eMedicine Specialties > Dermatology > Fungal Infections

Pityrosporum Folliculitis

Author: Siobahn M Bower, MD, Internal Medicine Resident, Creighton University
Coauthor(s): Daniel J Hogan, MD, Affiliate Teaching Faculty, Sun Coast Hospital; Investigator, Hill Top Research, Florida Research Center; Stephen H Mason, MD, Assistant Professor of Dermatology, Medical College of Georgia
Contributor Information and Disclosures

Updated: Sep 11, 2008

Introduction

Background

Pityrosporum folliculitis (PF) is an inflammatory skin disorder that typically manifests as a pruritic, follicular papulopustular eruption distributed on the upper trunk of young to middle-aged adults. Weary et al first described PF in 1969, and, later in 1973, Potter et al1 identified PF as a separate clinical and histologic diagnosis.

Yeasts, specifically Malassezia furfur, are the pathogenic agents in PF. M furfur has been linked to several skin diseases, including seborrheic dermatitis, folliculitis, pityriasis versicolor, and atopic dermatitis. In 1874, Malassez first described round and oval budding yeasts from scales of patients with seborrheic dermatitis. He coined the phrases "bottle bacillus of Unna" to describe the small oval cells in the scale and "spore of Malassez" to name the bud that is observed in association with the yeast. Saborouraud proposed the Pityrosporum genus in 1904 to describe the budding yeast cells without hyphal elements from normal skin. Later, in the 1900s, Pityrosporum ovale and Pityrosporum orbiculare were isolated by Castellani and Chalmers and Gordon, respectively.

These 2 yeast species, collectively with fungal forms, are classified as M furfur because of controversy and confusion of the grouping of various lipophilic yeasts and fungi of the skin. This grouping has simplified the classification to one name, which applies regardless of the morphology of the organism. With the advancement of technology, 7 species of Malassezia were recognized: M furfur, Malassezia pachydermatous, Malassezia sympodialis, Malassezia globosa, Malassezia obtusa, Malassezia restricta, and Malassezia slooffiae. However, the focus of this article is M furfur, which is considered the pathologic agent of PF. Lesions are chronic, erythematous, pruritic papules and pustules, which occur in a follicular pattern. These lesions are usually present on the back and chest and, occasionally, on the neck, shoulders, upper arms, and face.

The diagnosis of PF is based on clinical suspicion of the classic presentation of pruritic papulopustules found in a follicular pattern on the back, chest, upper arms, and, occasionally the neck. They are rarely present on the face. An improvement in the lesions with empiric antimycotic therapy supports a clinical diagnosis of PF.

A related Medscape CE course is Fungal Skin and Nail Infections: Practical Advice for Advanced Practice Clinicians. Additionally, a general folliculitis eMedicine article is Folliculitis.

Pathophysiology

M furfur (ie, P ovale and P orbiculare) is a lipophilic, saprophytic, budding, unipolar, dimorphic, gram-positive, double-walled, oval-to-round yeast. M furfur is part of the normal skin flora. It is suggested that the similar yeasts P orbiculare and P ovale are actually identical and that they are morphologic variants of M furfur.

Malassezia yeasts are classified as superficial mycoses that by definition do not invade past the cornified epithelium. In PF, however, the organism is present in the ostium and central and deep segments of the hair follicle.

Plugging of the follicle followed by an overgrowth of yeast that thrives in the sebaceous environment is believed to be the etiology. Malassezia yeasts require free fatty acids for survival. Usually, they are found in the stratum corneum and in pilar folliculi in areas with increased sebaceous gland activity such as the chest and back. The yeasts hydrolyze triglycerides into free fatty acids and create long-chain and medium-chain fatty acids from free fatty acids. The result is a cell-mediated response and activation of the alternative complement pathway, which leads to inflammation.

