoculated sheep blood agar after 4 days of incubation. Colonies grew only where the scraped inoculum was overlaid with olive oil. Because of the oil overlay, smears were difficult to stain, but careful teasing of a peripheral colony subjected to Gram staining showed typical oval yeast cells with collarettes (Fig. 2).
Figure 1. Diff-Quik stain of lesion scraping showing clusters of oval yeast cells of Malassezia displaying characteristic double-contoured walls and budding from one pole of the parent cell. Note the flat bud scar (collarette) on some yeasts at the site of separation of the bud from the mother cell and the absence of hyphae (magnification, ×1,000).
Discussion Malassezia folliculitis occurs in various patient groups, including immunosuppressed individuals, pregnant women, and occasionally following broad-spectrum antibiotic use, which can alter normal skin flora and allow Malassezia species to proliferate (2,4-6). Malassezia follicular lesions are most commonly distributed over the back, and chest, and occasionally on the upper aspect of the arms. The condition is generally benign and, as noted in the present case, can be confused with acne (2,5,6). Malassezia folliculitis is most common in young adults and is more frequent in tropical countries and in summer in temperate regions (2,4,6). Exposure to heat and humidity and sweating are also recognized as predisposing factors (6-8). Our patient 46
0196-4399/00 (see frontmatter)
Figure 2. Malassezia yeast cells in a Gram-stained smear of a colony growing under an olive oil overlay on 5% sheep blood agar. Note the characteristic double wall and unipolar budding with collarettes (magnification, ×1,000).
noted that her skin eruption, which followed antibiotic treatment, was more pronounced after intensive exerciseinduced sweating in July. Pityriasis versicolor is controlled by the use of fungistatic shampoos active against Malassezia species (6,8). These products are intended to remove scales, reduce Malassezia adherence to cor© 2011 Elsevier
neocytes, and prevent continued yeast growth. Exposure time to the cleansing solution is germane to the degree of penetration of the superficial stratum corneum. Piérard-Franchimont et al. (8) documented that in controlling Malassezia-induced dandruff, a 5minute residence time of the shampoo was superior to simple shampooing. Clinical Microbiology Newsletter 33:6,2011
However, in the case of Malassezia folliculitis, in which the follicles are plugged (9), the yeast forms are observed in the superficial or middle portion of the inflamed hair follicle. This region is comprised of encased cutaneous papules harboring hair follicles conjointly with an inflammatory reaction and intrafollicular mucin deposits within which Malassezia yeast forms are embedded (7). The depth of the follicular infection and inflammatory response and mucin pools may preclude the penetration of transient topical treatment, such as washing the involved area with a shampoo. In the present case, subsequent to microbiologic diagnosis, resolution of the folliculitis was achieved by the daily application for 10 min of topical antifungal cream containing 2.5% selenium sulfide for 10 days. This application of topical antifungal cream or systemic antifungal treatment with fluconazole or itraconazole is usually effective (6,10) Recently, the use of photodynamic therapy has been introduced for the treatment of recalcitrant Malassezia folliculitis (11).
Clinical Microbiology Newsletter 33:6,2011
Summary We describe a 21-year-old college student who developed recalcitrant erythematous papular lesions on her chest. Initially diagnosed as pityriasis versicolor, the lesions were partially responsive to washing with hair shampoo. The diagnosis of Malassezia folliculitis was made by evaluation of stained smears and culture of scrapings of the papular chest lesions. The daily application of a topical antifungal cream containing selenium sulfide for 10 min for 10 days brought about resolution of the infection without recurrence 3 months after treatment. References 1. Ashbee, H.R. 2006. Recent developments in the immunology and biology of Malassezia species. FEMS Immunol. Med. Microbiol. 47:14-23. 2. Tragiannidis, A. et al. 17 December 2010. Minireview: Malassezia infections in immune compromised patients. Mycoses 53:187-195. 3. Ahsbee, H.R. 2007. Update on the genus Malassezia. Med. Mycol. 45:287-303. 4. Gupta, A.K. et al. 2004. Skin diseases
© 2011 Elsevier
5.
6.
7.
8.
9.
10.
