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Malassezia (Pityrosporum) Folliculitis Clinical Presentation

  • Author: Sarah Sweeney Pinney, MD; Chief Editor: William D James, MD  more...
 
Updated: Apr 12, 2016
 

History

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.[11] Recalcitrant acne should be reevaluated for potential Pityrosporum infection.[12]

A history of hospitalization may also play a role in initial colonization.[13]

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Physical

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,[14] 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.[15]

Many patients have coexisting seborrheic dermatitis.[10]

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Causes

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:

  • Diabetes mellitus
  • Cushing disease
  • Hodgkin disease [16]
  • 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 [17]
  • HIV infection
  • Corticosteroids and/or immunosuppressant therapy following organ transplantation [18, 19, 20]
  • Crohn disease treated with infliximab a monoclonal antibody against tumor necrosis factor alpha. [21]

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[24] are other conditions that are associated with Pityrosporum folliculitis.

Other related and coexisting conditions may include the following:

  • Seborrheic dermatitis
  • Confluent and reticulated papillomatosis
  • Systemic candidiasis [25]

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.

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Contributor Information and Disclosures
Author

Sarah Sweeney Pinney, MD Assistant Professor, Department of Dermatology, University of Texas Medical School at Houston

Sarah Sweeney Pinney, MD is a member of the following medical societies: American Academy of Dermatology, Texas Dermatological Society, Texas Medical Association, Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Ronald P Rapini, MD Professor and Chair, Department of Dermatology, The University of Texas MD Anderson Cancer Center; Distinguished Chernosky Professor and Chair of Dermatology, Professor of Pathology, University of Texas McGovern Medical School at Houston

Ronald P Rapini, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Society for Investigative Dermatology, Texas Medical Association

Disclosure: Received royalty from Elsevier publishers for independent contractor; May receive consulting fee from FDA panel for consulting in future, since I am on one of their committees, but at this time so far have received zero from FDA.

Rashid M Rashid, MD, PhD Director, Mosaic Clinic Hair Transplant Center of Houston

Rashid M Rashid, MD, PhD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Texas Dermatological Society, International Society of Hair Restoration Surgery, Council for Nail Disorders, Houston Dermatological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Jaggi Rao, MD, FRCPC Clinical Professor of Medicine, Division of Dermatology and Cutaneous Sciences, Director of Dermatology Residency Program, University of Alberta Faculty of Medicine and Dentistry

Jaggi Rao, MD, FRCPC is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, Canadian Medical Association, Pacific Dermatologic Association, Royal College of Physicians and Surgeons of Canada, Canadian Medical Protective Association, Canadian Dermatology Association

Disclosure: Nothing to disclose.

Acknowledgements

Daniel J Hogan, MD Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center

Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, and Canadian Dermatology Association

Disclosure: Nothing to disclose.

Siobahn M Hruby, MD Internal Medicine Physician, Boys Town National Research Hospital

Siobahn M Hruby, MD is a member of the following medical societies: American College of Physicians and American Medical Association

Disclosure: Nothing to disclose.

Stephen H Mason, MD

Stephen H Mason is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Society for Dermatologic Surgery, Skin Cancer Foundation, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Brittany J Oswald, MD Resident Physician, Department of Internal Medicine, Ochsner Clinic Foundation Hospital

Brittany J Oswald is a member of the following medical societies: American Medical Association and American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

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This photo is high-power hematoxylin and eosin staining of a biopsy confirming Pityrosporum folliculitis. There is a hair shaft within a hair follicle with scattered amphophilic staining circular Pityrosporum yeast. Photo courtesy of Ronald Rapini, MD.
 
 
 
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