Pityrosporum Folliculitis Diagnosis and Management in 6 Female Adolescents with Acne Vulgaris

ARTICLE Pityrosporum Folliculitis Diagnosis and Management in 6 Female Adolescents With Acne Vulgaris

Katherine Ayers, BA; Susan M. Sweeney, MD; Karen Wiss, MD

Background: Pityrosporum folliculitis is a common in- All patients were treated with oral antifungals, and 5 of flammatory skin disorder that may mimic acne vulgaris. the 6 patients were also treated with topical antifungals. Some adolescents with recalcitrant follicular pustules or papules may have acne and Pityrosporum folliculitis si- Results: Six of 6 patients improved with antifungal treat- multaneously. Clinical response is dependent on treatment. All patients also required some ongoing therapy ing both conditions. for their acne.

Objectives: To demonstrate the similarity in clinical Conclusions: These patients demonstrate that follicular manifestation between acne vulgaris and Pityrosporum fol- papulopustular inflammation of the face, back, and chest liculitis, the benefit of potassium hydroxide prepara- may be due to a combination of acne vulgaris and Pityros- tion, and the benefit of appropriate antifungal therapy. porum folliculitis, a common yet less frequently identified disorder. Symptoms often wax and wane depending on the Patients: We describe 6 female adolescents with concur- patient’s activities, time of the year, current treatment regi- rent Pityrosporum folliculitis infection and acne vulgaris. mens, and other factors. Pityrosporum folliculitis will often worsen with traditional acne therapy and dramatically re- Intervention: A potassium hydroxide examination spond to antifungal therapy. was performed on all 6 patients from the exudate of follicular pustules exhibiting spores consistent with yeast. Arch Pediatr Adolesc Med. 2005;159:64-67

ITYROSPORUM FOLLICULITIS other yeast forms support the diagnosis. was first described in 1969 by It may be difficult to distinguish clini- Weary et al1 and noted to be cally from acne vulgaris. Traditional acne an acneiform eruption asso- therapies, especially antibiotics, worsen ciated with antibiotic use. It Pityrosporum folliculitis. We discuss 6 pa- isP an infection of the hair follicle thought tients with recalcitrant “acne” who had to be caused by the common cutaneous acne vulgaris and Pityrosporum folliculi- yeast, Malassezia furfur (Pityrosporum tis simultaneously. ovale) and possibly other strains of Mal- assezia.2-4 Malassezia is a dimorphic lipo- METHODS philic yeast that can be found in small numbers in the stratum corneum and hair follicles of up to 90% of individuals with- All patients were seen in the general pediatric out disease.2-4 Some individuals colo- dermatology clinics at University of Massa- nized with Malassezia develop folliculi- chusetts Memorial Health Care, Worcester, as part of routine clinic visits. The University of tis, while others develop tinea versicolor 5,6 Massachusetts Medical School institutional and seborrheic dermatitis. The papulo- review board was notified of this retrospec- pustular folliculitis is most commonly tive case review study and granted approval found on the chest, back, upper arms, and without full committee review. Author Affiliations: Division less frequently on the face. Often it is mis- of Dermatology, Departments diagnosed as acne.6,7 of Medicine (Drs Sweeney RESULTS and Wiss) and Pediatrics Pityrosporum folliculitis typically ap- (Drs Sweeney and Wiss), pears as 1- to 2-mm pruritic, monomor- University of Massachusetts phic, pink papules and pustules. Positive All 6 of the patients seen at University of Medical School (Ms Ayers), potassium hydroxide (KOH) examina- Massachusetts Memorial dermatology clin- Worcester. tion results showing numerous spores and ics were adolescent white girls with a his-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Table. Clinical Characteristics and Treatment of 6 Patients With Concurrent Pityrosporum Folliculitis and Acne Vulgaris