11.
associated with Malassezia species. J. Am. Acad. Dermatol. 51:785-798. Weary, P.E. et al. 1969. Acneform eruption resulting from antibiotic administration. Arch. Dermatol. 100:179-183. Levin, N.A. 2009. Beyond spaghetti and meatballs: skin diseases associated with the Malassezia yeasts. Dermatol. Nursing 21:7-14. Sina, B., C.L. Kauffman, and C.S. Samorodin. 1995. Intrafollicular mucin deposits in Pityrosporum folliculitis. J. Am. Acad. Dermatol. 32:807-809. Piérard-Franchimont, C. et al. 2003. Effect of residence time on the efficacy of antidandruff shampoos. Int. J. Cosmetic Sci. 25:267-271. Potter, B.S., C.F. Burgoon, Jr., and W.C. Johnson. 1973. Pityrosporum folliculitis. Report of seven cases and review of the Pityrosporum organisms relative to cutaneous disease. Arch. Dermatol. 107:388-391. Erchiga, V.C. and V.D. Florencio. 2002. Malassezia species in skin diseases. Curr. Opin. Infect. Dis. 15:133-142. Lee, J.W., B.J. Kim, and M.N. Kim. 2010. Photodynamic therapy: new treatment for recalcitrant Malassezia folliculitis. Lasers Surg. Med. 42:192-196.
0196-4399/00 (see frontmatter)
47
Successful Treatment of Protracted Malassezia Folliculitis Initially Misdiagnosed as Pityriasis Versicolor Edward J. Bottone, Ph.D.,1,2 and Christopher M. Marro, B.A.,2 1Division of Infectious Diseases, Mount Sinai School of Medicine, New York, New York and 2Division of Infectious Diseases, New York Medical College, Valhalla, New York
Introduction Malassezia species are part of the normal human cutaneous flora, occurring mainly on the trunk and head, with the highest densities in post-pubertal adolescents (1). Except for Malassezia pachydermatis, the remaining six species require an exogenous source of lipid for growth, because they are unable to synthesize C14 to C16 fatty acids (1). Clinically, Malassezia species cause a variety of recurrent cutaneous infections, i.e., pityriasis versicolor, folliculitis, seborrheic dermatitis, and a spectrum of other dermatologic Mailing address: Edward J. Bottone, Ph.D., Division of Infectious Diseases, Box 1090, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029. Tel.: 212-241-6741. Fax: 212-5343240. E-mail: [email protected]
Clinical Microbiology Newsletter 33:6,2011
disorders (2). Catheter-related fungemia associated with administration of total parenteral nutrition through central venous catheters has also been documented, especially in premature neonates (3). In regard to cutaneous infections, we report here the occurrence of a protracted case of Malassezia folliculitis in a college student, which was cured by the application of topical cream containing 2.5% selenium sulfide after the correct diagnosis of folliculitis was made rather than a diagnosis of pityriasis versicolor.
Case Report In July 2009, a 21-year-old college student began to notice small round lesions appearing only on her chest. She had no prior history of such an eruption, which began shortly after she completed a course of azithromycin for an upper © 2011 Elsevier
respiratory tract infection. Initially, the student was not alarmed by the eruption, which she attributed to an acneform outbreak. After 3 months without resolution, the papules became more pronounced and moderately pruritic, especially after an intensive, sweat-inducing 1- to 2-hour workout in the non-air-conditioned college gymnasium. Because of the persistence of the lesions, the student consulted a dermatologist, who superficially scraped her chest with a scalpel and subjected the specimen to a KOH test, which was interpreted as negative because of the absence of yeast forms and hyphae. Nevertheless, her eruption was diagnosed as tinea (pityriasis) versicolor, and she was instructed to wash the area with an antidandruff shampoo containing 1% zinc pyrithione. Two months of once-daily 3-minute washings with the 0196-4399/00 (see frontmatter)
45
shampoo resulted in partial resolution of the lesions. At this juncture, because of the persistence of the lesions, a microbiologic consultation was undertaken, during which small, dome-shaped erythematous papular lesions with a central “dell,” representing the follicle, were noted scattered over the patient’s chest. With use of a sterile scalpel, two lesions were individually unroofed, and the bases of the lesions were scraped. The tissue fragments collected were smeared onto glass slides. Fragments from the second scraping were directly inoculated onto 5% sheep blood agar that was overlaid with sterile olive oil and incubated at 35oC after the stained smears were reviewed.
Microbiology The two slides were stained by the Diff-Quick (IMEB Inc, San Marco, CA) method and examined microscopically. Numerous yeast cells with unipolar budding and collarettes at the sites of budding were seen (Fig. 1). Hyphae were not observed in either of the stained preparations. Dry white colonies developed on the inoculated sheep blood agar after 4 days of incubation. Colonies grew only where the scraped inoculum was overlaid with olive oil. Because of the oil overlay, smears were difficult to stain, but careful teasing of a peripheral colony subjected to Gram staining showed typical oval yeast cells with collarettes (Fig. 2).
Figure 1. Diff-Quik stain of lesion scraping showing clusters of oval yeast cells of Malassezia displaying characteristic double-contoured walls and budding from one pole of the parent cell. Note the flat bud scar (collarette) on some yeasts at the site of separation of the bud from the mother cell and the absence of hyphae (magnification, ×1,000).
