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PityrosporumFolliculitis

PityrosporumFolliculitis BackgroundPityrosporumfolliculitis is a common inflammatory skin disorder that may mimic acne vulgaris. Some adolescents with recalcitrant follicular pustules or papules may have acne and Pityrosporumfolliculitis simultaneously. Clinical response is dependent on treating both conditions.ObjectivesTo demonstrate the similarity in clinical manifestation between acne vulgaris and Pityrosporumfolliculitis, the benefit of potassium hydroxide preparation, and the benefit of appropriate antifungal therapy.PatientsWe describe 6 female adolescents with concurrent Pityrosporumfolliculitis infection and acne vulgaris.InterventionA potassium hydroxide examination was performed on all 6 patients from the exudate of follicular pustules exhibiting spores consistent with yeast. All patients were treated with oral antifungals, and 5 of the 6 patients were also treated with topical antifungals.ResultsSix of 6 patients improved with antifungal treatment. All patients also required some ongoing therapy for their acne.ConclusionsThese patients demonstrate that follicular papulopustular inflammation of the face, back, and chest may be due to a combination of acne vulgaris and Pityrosporumfolliculitis, a common yet less frequently identified disorder. Symptoms often wax and wane depending on the patient’s activities, time of the year, current treatment regimens, and other factors. Pityrosporumfolliculitis will often worsen with traditional acne therapy and dramatically respond to antifungal therapy.Pityrosporumfolliculitis was first described in 1969 by Weary et aland noted to be an acneiform eruption associated with antibiotic use. It is an infection of the hair follicle thought to be caused by the common cutaneous yeast, Malassezia furfur(Pityrosporum ovale) and possibly other strains of Malassezia.Malasseziais a dimorphic lipophilic yeast that can be found in small numbers in the stratum corneum and hair follicles of up to 90% of individuals without disease.Some individuals colonized with Malasseziadevelop folliculitis, while others develop tinea versicolor and seborrheic dermatitis.The papulopustular folliculitis is most commonly found on the chest, back, upper arms, and less frequently on the face. Often it is misdiagnosed as acne.Pityrosporumfolliculitis typically appears as 1- to 2-mm pruritic, monomorphic, pink papules and pustules. Positive potassium hydroxide (KOH) examination results showing numerous spores and other yeast forms support the diagnosis. It may be difficult to distinguish clinically from acne vulgaris. Traditional acne therapies, especially antibiotics, worsen Pityrosporumfolliculitis. We discuss 6 patients with recalcitrant “acne” who had acne vulgaris and Pityrosporumfolliculitis simultaneously.METHODSAll patients were seen in the general pediatric dermatology clinics at University of Massachusetts Memorial Health Care, Worcester, as part of routine clinic visits. The University of Massachusetts Medical School institutional review board was notified of this retrospective case review study and granted approval without full committee review.RESULTSAll 6 of the patients seen at University of Massachusetts Memorial dermatology clinics were adolescent white girls with a history of pruritic papules and pustules on the face, chest, and/or back (Table). The patients had limited responses to traditional acne therapies and recent exacerbation of their symptoms. In addition to the traditional inflammatory papules, pustules, and comedones of acne vulgaris, these patients also displayed uniform 1- to 2-mm monomorphic, erythematous papules and pustules (Figure 1and Figure 2) that were pruritic during hot, humid weather and increased activity. A KOH examination on scrapings of the monomorphic pustules revealed spores and budding yeast forms consistent with Pityrosporumfolliculitis in all 6 patients. They were diagnosed with Pityrosporumfolliculitis in addition to acne vulgaris. Any oral antibiotics that were being used at the time of diagnosis were discontinued. Six of 6 patients responded well to a combination of topical and oral antifungal treatment. Four