Pityriasis Versicolor in Children and Adolescents: an Update
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Current Fungal Infection Reports (2019) 13:157–168 https://doi.org/10.1007/s12281-019-00360-8 FUNGAL INFECTIONS OF SKIN AND SUBCUTANEOUS TISSUE (A BONIFAZ AND M PEREIRA, SECTION EDITORS) Pityriasis Versicolor in Children and Adolescents: an Update Karen Adilene Camargo-Sánchez1 & Mirna Toledo-Bahena1 & Carlos Mena-Cedillos1 & Erika Ramirez-Cortes2 & Sonia Toussaint-Caire3 & Adriana Valencia-Herrera1 & Marcela Salazar-García4 & Alexandro Bonifaz5 Published online: 7 November 2019 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Purpose of Review Pityriasis versicolor (PV) is a superficial mycosis that it can occur at any age, even in newborns. In this review, we will describe epidemiological data, mycological characteristics of yeast, pathogenesis and clinical characteristics of the disease, different diagnostic resources, and the current recommendations for treatment. Recent Findings The typical morphology and topography of PV allow us to make a quick diagnosis, but atypical presentations have been described. Diagnostic tools, such as dermoscopy, can also reveal patterns that allow the evaluation of characteristics of scales and pigment in lesions. The discovery of new species and new mechanisms of interaction with the host has broadened the panorama of aetiological possibilities. Summary Although PV is a common disorder, extensive research is necessary to better understand the pathophysiology of the disease, immunological characteristics of the pathogen-host relationship and resources needed to precisely diagnose the disease, treat the disease, and avoid its chronic and recurrent course. Keywords Pityriasis versicolor . Malassezia spp. children . adolescents . tinea versicolor . superficial mycoses . hypopigmented lesions Introduction new species of Malassezia as etiological agents and mecha- nisms of interaction with the host, as well as new treatment Superficial mycoses are frequent entities in daily medical opportunities. In this review, we will focus on these findings practice, so their recognition is important. Pityriasis versicolor and also describe the concepts regarding epidemiology, diag- (PV) is one of them and its most common manifestation facil- nosis, treatment and prognosis. itates diagnosis; however, there are new clinical forms de- scribed that extend the differential diagnoses of the disorder, Concept This article is part of the Topical Collection on Fungal Infections of Skin and Subcutaneous Tissue PV is a superficial (restricted to the stratum corneum), chronic * and relapsing mycosis caused by yeasts of the genus Adriana Valencia-Herrera •• [email protected] Malassezia [1 ]. The name PV derives from the fine desqua- mation, appearing similar to bran and being present in the lesions that characterize this condition, which can be 1 Department of Dermatology, Hospital Infantil de México Federico Gómez, Dr. Márquez 162, Col. Doctores, Del. Cuauhtémoc, hypopigmented or hyperpigmented. PV has also been called CP 06720 Ciudad de México, México tinea versicolor, mainly in Anglo-Saxon literature, because the – 2 Hospital Star Médica Infantil Privado, Ciudad de México, México aetiological agent is called Microsporon furfur [2 4]. 3 Division of Dermatology, Hospital General Dr. Manuel Gea González, Ciudad de México, México 4 Department of Biomedical Research, Hospital Infantil de México Epidemiology Federico Gómez, Ciudad de México, México 5 Department of Dermatology and Mycology, Hospital General de PV is a cosmopolitan entity but is predominately found in México Dr. Eduardo Liceaga, Ciudad de, MéxicoMéxico tropical regions where it affects up to 40–50% of individuals 158 Curr Fungal Infect Rep (2019) 13:157–168 and tends to recur in summer, unlike regions such as Sweden The genus Malassezia currently includes 18 species that where a frequency of up to 0.5% has been reported [5, 6]. are present on the skin, 10 of which have been found on Although no recent studies have been performed on the dis- human skin, while the remaining 8 species were isolated from ease, Heidrich et al. reported a 0.3% decrease in the preva- homeothermic animals, as shown in Table 2 [4, 28, 29]. lence per year [1••]. Although M. furfur was previously considered a unique aetiological agent of PV,we currently know that the frequency Age of M. furfur as a causative agent varies across different species based on reports from multiple studies according to the region PV can occur at any age and some reports indicate its emer- studied, the year of the study and the methods used to identify gence even in the neonatal period in association with factors Malassezia species; for example: such as prematurity, hospitalization in intensive care units, – high humidity in incubators, direct contact with affected fam- In Argentina in 2012, M. sympodialis and M. globosa ily members and persistence of maternal hormones. PV is were reported to have the highest frequencies at 51% more common in adolescents and young adults. The predom- and 40%, respectively [26]. – inant age group varies in different studies, with some patients In Adana, Turkey, in 2009, M. globosa was documented aged older than 30 years [1••, 7–11]. In infants, frequencies in 47.7% of PV cases, M. furfur was documented in ranging from 3.7 to 31% have been described [12, 13]. 