Frequency

United States

Malassezia organisms can be found on the skin in 75-98% of healthy people. These organisms are part of the normal skin florae of many individuals who do not have signs or symptoms of folliculitis or other disease. Colonization by M furfur begins soon after birth, and the peak presence of the yeasts occurs in late adolescence and early adult life, coinciding with increasing activity of sebaceous glands and concentration of lipids in the skin.

International

P ovale is present on 90-100% of the surface of healthy skin; higher numbers of the yeast are present on the chest and back. Certain climates influence the percentage of people with P ovale and the number of people with PF. People living in warm and humid climates have a higher incidence of PF.  One clinic in the Philippines documented that 16% of all patient visits were a result of PF.2 A 2008 report from China cites that 1.5% off all dermatology patients were diagnosed with PF, most of them healthy, middle-aged males.3

Mortality/Morbidity

PF may be a bothersome condition (ie, severe pruritus), but the lesions are benign. Some underlying conditions that predispose the patient to PF include diabetes mellitus, immunodeficiency, and systemic candidiasis4 ; these conditions may cause morbidity. Consider the presence of predisposing conditions when PF is diagnosed.

Race

No known racial differences in the frequency of PF exist.

Sex

Reports vary from a male-to-female ratio of 1:1 to a predominance of one or the other sex. In the literature, the consensus is that the female-to-male ratio is 1.5:1.

Age

The disease is recognized as one that affects youths and young and middle-aged adults5 ; PF is most common in those aged 13-45 years. However, 3 cases of PF occurred in an ICU setting in older individuals who were in consecutive beds, who received care from the same nursing staff, and who all received high-dose antibiotics.6

Clinical

History

  • The 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 PF 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.7

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.
  • PF is present on body locations in which Malassezia organisms are most abundant: back and chest, neck, shoulders, scalp,8 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.
  • PF often is mistaken for acne vulgaris; however, no comedones or cysts are associated with PF.9
  • Many patients have coexisting seborrheic dermatitis.4

Causes

PF 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 disease10
    • HIV infection
    • Corticosteroids and/or immunosuppressant therapy following organ transplantation11,12
  • An increase in sebum production, such as that in pregnancy,13,14 and high levels of androgens may potentiate the development of PF.
  • Antibiotics can alter normal skin flora, allowing the yeast to proliferate.
  • PF 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 PF.
  • Anticonvulsant therapy and Down syndrome15 are other conditions that are associated with PF.
  • Other related and coexisting conditions may include the following:
    • Seborrheic dermatitis
    • Confluent and reticulated papillomatosis
    • Systemic candidiasis16
  • Some individuals seem to have an innate propensity for PF.
    • In one experiment, Malassezia yeasts were applied to occluded forearm skin in patients with PF. Flares of PF occurred at the application site.
    • In the same experiment, PF did not develop in patients with no prior diagnosis of the condition.

More on Pityrosporum Folliculitis

Overview: Pityrosporum Folliculitis
Differential Diagnoses & Workup: Pityrosporum Folliculitis
Treatment & Medication: Pityrosporum Folliculitis
Follow-up: Pityrosporum Folliculitis
References
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References

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Further Reading

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Keywords

Pityrosporum folliculitis, fungal infection, skin fungus, PF, Malassezia folliculitis, PF, Pityrosporum orbiculare, P orbiculare, Pityrosporum ovale, P ovale, Malassezia furfur, M furfur

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Contributor Information and Disclosures

Author

Siobahn M Bower, MD, Internal Medicine Resident, Creighton University
Siobahn M Bower, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel J Hogan, MD, Affiliate Teaching Faculty, Sun Coast Hospital; 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.

Stephen H Mason, MD, Assistant Professor of Dermatology, Medical College of Georgia
Stephen H Mason, MD 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.

Medical Editor

Jean-Hilaire Saurat, MD, Chair, Professor, Department of Dermatology, University of Geneva, Switzerland
Jean-Hilaire Saurat, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

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, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

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