Malassezia (Pityrosporum) Folliculitis Clinical Presentation
- Author: Sarah Sweeney Pinney, MD; Chief Editor: William D James, MD more...
The Pityrosporum folliculitis patient's history is that of a chronic, often extremely pruritic, papular and pustular eruption with perifollicular erythema most commonly on the back, upper arms, and chest.
The main differential diagnoses of Pityrosporum folliculitis are acne vulgaris and staphylococcal folliculitis. Often, patients have been treated with medication appropriate for acne vulgaris, resulting in no improvement or worsening of their condition. Recalcitrant acne should be reevaluated for potential Pityrosporum infection.
A history of hospitalization may also play a role in initial colonization.
Multiple, discrete, 2- to 4-mm erythematous monomorphic, papules and, later, pustules are observed. Lesions have a definite follicular pattern. Material expressed from pustules is white to yellow.
Pityrosporum folliculitis is present on body locations in which Malassezia organisms are most abundant: back and chest, neck, shoulders, scalp, upper arms (occasional), and face (rare).
Under a Wood light, bright blue or white fluorescence is observed in clinically uninvolved follicles in the location of the lesions.
Pityrosporum folliculitis often is mistaken for acne vulgaris; however, no comedones or cysts are associated with Pityrosporum folliculitis.
Many patients have coexisting seborrheic dermatitis.
Pityrosporum folliculitis is caused by Malassezia yeasts, which are lipophilic. Several factors can lead to changes in immunity, sebum production, and the growth of skin flora. These factors help to produce favorable conditions for growth of these yeasts.
Systemic diseases and pharmacologic agents that encourage the growth of yeast, possibly because of alterations in immunity, include the following:
Hodgkin disease 
Cancer treated with cetuximab (IMC-C225; marketed under the name Erbitux), a chimeric (mouse/human) monoclonal antibody epidermal growth factor receptor (EGFR) inhibitor for the treatment of metastatic colorectal cancer and head and neck cancer 
Corticosteroids and/or immunosuppressant therapy following organ transplantation [18, 19, 20]
Crohn disease treated with infliximab a monoclonal antibody against tumor necrosis factor alpha. 
An increase in sebum production, such as that in pregnancy,[22, 23] and high levels of androgens may potentiate the development of Pityrosporum folliculitis.
Antibiotics can alter normal skin flora, allowing the yeast to proliferate.
Pityrosporum folliculitis more frequently occurs in environments of high heat and humidity.
Occlusion of the skin and hair follicles with cosmetics, lotions, sunscreens, emollients, olive oil, or clothing creates favorable conditions for Pityrosporum folliculitis.
Anticonvulsant therapy and Down syndrome are other conditions that are associated with Pityrosporum folliculitis.
Other related and coexisting conditions may include the following:
Confluent and reticulated papillomatosis
Systemic candidiasis 
Some individuals seem to have an innate propensity for Pityrosporum folliculitis. In one experiment, Malassezia yeasts were applied to occluded forearm skin in patients with Pityrosporum folliculitis. Flares of Pityrosporum folliculitis occurred at the application site. In the same experiment, Pityrosporum folliculitis did not develop in patients with no prior diagnosis of the condition.
Potter BS, Burgoon CF Jr, Johnson WC. Pityrosporum folliculitis. Report of seven cases and review of the Pityrosporum organism relative to cutaneous disease. Arch Dermatol. 1973 Mar. 107(3):388-91. [Medline].
Levin NA. Beyond spaghetti and meatballs: skin diseases associated with the Malassezia yeasts. Dermatol Nurs. 2009 Jan-Feb. 21(1):7-13, 51; quiz 14. [Medline].
Gaitanis G, Velegraki A, Mayser P, Bassukas ID. Skin diseases associated with Malassezia yeasts: facts and controversies. Clin Dermatol. 2013 Jul-Aug. 31(4):455-63. [Medline].
Gaitanis G, Magiatis P, Hantschke M, Bassukas ID, Velegraki A. The malassezia genus in skin and systemic diseases. Clin Microbiol Rev. 2012 Jan. 25(1):106-41. [Medline].