of the 6 patients experienced flares of symptoms especially during hot and humid weather requiring intermittent treatment with both oral and topical antifungals. The patients were also treated with topical or oral medications for their acne vulgaris, but antibiotics, especially oral antibiotics, were used sparingly and only when necessary.Figure 1.A 15-year-old girl with 1- to 2-mm erythematous papules and pustules of Pityrosporumfolliculitis.Figure 2.Close-up view of the same patient showing multiple tiny pustules.Table. Clinical Characteristics and Treatment of 6 Patients With Concurrent PityrosporumFolliculitis and Acne VulgarisPatient/Age, yDurationAreas of InvolvementPrevious TreatmentTreatmentResults1/165 yMonomorphic pink papules and pustules on cheeks and shouldersOral TMP/Sulfa; azelaic acid cream; adapalene gelDiscontinued TMP/Sulfa; ketoconazole 200 mg PO once daily for 2 wk then 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 needed8-mo F/U: complete resolution of inflammatory papules and pustules; flares during humid weather and increased activity2/164-6 wk1- to 2-mm Monomorphic papules and pustules on chest and upper backErythromycin solution; antibacterial soapKetoconazole 200 mg PO BID for 1 d, then daily for 2 wk; 2% ketoconazole shampoo 2-3 times per 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 wk6-mo F/U: decreased number of comedones; no inflammatory papules or pustules3/153 wk1- to 2-mm Monomorphic, erythematous papules and pustules on forehead and lateral cheeks (Figures 1 and 2)Topical 1% clindamycin solution twice daily; cephalexin 500 mg PO twice daily for 2 wkDiscontinued oral cephalexin and topical clindamycin; ketoconazole 200 mg PO daily for 2 wk, repeat for flares in hot weather; 2% ketoconazole cream twice daily as needed; ketoconazole 2% shampoo daily as needed3-mo F/U: decreased number of papules and pustules; started taking cephalexin again, 500 mg PO twice daily; tretinoin 0.04% microgel at bedtime; benzoyl peroxide 5% wash daily as needed 9-mo F/U: stopped using all oral and topical antibiotics; ketoconazole 2% cream as needed; 20% azelaic acid cream daily as needed 14-mo F/U: increasing number of pruritic pustules and inflammatory papules not responding to oral 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 isotretinoin4/1212 moMonomorphic, pink papules, pustules, and closed comedones on cheeks, forehead, shoulders, and backMinocycline 100 mg PO daily; benzoyl peroxide 2.5% wash; 0.1% tretinoin gel; 20% azelaic acid creamDiscontinued minocycline administration; fluconazole (40 mg/mL) 2.5 mL daily for 2 wk; 2% ketoconazole shampoo 3 times per week as needed24-mo F/U: rare comedones and inflammatory papules (acne); no pustules5/924 moPruritic, erythematous, monomorphic papules and pustules on face, chest, and back; comedones and pitted scars on faceOral erythromycin; 0.1% tretinoin gel; 1% clindamycin gel; 5% benzoyl peroxide, 0.5% gel; hydrocortisone lotionKetoconazole 200 mg PO daily for 2 wk; 2% ketoconazole shampoo 2-3 per week; 0.04% tretinoin microgel daily; 4% benzoyl peroxide wash daily1-mo F/U: pruritic inflammatory papules and small pustules resolved; comedones and larger pustules increased in number; cephalexin 500 mg PO twice daily prescribed for acne 1-y F/U: markedly improved6/1548 moPruritic 1- to 2-mm erythematous, monomorphic papules and pustules on forehead; larger pustules on cheeks, jawline, and neckMinocycline 100 mg PO BID for 2 moDiscontinued minocycline administration; ketoconazole 200 mg PO daily for 3 wk; 2% ketoconazole shampoo daily; 0.4% tretinoin microgel at bedtime; 1% clindamycin lotion daily; 2.5% benzoyl peroxide wash daily3-wk F/U: greatly reduced number of papules and pustules; pruritus resolvedAbbreviations: BID, twice daily; F/U, follow-up; PO, by mouth; TMP/Sulfa, trimethoprim/sulfamethoxazole.COMMENTPityrosporumfolliculitis may be underdiagnosed because it can mimic acne vulgaris. Typical patients will not respond to or only partially respond to topical and oral antibiotics, topical retinoids, and other acne treatments. A KOH examination is an easy, inexpensive, and accessible method of immediately clarifying the diagnosis.The pathophysiologic features of