Patient/ Age, y Duration Areas of Involvement Previous Treatment Treatment Results 1/16 5 y Monomorphic pink Oral TMP/Sulfa; Discontinued TMP/Sulfa; 8-mo F/U: complete resolution of inflammatory papules papules and azelaic acid cream; ketoconazole 200 mg PO and pustules; flares during humid weather and pustules on cheeks adapalene gel once daily for 2 wk then increased activity and shoulders 400 mg PO once per week for 6 wk for flares (during increased activity and hot weather); 2% ketoconazole shampoo daily for 2 wk, then as needed 2/16 4-6 wk 1- to 2-mm Erythromycin Ketoconazole 200 mg PO 6-mo F/U: decreased number of comedones; no Monomorphic solution; BID for 1 d, then daily for inflammatory papules or pustules papules and antibacterial soap 2 wk; 2% ketoconazole pustules on chest shampoo 2-3 times per and upper back week as needed; transient improvement; switched to: fluconazole 200 mg PO once per week for 3 wk, then once per month for 5 mo; 2.5% selenium sulfide shampoo 3 times per wk 3/15 3 wk 1- to 2-mm Topical 1% Discontinued oral 3-mo F/U: decreased number of papules and pustules; Monomorphic, clindamycin cephalexin and topical started taking cephalexin again, 500 mg PO twice erythematous solution twice clindamycin;ketoconazole daily; tretinoin 0.04% microgel at bedtime; benzoyl papules and daily; cephalexin 200 mg PO daily for 2 peroxide 5% wash daily as needed pustules on 500 mg PO twice wk, repeat for flares in 9-mo F/U: stopped using all oral and topical antibiotics; forehead and lateral daily for 2 wk hot weather; 2% ketoconazole 2% cream as needed; 20% azelaic acid cheeks (Figures 1 ketoconazole cream twice cream daily as needed and 2) daily as needed; 14-mo F/U: increasing number of pruritic pustules and ketoconazole 2% inflammatory papules not responding to oral shampoo daily as needed ketoconazole, oral antibiotics, or topical treatments; started taking 6-mo course of oral isotretinoin (total 120-mg/kg dose); complete resolution of symptoms 3 mo after taking oral isotretinoin 4/12 12 mo Monomorphic, pink Minocycline 100 mg Discontinued minocycline 24-mo F/U: rare comedones and inflammatory papules papules, pustules, PO daily; benzoyl administration; (acne); no pustules and closed peroxide 2.5% fluconazole (40 mg/mL) comedones on wash; 0.1% 2.5 mL daily for 2 wk; cheeks, forehead, tretinoin gel; 20% 2% ketoconazole shoulders, and azelaic acid cream shampoo 3 times per back week as needed 5/9 24 mo Pruritic, Oral erythromycin; Ketoconazole 200 mg PO 1-mo F/U: pruritic inflammatory papules and small erythematous, 0.1% tretinoin gel; daily for 2 wk; 2% pustules resolved; comedones and larger pustules monomorphic 1% clindamycin ketoconazole shampoo increased in number; cephalexin 500 mg PO twice papules and gel; 5% benzoyl 2-3 per week; 0.04% daily prescribed for acne pustules on face, peroxide, tretinoin microgel daily; 1-y F/U: markedly improved chest, and back; 0.5% gel; 4% benzoyl peroxide comedones and hydrocortisone wash daily pitted scars on face lotion 6/15 48 mo Pruritic 1- to 2-mm Minocycline 100 mg Discontinued minocycline 3-wk F/U: greatly reduced number of papules and erythematous, PO BID for 2 mo administration; pustules; pruritus resolved monomorphic ketoconazole 200 mg PO papules and daily for 3 wk; 2% pustules on ketoconazole shampoo forehead; larger daily; 0.4% tretinoin pustules on cheeks, microgel at bedtime; 1% jawline, and neck clindamycin lotion daily; 2.5% benzoyl peroxide wash daily