Akaza N, Akamatsu H, Sasaki Y, et al. Malassezia folliculitis is caused by cutaneous resident Malassezia species. Med Mycol. 2009. 47(6):618-24. [Medline].
Jacinto-Jamora S, Tamesis J, Katigbak ML. Pityrosporum folliculitis in the Philippines: diagnosis, prevalence, and management. J Am Acad Dermatol. 1991 May. 24(5 Pt 1):693-6. [Medline].
Bulmer GS, Pu XM, Yi LX. Malassezia folliculitis in China. Mycopathologia. 2008 Jun. 165(6):411-2. [Medline].
Back O, Faergemann J, Hornqvist R. Pityrosporum folliculitis: a common disease of the young and middle-aged. J Am Acad Dermatol. 1985 Jan. 12(1 Pt 1):56-61. [Medline].
Archer-Dubon C, Icaza-Chivez ME, Orozco-Topete R, Reyes E, Baez-Martinez R, Ponce de Leon S. An epidemic outbreak of Malassezia folliculitis in three adult patients in an intensive care unit: a previously unrecognized nosocomial infection. Int J Dermatol. 1999 Jun. 38(6):453-6. [Medline].
Gupta AK, Batra R, Bluhm R, Boekhout T, Dawson TL Jr. Skin diseases associated with Malassezia species. J Am Acad Dermatol. 2004 Nov. 51(5):785-98. [Medline].
Levy A, Feuilhade de Chauvin M, Dubertret L, Morel P, Flageul B. [Malassezia folliculitis: characteristics and therapeutic response in 26 patients]. Ann Dermatol Venereol. 2007 Nov. 134(11):823-8. [Medline].
Gupta P, Chakrabarti A, Singhi S, Kumar P, Honnavar P, Rudramurthy SM. Skin Colonization by Malassezia spp. in Hospitalized Neonates and Infants in a Tertiary Care Centre in North India. Mycopathologia. 2014 Jul 19. [Medline].
Aytimur D, Sengöz V. Malassezia folliculitis on the scalp of a 12-year-old healthy child. J Dermatol. 2004 Nov. 31(11):936-8. [Medline].
Ayers K, Sweeney SM, Wiss K. Pityrosporum folliculitis: diagnosis and management in 6 female adolescents with acne vulgaris. Arch Pediatr Adolesc Med. 2005 Jan. 159(1):64-7. [Medline].
Helm KF, Lookingbill DP. Pityrosporum folliculitis and severe pruritus in two patients with Hodgkin's disease. Arch Dermatol. 1993 Mar. 129(3):380-1. [Medline].
Cholongitas E, Pipili C, Ioannidou D. Malassezia folliculitis presented as acneiform eruption after cetuximab administration. J Drugs Dermatol. 2009 Mar. 8(3):274-5. [Medline].
Alves EV, Martins JE, Ribeiro EB, Sotto MN. Pityrosporum folliculitis: renal transplantation case report. J Dermatol. 2000 Jan. 27(1):49-51. [Medline].
Bufill JA, Lum LG, Caya JG, et al. Pityrosporum folliculitis after bone marrow transplantation. Clinical observations in five patients. Ann Intern Med. 1988 Apr. 108(4):560-3. [Medline].
Blaes AH, Cavert WP, Morrison VA. Malassezia: is it a pulmonary pathogen in the stem cell transplant population?. Transpl Infect Dis. 2009 Aug. 11(4):313-7. [Medline].
Nasir A, El Bahesh E, Whitten C, Lawson A, Udall JN Jr. Pityrosporum folliculitis in a Crohn's disease patient receiving infliximab. Inflamm Bowel Dis. 2010 Jan. 16(1):7-8. [Medline].
Heymann WR, Wolf DJ. Malassezia (Pityrosporon) folliculitis occurring during pregnancy. Int J Dermatol. 1986 Jan-Feb. 25(1):49-51. [Medline].
Parlak AH, Boran C, Topcuoglu MA. Pityrosporum folliculitis during pregnancy: a possible cause of pruritic folliculitis of pregnancy. J Am Acad Dermatol. 2005 Mar. 52(3 Pt 1):528-9. [Medline].