Pityrosporumfolliculitis involve follicular occlusion followed by an overgrowth of yeast that thrives in a sebaceous environment.Altered host immunity is also thought to play a role in Pityrosporumfolliculitis because 90% of people have Malasseziaas a part of their normal skin flora without signs and symptoms of folliculitis or other disease.Furthermore, Pityrosporumfolliculitis is associated with the use of oral corticosteroids, diabetes mellitus, organ transplantation, chemotherapy, and other immunosuppressed states.Pityrosporumfolliculitis is commonly found in adolescents presumably because of the increased activity of their sebaceous glands. Some colonized individuals develop tinea versicolor, and others develop Pityrosporumfolliculitis. Perhaps the density of lipids in the pilosebaceous unit of acne-prone individuals leads to a higher concentration of the organism in hair follicles and thus a folliculitis. All of our patients were female, and some other studies also report increased incidence among girls. However, a predominance in boys and equal sex distribution have also been described.In our patients, the female predominance may reflect a referral bias of girls to female physicians. Pityrosporumfolliculitis is also more common in hot and humid climates.Four of our 6 patients had flares during hot, humid weather and with increased episodes of sweating.Given the role of follicular plugging, it is no surprise that our patients had a combination of acne and Pityrosporumfolliculitis. Treatment regimens that address both of these conditions are necessary for improvement. Antibiotics commonly used to treat acne may suppress normal bacterial flora and allow overgrowth of Malassezia. This may explain some cases of what appears to be persistent acne that shows no improvement and actually worsens with oral antibiotic treatment as seen in patient 4.In treating recalcitrant acne complicated by Pityrosporumfolliculitis, host response plays a significant role in determining whether a patient may be able to permanently eradicate the yeast colonization. Patients may require prophylaxis or retreatment (ie, antifungal shampoos and/or pulse dosing of oral antifungals), especially during times in which they are prone to breakouts. Five of our 6 patients who responded to oral antifungal treatment also required maintenance with ketoconazole shampoo or selenium sulfide shampoo. In addition, 3 of these 6 patients required multiple courses of oral antifungals.Pityrosporumfolliculitis usually responds well to oral antifungal medications. Topical antifungals are less useful in the initial treatment of Pityrosporumfolliculitis but are important in maintenance and prophylaxis. The discontinuation of oral and topical antibiotics is also useful when treating Pityrosporumfolliculitis. Furthermore, one is able to get a clearer picture of the extent of the acne once the folliculitis is treated if some or all of acne medications are discontinued prior to the initiation of antifungal treatment.A KOH mount can be prepared by gently scraping 1 of the monomorphic pustules with a sterile scalpel blade, smearing the pustular contents on a glass slide, and treating it with 1 to 2 drops of 10% KOH and a coverslip. The slide can then be examined under the microscope for spores. This allows for a more immediate diagnosis than either skin biopsy or culture.Cultures of Malasseziaare rarely required for diagnosis and are complicated by the yeast’s special culture-medium requirements. Malasseziagrows only within a medium rich in C12, C13, and C14fatty acids, which can be achieved by adding olive oil to the medium.These patients were described with the goal of encouraging physicians to have a high suspicion for Pityrosporumfolliculitis in adolescent patients with recalcitrant acne. We also advocate performing a KOH preparation in any patient with monomorphic or acneiform pustules on the scalp, trunk, or upper extremities who is not responding to or worsening with antibiotics. There is no one specific treatment regimen that can be suggested to eradicate both acne vulgaris and Pityrosporumfolliculitis. Therefore, close patient follow-up to monitor response to therapy is important. Our patients