Abbreviations: BID, twice daily; F/U, follow-up; PO, by mouth; TMP/Sulfa, trimethoprim/sulfamethoxazole.

tory of pruritic papules and pustules on the face, chest, inflammatory papules, pustules, and comedones of acne and/or back (Table). The patients had limited re- vulgaris, these patients also displayed uniform 1- to 2-mm sponses to traditional acne therapies and recent exacer- monomorphic, erythematous papules and pustules bation of their symptoms. In addition to the traditional (Figure 1 and Figure 2) that were pruritic during hot,

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out signs and symptoms of folliculitis or other disease.2,4 Furthermore, Pityrosporum folliculitis is associ- ated with the use of oral corticosteroids, diabetes mellitus, organ transplantation, chemotherapy, and other immu- nosuppressed states.8,9 Pityrosporum folliculitis is commonly found in adolescents presumably because of the increased activity of their sebaceous glands. Some colonized individuals develop tinea versicolor, and others develop Pityrosporum folliculitis. Perhaps the density of lipids in the piloseba- Figure 1. A 15-year-old girl with 1- to 2-mm erythematous papules and pustules of Pityrosporum folliculitis. ceous unit of acne-prone individuals leads to a higher con- centration of the organism in hair follicles and thus a folliculitis. All of our patients were female, and some other humid weather and increased activity. A KOH examina- studies also report increased incidence among girls. How- tion on scrapings of the monomorphic pustules re- ever, a predominance in boys and equal sex distribution vealed spores and budding yeast forms consistent with have also been described.5,7 In our patients, the female Pityrosporum folliculitis in all 6 patients. They were di- predominance may reflect a referral bias of girls to fe- agnosed with Pityrosporum folliculitis in addition to acne male physicians. Pityrosporum folliculitis is also more com- vulgaris. Any oral antibiotics that were being used at the mon in hot and humid climates.5,8 Four of our 6 pa- time of diagnosis were discontinued. Six of 6 patients re- tients had flares during hot, humid weather and with sponded well to a combination of topical and oral anti- increased episodes of sweating. fungal treatment. Four of the 6 patients experienced flares Given the role of follicular plugging, it is no surprise of symptoms especially during hot and humid weather that our patients had a combination of acne and Pityros- requiring intermittent treatment with both oral and topi- porum folliculitis. Treatment regimens that address both cal antifungals. The patients were also treated with topi- of these conditions are necessary for improvement. cal or oral medications for their acne vulgaris, but anti- Antibiotics commonly used to treat acne may suppress biotics, especially oral antibiotics, were used sparingly normal bacterial flora and allow overgrowth of Malasse- and only when necessary. zia. This may explain some cases of what appears to be persistent acne that shows no improvement and actu- COMMENT ally worsens with oral antibiotic treatment as seen in patient 4. Pityrosporum folliculitis may be underdiagnosed In treating recalcitrant acne complicated by Pityros- because it can mimic acne vulgaris. Typical patients porum folliculitis, host response plays a significant role will not respond to or only partially respond to topical in determining whether a patient may be able to perma- and oral antibiotics, topical retinoids, and other acne nently eradicate the yeast colonization. Patients may re- treatments. A KOH examination is an easy, inexpen- quire prophylaxis or retreatment (ie, antifungal sham- sive, and accessible method of immediately clarifying poos and/or pulse dosing of oral antifungals), especially the diagnosis. during times in which they are prone to breakouts. Five The pathophysiologic features of Pityrosporum fol- of our 6 patients who responded to oral antifungal treat- liculitis involve follicular occlusion followed by an over- ment also required maintenance with ketoconazole sham- growth of yeast that thrives in a