Kavanagh GM, Leeming JP, Marshman GM, Reynolds NJ, Burton JL. Folliculitis in Down's syndrome. Br J Dermatol. 1993 Dec. 129(6):696-9. [Medline].
Klotz SA, Drutz DJ, Huppert M, Johnson JE. Pityrosporum folliculitis. Its potential for confusion with skin lesions of systemic candidiasis. Arch Intern Med. 1982 Nov. 142(12):2126-9. [Medline].
Yu HJ, Lee SK, Son SJ, Kim YS, Yang HY, Kim JH. Steroid acne vs. Pityrosporum folliculitis: the incidence of Pityrosporum ovale and the effect of antifungal drugs in steroid acne. Int J Dermatol. 1998 Oct. 37(10):772-7. [Medline].
Shibata N, Saitoh T, Tadokoro Y, Okawa Y. The cell wall galactomannan antigen from Malassezia furfur and Malassezia pachydermatis contains beta-1,6-linked linear galactofuranosyl residues and its detection has diagnostic potential. Microbiology. 2009 Oct. 155:3420-9. [Medline].
Faergemann J, Bergbrant IM, Dohse M, Scott A, Westgate G. Seborrhoeic dermatitis and Pityrosporum (Malassezia) folliculitis: characterization of inflammatory cells and mediators in the skin by immunohistochemistry. Br J Dermatol. 2001 Mar. 144(3):549-56. [Medline].
Elmets CA. Management of common superficial fungal infections in patients with AIDS. J Am Acad Dermatol. 1994 Sep. 31(3 Pt 2):S60-3. [Medline].
Ferrandiz C, Ribera M, Barranco JC, Clotet B, Lorenzo JC. Eosinophilic pustular folliculitis in patients with acquired immunodeficiency syndrome. Int J Dermatol. 1992 Mar. 31(3):193-5. [Medline].
Hald M, Arendrup MC, Svejgaard EL, Lindskov R, Foged EK, Saunte DM. Evidence-based Danish Guidelines for the Treatment of Malassezia-related Skin Diseases. Acta Derm Venereol. 2014 Feb 20. [Medline].
Prohic A, Jovovic Sadikovic T, Krupalija-Fazlic M, Kuskunovic-Vlahovljak S. Malassezia species in healthy skin and in dermatological conditions. Int J Dermatol. 2015 Dec 29. [Medline].
Hill MK, Goodfield JD, Rodgers FG, Crowley JL, Saihan EM. Skin surface electron microscopy in Pityrosporum folliculitis. The role of follicular occlusion in disease and the response to oral ketoconazole. Arch Dermatol. 1990 Feb. 126(2):181-4. [Medline].
Ford GP, Ive FA, Midgley G. Pityrosporum folliculitis and ketoconazole. Br J Dermatol. 1982 Dec. 107(6):691-5. [Medline].
Viana de Andrade AC, Pithon MM, Oiticica OM. Pityrosporum folliculitis in an immunocompetent patient: clinical case description. Dermatol Online J. 2013 Aug 15. 19(8):19273. [Medline].
Pedrosa AF, Lisboa C, Gonçalves Rodrigues A. Malassezia infections: a medical conundrum. J Am Acad Dermatol. 2014 Jul. 71 (1):170-6. [Medline].
Friedman SJ. Pityrosporum folliculitis: treatment with isotretinoin. J Am Acad Dermatol. 1987 Mar. 16(3 Pt 1):632-3. [Medline].
Goodfield MJ, Saihan EM. Failure of isotretinoin therapy in Pityrosporum folliculitis. J Am Acad Dermatol. 1988 Jan. 18(1 Pt 1):143-4. [Medline].
Lee JW, Lee HI, Kim MN, Kim BJ, Chun YJ, Kim D. Topical photodynamic therapy with methyl aminolevulinate may be an alternative therapeutic option for the recalcitrant Malassezia folliculitis. Int J Dermatol. 2011 Apr. 50(4):488-90. [Medline].
Longley BJ. Fungal diseases. Elder D, Elenitas R, Jaworsky C, Johnson B, eds. Lever's Histopathology of the Skin. 8th ed. 1997. 522.