responded well to oral ketoconazole or fluconazole. Patients must be advised of potential adverse effects of ketoconazole and other antifungals including nausea, vomiting, diarrhea, abdominal pain, and hepatotoxicity. Liver function should be evaluated in patients on long courses or multiple courses of oral ketoconazole.Correspondence:Karen Wiss, MD, Pediatric Dermatology, University of Massachusetts Medical School, Hahnemann Campus, 281 Lincoln St, Worcester, MA 01605 (wissk@ummhc.org).Accepted for Publication: August 19, 2004.REFERENCESPEWearyCMRussellHKButlerYTHsuAcneform eruption resulting from antibiotic administration.Arch Dermatol19691001791834240434JFaergemannSJohanssonOBäckAScheyniusAn immunologic and cultural study of Pityrosporumfolliculitis.J Am Acad Dermatol1986144294333958257MKHillMJGoodfieldFGRodgersJLCrowleyEMSaihanSkin surface electron microscopy in Pityrosporumfolliculitis: the role of follicular occlusion in disease and the response to oral ketoconazole.Arch Dermatol1990126107110742143368SORobertsPityrosporum orbiculare: incidence and distribution on clinically normal skin.Br J Dermatol1969812642695813527OBäckJFaergemannRHörnqvistPityrosporumfolliculitis: a common disease of the young and middle aged.J Am Acad Dermatol19851256613980804HJYuSKLeeSJSonYSKimHYYangJHKimSteroid acne vs Pityrosporumfolliculitis: the incidence of Pityrosporum ovaleand the effect of antifungal drugs in steroid acne.Int J Dermatol1998377727779802688MAbdel-RazekGFadalyMAbdel-RaheimFAl-MorsyPityrosporum(Malassezia) folliculitis in Saudi Arabia: diagnosis and therapeutic trials.Clin Exp Dermatol1995204064098593718EVAlvesJEMartinsEBRibeiroMNSottoPityrosporumfolliculitis: renal transplantation case report.J Dermatol200027495110692826SJRupkeFungal skin disorders.Prim Care20002740742110815051 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Pediatrics American Medical Association

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American Medical Association
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Copyright 2005 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
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2168-6203
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2168-6211
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10.1001/archpedi.159.1.64
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15630060
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Abstract

BackgroundPityrosporumfolliculitis is a common inflammatory skin disorder that may mimic acne vulgaris. Some adolescents with recalcitrant follicular pustules or papules may have acne and Pityrosporumfolliculitis simultaneously. Clinical response is dependent on treating both conditions.ObjectivesTo demonstrate the similarity in clinical manifestation between acne vulgaris and Pityrosporumfolliculitis, the benefit of potassium hydroxide preparation, and the benefit of appropriate antifungal therapy.PatientsWe describe 6 female adolescents with concurrent Pityrosporumfolliculitis infection and acne vulgaris.InterventionA potassium hydroxide examination was performed on all 6 patients from the exudate of follicular pustules exhibiting spores consistent with yeast. All patients were treated with oral antifungals, and 5 of the 6 patients were also treated with topical antifungals.ResultsSix of 6 patients improved with antifungal treatment. All patients also required some ongoing therapy for their acne.ConclusionsThese patients demonstrate that follicular papulopustular inflammation of the face, back, and chest may be due to a combination of acne vulgaris and Pityrosporumfolliculitis, a common yet less frequently identified disorder. Symptoms often wax and wane depending on the patient’s activities, time of the year, current treatment regimens, and other factors. Pityrosporumfolliculitis will often worsen with traditional acne therapy and dramatically respond to antifungal therapy.Pityrosporumfolliculitis was first described in 1969 by Weary et aland noted to be an acneiform eruption associated with antibiotic use. It is an infection of the hair follicle thought to be caused by the common cutaneous yeast, Malassezia furfur(Pityrosporum ovale) and possibly other strains