Discussion Malassezia folliculitis occurs in various patient groups, including immunosuppressed individuals, pregnant women, and occasionally following broad-spectrum antibiotic use, which can alter normal skin flora and allow Malassezia species to proliferate (2,4-6). Malassezia follicular lesions are most commonly distributed over the back, and chest, and occasionally on the upper aspect of the arms. The condition is generally benign and, as noted in the present case, can be confused with acne (2,5,6). Malassezia folliculitis is most common in young adults and is more frequent in tropical countries and in summer in temperate regions (2,4,6). Exposure to heat and humidity and sweating are also recognized as predisposing factors (6-8). Our patient 46
0196-4399/00 (see frontmatter)
Figure 2. Malassezia yeast cells in a Gram-stained smear of a colony growing under an olive oil overlay on 5% sheep blood agar. Note the characteristic double wall and unipolar budding with collarettes (magnification, ×1,000).
noted that her skin eruption, which followed antibiotic treatment, was more pronounced after intensive exerciseinduced sweating in July. Pityriasis versicolor is controlled by the use of fungistatic shampoos active against Malassezia species (6,8). These products are intended to remove scales, reduce Malassezia adherence to cor© 2011 Elsevier
neocytes, and prevent continued yeast growth. Exposure time to the cleansing solution is germane to the degree of penetration of the superficial stratum corneum. Piérard-Franchimont et al. (8) documented that in controlling Malassezia-induced dandruff, a 5minute residence time of the shampoo was superior to simple shampooing. Clinical Microbiology Newsletter 33:6,2011
However, in the case of Malassezia folliculitis, in which the follicles are plugged (9), the yeast forms are observed in the superficial or middle portion of the inflamed hair follicle. This region is comprised of encased cutaneous papules harboring hair follicles conjointly with an inflammatory reaction and intrafollicular mucin deposits within which Malassezia yeast forms are embedded (7). The depth of the follicular infection and inflammatory response and mucin pools may preclude the penetration of transient topical treatment, such as washing the involved area with a shampoo. In the present case, subsequent to microbiologic diagnosis, resolution of the folliculitis was achieved by the daily application for 10 min of topical antifungal cream containing 2.5% selenium sulfide for 10 days. This application of topical antifungal cream or systemic antifungal treatment with fluconazole or itraconazole is usually effective (6,10) Recently, the use of photodynamic therapy has been introduced for the treatment of recalcitrant Malassezia folliculitis (11).
Clinical Microbiology Newsletter 33:6,2011
Summary We describe a 21-year-old college student who developed recalcitrant erythematous papular lesions on her chest. Initially diagnosed as pityriasis versicolor, the lesions were partially responsive to washing with hair shampoo. The diagnosis of Malassezia folliculitis was made by evaluation of stained smears and culture of scrapings of the papular chest lesions. The daily application of a topical antifungal cream containing selenium sulfide for 10 min for 10 days brought about resolution of the infection without recurrence 3 months after treatment. References 1. Ashbee, H.R. 2006. Recent developments in the immunology and biology of Malassezia species. FEMS Immunol. Med. Microbiol. 47:14-23. 2. Tragiannidis, A. et al. 17 December 2010. Minireview: Malassezia infections in immune compromised patients. Mycoses 53:187-195. 3. Ahsbee, H.R. 2007. Update on the genus Malassezia. Med. Mycol. 45:287-303. 4. Gupta, A.K. et al. 2004. Skin diseases
© 2011 Elsevier
5.
6.
7.
8.
9.
10.
11.
associated with Malassezia species. J. Am. Acad. Dermatol. 51:785-798. Weary, P.E. et al. 1969. Acneform eruption resulting from antibiotic administration. Arch. Dermatol. 100:179-183. Levin, N.A. 2009. Beyond spaghetti and meatballs: skin diseases associated with the Malassezia yeasts. Dermatol. Nursing 21:7-14. Sina, B., C.L. Kauffman, and C.S. Samorodin. 1995. Intrafollicular mucin deposits in Pityrosporum folliculitis. J. Am. Acad. Dermatol. 32:807-809. Piérard-Franchimont, C. et al. 2003. Effect of residence time on the efficacy of antidandruff shampoos. Int. J. Cosmetic Sci. 25:267-271. Potter, B.S., C.F. Burgoon, Jr., and W.C. Johnson. 1973. Pityrosporum folliculitis. Report of seven cases and review of the Pityrosporum organisms relative to cutaneous disease. Arch. Dermatol. 107:388-391. Erchiga, V.C. and V.D. Florencio. 2002. Malassezia species in skin diseases. Curr. Opin. Infect. Dis. 15:133-142. Lee, J.W., B.J. Kim, and M.N. Kim. 2010. Photodynamic therapy: new treatment for recalcitrant Malassezia folliculitis. Lasers Surg. Med. 42:192-196.
0196-4399/00 (see frontmatter)
47