sebaceous environ- poo or selenium sulfide shampoo. In addition, 3 of these ment.3,7 Altered host immunity is also thought to play a 6 patients required multiple courses of oral antifungals. role in Pityrosporum folliculitis because 90% of people Pityrosporum folliculitis usually responds well to oral have Malassezia as a part of their normal skin flora with- antifungal medications. Topical antifungals are less use-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 ful in the initial treatment of Pityrosporum folliculitis but must be advised of potential adverse effects of ketocona- are important in maintenance and prophylaxis. The dis- zole and other antifungals including nausea, vomiting, continuation of oral and topical antibiotics is also use- diarrhea, abdominal pain, and hepatotoxicity. Liver func- ful when treating Pityrosporum folliculitis. Further- tion should be evaluated in patients on long courses or more, one is able to get a clearer picture of the extent of multiple courses of oral ketoconazole. the acne once the folliculitis is treated if some or all of acne medications are discontinued prior to the initia- tion of antifungal treatment. Accepted for Publication: August 19, 2004. A KOH mount can be prepared by gently scraping 1 Correspondence: Karen Wiss, MD, Pediatric Derma- of the monomorphic pustules with a sterile scalpel blade, tology, University of Massachusetts Medical School, Hah- smearing the pustular contents on a glass slide, and treat- nemann Campus, 281 Lincoln St, Worcester, MA 01605 ing it with 1 to 2 drops of 10% KOH and a coverslip. The ([email protected]). slide can then be examined under the microscope for spores. This allows for a more immediate diagnosis than REFERENCES either skin biopsy or culture.6 Cultures of Malassezia are rarely required for diagnosis and are complicated by the 1. Weary PE, Russell CM, Butler HK, Hsu YT. Acneform eruption resulting from an- yeast’s special culture-medium requirements. Malasse- tibiotic administration. Arch Dermatol. 1969;100:179-183. zia grows only within a medium rich in C12,C13, and C14 2. Faergemann J, Johansson S, Bäck O, Scheynius A. An immunologic and cultural fatty acids, which can be achieved by adding olive oil to study of Pityrosporum folliculitis. J Am Acad Dermatol. 1986;14:429-433. the medium.9 3. Hill MK, Goodfield MJ, Rodgers FG, Crowley JL, Saihan EM. Skin surface electron microscopy in Pityrosporum folliculitis: the role of follicular occlusion in disease These patients were described with the goal of en- and the response to oral ketoconazole. Arch Dermatol. 1990;126:1071-1074. couraging physicians to have a high suspicion for Pit- 4. Roberts SO. Pityrosporum orbiculare: incidence and distribution on clinically nor- yrosporum folliculitis in adolescent patients with recal- mal skin. Br J Dermatol. 1969;81:264-269. citrant acne. We also advocate performing a KOH 5. Bäck O, Faergemann J, Hörnqvist R. Pityrosporum folliculitis: a common disease preparation in any patient with monomorphic or acne- of the young and middle aged. J Am Acad Dermatol. 1985;12:56-61. 6. Yu HJ, Lee SK, Son SJ, Kim YS, Yang HY, Kim JH. Steroid acne vs Pityrosporum iform pustules on the scalp, trunk, or upper extremities folliculitis: the incidence of Pityrosporum ovale and the effect of antifungal drugs who is not responding to or worsening with antibiotics. in steroid acne. Int J Dermatol. 1998;37:772-777. There is no one specific treatment regimen that can be 7. Abdel-Razek M, Fadaly G, Abdel-Raheim M, Al-Morsy F. Pityrosporum (Malasse- suggested to eradicate both acne vulgaris and Pityrospo- zia) folliculitis in Saudi Arabia: diagnosis and therapeutic trials. Clin Exp Dermatol. 1995;20:406-409. rum folliculitis. Therefore, close patient follow-up to moni- 8. Alves EV, Martins JE, Ribeiro EB, Sotto MN. Pityrosporum folliculitis: renal trans- tor response to therapy is important. Our patients re- plantation case report. J Dermatol. 2000;27:49-51. sponded well to oral ketoconazole or fluconazole. Patients 9. Rupke SJ. Fungal skin disorders. Prim Care. 2000;27:407-421.

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