of Malassezia.Malasseziais a dimorphic lipophilic yeast that can be found in small numbers in the stratum corneum and hair follicles of up to 90% of individuals without disease.Some individuals colonized with Malasseziadevelop folliculitis, while others develop tinea versicolor and seborrheic dermatitis.The papulopustular folliculitis is most commonly found on the chest, back, upper arms, and less frequently on the face. Often it is misdiagnosed as acne.Pityrosporumfolliculitis typically appears as 1- to 2-mm pruritic, monomorphic, pink papules and pustules. Positive potassium hydroxide (KOH) examination results showing numerous spores and other yeast forms support the diagnosis. It may be difficult to distinguish clinically from acne vulgaris. Traditional acne therapies, especially antibiotics, worsen Pityrosporumfolliculitis. We discuss 6 patients with recalcitrant “acne” who had acne vulgaris and Pityrosporumfolliculitis simultaneously.METHODSAll patients were seen in the general pediatric dermatology clinics at University of Massachusetts Memorial Health Care, Worcester, as part of routine clinic visits. The University of Massachusetts Medical School institutional review board was notified of this retrospective case review study and granted approval without full committee review.RESULTSAll 6 of the patients seen at University of Massachusetts Memorial dermatology clinics were adolescent white girls with a history of pruritic papules and pustules on the face, chest, and/or back (Table). The patients had limited responses to traditional acne therapies and recent exacerbation of their symptoms. In addition to the traditional inflammatory papules, pustules, and comedones of acne vulgaris, these patients also displayed uniform 1- to 2-mm monomorphic, erythematous papules and pustules (Figure 1and Figure 2) that were pruritic during hot, humid weather and increased activity. A KOH examination on scrapings of the monomorphic pustules revealed spores and budding yeast forms consistent with Pityrosporumfolliculitis in all 6 patients. They were diagnosed with Pityrosporumfolliculitis in addition to acne vulgaris. Any oral antibiotics that were being used at the time of diagnosis were discontinued. Six of 6 patients responded well to a combination of topical and oral antifungal treatment. Four of the 6 patients experienced flares of symptoms especially during hot and humid weather requiring intermittent treatment with both oral and topical antifungals. The patients were also treated with topical or oral medications for their acne vulgaris, but antibiotics, especially oral antibiotics, were used sparingly and only when necessary.Figure 1.A 15-year-old girl with 1- to 2-mm erythematous papules and pustules of Pityrosporumfolliculitis.Figure 2.Close-up view of the same patient showing multiple tiny pustules.Table. Clinical Characteristics and Treatment of 6 Patients With Concurrent PityrosporumFolliculitis and Acne VulgarisPatient/Age, yDurationAreas of InvolvementPrevious TreatmentTreatmentResults1/165 yMonomorphic pink papules and pustules on cheeks and shouldersOral TMP/Sulfa; azelaic acid cream; adapalene gelDiscontinued TMP/Sulfa; ketoconazole 200 mg PO once daily for 2 wk then 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 needed8-mo F/U: complete resolution of inflammatory papules and pustules; flares during humid weather and increased activity2/164-6 wk1- to 2-mm Monomorphic papules and pustules on chest and upper backErythromycin solution; antibacterial soapKetoconazole 200 mg PO BID for 1 d, then daily for 2 wk; 2% ketoconazole shampoo 2-3 times per 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 wk6-mo F/U: decreased number of comedones; no inflammatory papules or pustules3/153 wk1- to 2-mm Monomorphic, erythematous papules and pustules on forehead and lateral cheeks (Figures 1 and 2)Topical 1% clindamycin solution twice daily; cephalexin 500 mg PO twice daily for 2 wkDiscontinued oral cephalexin and topical clindamycin; ketoconazole 200 mg PO daily for 2 wk, repeat for flares in hot weather; 2% ketoconazole cream twice daily as needed; ketoconazole 2% shampoo daily as needed3-mo F/U: decreased number of papules and pustules; started