36.4% of PV cases and M. slooffiae was documented in 15.9% of PV cases [31]. – In 2014, in Iran, M. globosa was isolated in 65.1% of PV Gender cases and M. obtusa was isolated in 17.4% of PV cases [17]. PV is more common in men, which has been attributed to – In 28 students in northeast Iran, M. restricta was the most increased sebaceous activity [1••]. However, some studies frequently detected species [20]. have reported a higher frequency in women, most likely be- – In recurrent disseminated PV, a newly proposed form of cause women seek medical care more often than men [9, 14, the disease, M. japonica and M. furfur were isolated more 15]. frequently [32]. However, in 2013, in patients with exten- sive PV,species other than those previously reported were Phototype not detected [28]. PV usually presents in dark phototypes, but this link is con- Notably, as shown in Table 2, M. pachydermatis and sidered to correspond to a more prominent appearance of the M. nana, which were initially isolated in animals, have also lesions; however, some studies do not support the tendency been isolated in PV lesions, as indicated in Table 1,wherewe towards hypopigmented lesions in individuals with darker show the Malassezia species isolated from PV lesions in stud- skin or that the predisposition is dependent on age or gender ies conducted in the last 5 years. •• [1 , 16]. To differentiate between Malassezia species, a combination Table 1 shows the characteristics of patients with PV in of biochemical, morphological, biological and molecular tests studies published in the last 5 years. is required. Morphologically, Malassezia yeasts measure 1.5– 10 μm, exhibit asexual reproduction with monopolar budding, have shapes varying from spherical to ovoid, and have a thick Aetiology (Mycological Characteristics) wall compared to other yeasts (measuring 0.12 μm), which accounts for up to 26–37% of the cell volume. Cultures should The genus Malassezia includes yeasts of the division be performed in special media, such as Sabouraud-dextrose Basidiomycota, subphylum Ustilaginomycotina, class supplemented with sterile olive oil, Dixon medium or its mod- Malasseziomycetes and family Malasseziaceae, most of ified formula, Leeming and Notman agar and Ushijima medi- which are dependent on lipids (except M. pachydermatis). um, except for the species M. pachydermatis, which is capable These yeasts are part of the microbiota of nearly the entire of growing in conventional media. The saprophytic (yeast) surface of the human skin, except for the soles of the feet phase requires the presence of fatty acids for its progression and are mainly found on areas such as the scalp, face and and yields mycelium (the opportunistic phase) under favorable trunk. Under certain conditions, these yeasts are associated conditions. To achieve this, temperatures between 30 and 35 °C with a broad spectrum of clinical entities, although PV is the and humidity must be supplied to the cultures, which should be most common disease caused by such agents and the only placed in plastic bags to prevent desiccation. Biochemical and disease for which Malassezia has been established as a caus- physiological tests and reagents, such as the catalase reaction, ative agent [1••, 26, 27]. β-glucosidase, polysorbate requirements 20, 40, 60, and 80 Curr Fungal Infect Rep (2019) 13:157 Table 1 Epidemiological characteristics and species of Malassezia in PV Author Country Year Number of Gender Age group with higher Most frequent clinical Most frequent anatomical Identified species Identification method patients (%) frequency (years) variant location Rodoplu et al. Turkey 2014 146 M=82.8 18–34 NR More than 1 area M. globosa 65.1% Catalase activity and [17] F=17.1 M. obtusa 17.4% β-glucosidase, M. japonica 7.4% SDA culture, assimilation of M. nana 3.7% cremophor EL, utilization of Tweens 20, 40, 60, and 80, precipitate production in mDixon – Xie et al. [18] China 2014 24 NR NR NR NR M. globosa 95.8% RT-PCR 168 M. restricta 91.7% M. dermatis 33.3% Ibekwe et al. Nigeria 2015 304 M=38.8 12–21 Hypopigmented Face M. furfur 81.7% PCR-RFLP [19] F=61.1 M. restricta 5.1% M. sympodialis 2.3% Heidrich et al. Brazil 2015 2239 M= 42 21–30 NR Trunk NR NR [1] F= 58 Sharma et al. India 2016 262 M=65.6 21–30 Hypopigmented Neck M. furfur 77.3% PCR-RFLP [10] F=34.4 M. globosa 12.4% Moallaei et al. Iran 2017 42 M=59.5 18–22 NR Neck M. restricta PCR- RFLP [20] F=40.5 (8.4%) M. globosa (6.2%) M. sympodialis (4.2%) M. furfur 3% Yahya et al. [15] Nigeria 2017 265 M=40.2 20–29 NR NR NR NR F=59.8 Elshabrawy et al.