taking cephalexin again, 500 mg PO twice daily; tretinoin 0.04% microgel at bedtime; benzoyl peroxide 5% wash daily as needed 9-mo F/U: stopped using all oral and topical antibiotics; ketoconazole 2% cream as needed; 20% azelaic acid cream daily as needed 14-mo F/U: increasing number of pruritic pustules and inflammatory papules not responding to oral 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 isotretinoin4/1212 moMonomorphic, pink papules, pustules, and closed comedones on cheeks, forehead, shoulders, and backMinocycline 100 mg PO daily; benzoyl peroxide 2.5% wash; 0.1% tretinoin gel; 20% azelaic acid creamDiscontinued minocycline administration; fluconazole (40 mg/mL) 2.5 mL daily for 2 wk; 2% ketoconazole shampoo 3 times per week as needed24-mo F/U: rare comedones and inflammatory papules (acne); no pustules5/924 moPruritic, erythematous, monomorphic papules and pustules on face, chest, and back; comedones and pitted scars on faceOral erythromycin; 0.1% tretinoin gel; 1% clindamycin gel; 5% benzoyl peroxide, 0.5% gel; hydrocortisone lotionKetoconazole 200 mg PO daily for 2 wk; 2% ketoconazole shampoo 2-3 per week; 0.04% tretinoin microgel daily; 4% benzoyl peroxide wash daily1-mo F/U: pruritic inflammatory papules and small pustules resolved; comedones and larger pustules increased in number; cephalexin 500 mg PO twice daily prescribed for acne 1-y F/U: markedly improved6/1548 moPruritic 1- to 2-mm erythematous, monomorphic papules and pustules on forehead; larger pustules on cheeks, jawline, and neckMinocycline 100 mg PO BID for 2 moDiscontinued minocycline administration; ketoconazole 200 mg PO daily for 3 wk; 2% ketoconazole shampoo daily; 0.4% tretinoin microgel at bedtime; 1% clindamycin lotion daily; 2.5% benzoyl peroxide wash daily3-wk F/U: greatly reduced number of papules and pustules; pruritus resolvedAbbreviations: BID, twice daily; F/U, follow-up; PO, by mouth; TMP/Sulfa, trimethoprim/sulfamethoxazole.COMMENTPityrosporumfolliculitis may be underdiagnosed because it can mimic acne vulgaris. Typical patients will not respond to or only partially respond to topical and oral antibiotics, topical retinoids, and other acne treatments. A KOH examination is an easy, inexpensive, and accessible method of immediately clarifying the diagnosis.The pathophysiologic features of Pityrosporumfolliculitis involve follicular occlusion followed by an overgrowth of yeast that thrives in a sebaceous environment.Altered host immunity is also thought to play a role in Pityrosporumfolliculitis because 90% of people have Malasseziaas a part of their normal skin flora without signs and symptoms of folliculitis or other disease.Furthermore, Pityrosporumfolliculitis is associated with the use of oral corticosteroids, diabetes mellitus, organ transplantation, chemotherapy, and other immunosuppressed states.Pityrosporumfolliculitis is commonly found in adolescents presumably because of the increased activity of their sebaceous glands. Some colonized individuals develop tinea versicolor, and others develop Pityrosporumfolliculitis. Perhaps the density of lipids in the pilosebaceous unit of acne-prone individuals leads to a higher concentration of the organism in hair follicles and thus a folliculitis. All of our patients were female, and some other studies also report increased incidence among girls. However, a predominance in boys and equal sex distribution have also been described.In our patients, the female predominance may reflect a referral bias of girls to female physicians. Pityrosporumfolliculitis is also more common in hot and humid climates.Four of our 6 patients had flares during hot, humid weather and with increased episodes of sweating.Given the role of follicular plugging, it is no surprise that our patients had a combination of acne and Pityrosporumfolliculitis. Treatment regimens that address both of these conditions are necessary for improvement. Antibiotics commonly used to treat acne may suppress normal bacterial flora and allow overgrowth of Malassezia. This may explain some cases of what appears to be persistent acne that shows no improvement and actually worsens with oral antibiotic treatment as seen in patient 4.In treating recalcitrant acne complicated by Pityrosporumfolliculitis, host response plays a significant role in determining whether a patient may be able to permanently eradicate the yeast colonization. Patients may require prophylaxis or retreatment (ie, antifungal shampoos and/or pulse dosing of oral antifungals), especially during times in which they are prone to breakouts. Five of our 6 patients who responded to oral antifungal treatment also required maintenance with ketoconazole shampoo or selenium sulfide shampoo. In addition, 3 of these 6 patients required multiple courses of oral antifungals.Pityrosporumfolliculitis usually responds well to oral antifungal medications. Topical antifungals are less useful in the initial treatment of Pityrosporumfolliculitis but are important in maintenance and prophylaxis. The discontinuation of oral and topical antibiotics is also useful when treating Pityrosporumfolliculitis. Furthermore, one is able to get a clearer picture of the extent of the acne once the folliculitis is treated if some or all of acne medications are discontinued prior to the initiation of antifungal treatment.A KOH mount can be prepared by gently scraping 1 of the monomorphic pustules with a sterile scalpel blade, smearing the pustular contents on a glass slide, and treating it with 1 to 2 drops of 10% KOH and a coverslip. The slide can then be examined under the microscope for spores. This allows for a more immediate diagnosis than either skin biopsy or culture.Cultures of Malasseziaare rarely required for diagnosis and are complicated by the yeast’s special culture-medium requirements. Malasseziagrows only within a medium rich in C12, C13, and C14fatty acids, which can be achieved by adding olive oil to the medium.These patients were described with the goal of encouraging physicians to have a high suspicion for Pityrosporumfolliculitis in adolescent patients with recalcitrant acne. We also advocate performing a KOH preparation in any patient with monomorphic or acneiform pustules on the scalp, trunk, or upper extremities who is not responding to or worsening with antibiotics. There is no one specific treatment regimen that can be suggested to eradicate both acne vulgaris and Pityrosporumfolliculitis. Therefore, close patient follow-up to monitor response to therapy is important. Our patients responded well to oral ketoconazole or fluconazole. Patients must be advised of potential adverse effects of ketoconazole and other antifungals including nausea, vomiting, diarrhea, abdominal pain, and hepatotoxicity. Liver function should be evaluated in patients on long courses or multiple courses of oral ketoconazole.Correspondence:Karen Wiss, MD, Pediatric Dermatology, University of Massachusetts Medical School, Hahnemann Campus, 281 Lincoln St, Worcester, MA 01605 (wissk@ummhc.org).Accepted for Publication: August 19, 2004.REFERENCESPEWearyCMRussellHKButlerYTHsuAcneform eruption resulting from antibiotic administration.Arch Dermatol19691001791834240434JFaergemannSJohanssonOBäckAScheyniusAn immunologic and cultural study of Pityrosporumfolliculitis.J Am Acad Dermatol1986144294333958257MKHillMJGoodfieldFGRodgersJLCrowleyEMSaihanSkin surface electron microscopy in Pityrosporumfolliculitis: the role of follicular occlusion in disease and the response to oral ketoconazole.Arch Dermatol1990126107110742143368SORobertsPityrosporum orbiculare: incidence and distribution on clinically normal skin.Br J Dermatol1969812642695813527OBäckJFaergemannRHörnqvistPityrosporumfolliculitis: a common disease of the young and middle aged.J Am Acad Dermatol19851256613980804HJYuSKLeeSJSonYSKimHYYangJHKimSteroid acne vs Pityrosporumfolliculitis: the incidence of Pityrosporum ovaleand the effect of antifungal drugs in steroid acne.Int J Dermatol1998377727779802688MAbdel-RazekGFadalyMAbdel-RaheimFAl-MorsyPityrosporum(Malassezia) folliculitis in Saudi Arabia: diagnosis and therapeutic trials.Clin Exp Dermatol1995204064098593718EVAlvesJEMartinsEBRibeiroMNSottoPityrosporumfolliculitis: renal transplantation case report.J Dermatol200027495110692826SJRupkeFungal skin disorders.Prim Care20002740742110815051

Journal

JAMA PediatricsAmerican Medical Association

Published: Jan 1, 2005

References