Pityrosporum Folliculitis

Pityrosporum folliculitis is a condition where the yeast, pityrosporum, gets down into the hair follicles and multiplies, setting up an itchy, acnelike eruption. Pityrosporum folliculitis sometimes turns out to be the reason a case of acne isn't getting better after being on antibiotics for months. It is especially common in the cape distribution (upper chest, upper back) and the pimples are pinhead sized and uniform. This yeast is a normal skin inhabitant, different from the yeast that causes thrush and from baker's or food yeast. Everyone has it on his or her skin but in most cases it causes no problem. The condition affects young to middle-aged adults of either sex. It is associated with a tendency to seborrheic dermatitis or severe dandruff. Pityrosporum folliculitis is not an infection as such; it is an overgrowth of what is normally there. The yeast overgrowth may be encouraged by external factors and/or by reduced resistance on the part of the host. The reasons why a particular patient develops pityrosporum folliculitis are not fully understood but the following are believed to be important: The yeast tends to overgrow in hot, humid, sweaty environments, clothing that doesn't "breathe" especially synthetics, which encourages sweating. Application of greasy sunscreens and oily emollients such as coconut oil. An oily-skin tendency - the yeast feeds on skin oil. Skin oil production mainly depends on hormone factors. Decreased resistance to microorganisms (immunity). Stress or fatigue Diabetes Oral steroids such as prednisone Oral contraceptive pill Being overweight, resulting in more sweating and tighter clothing.

Oral antibiotics can aggravate pityrosporum folliculitis because skin-inhabitant bacteria and yeasts are normally in competition on the skin surface. When antibiotics suppress the bacteria the pityrosporum yeasts can over grow. The rash consists of tiny itchy rounded pink pimples with an occasional tiny whitehead. The spots are located mainly on the upper back, shoulders and chest. Sometimes spots are found on the forearms, back of the hands, lower legs and face. The tendency to scratch spots is greatest on the forearms, face and scalp. Most patients have oily skin. Most patients seek advice because of the itch. This may have led their doctors to suspect scabies or other mite infestations. The itch tends to come in episodes, accompanied by a stinging sensation. Some patients notice the itch is worse after sweat inducing exercise or after a hot shower. When scratched, the spots may display a local hive-like reaction with a surrounding red flare. Patients may also have tinea versicolor or seborrheic dermatitis. In these conditions an overgrowth of the same pityrosporum yeast is believed to be involved. Patients may also have true acne accompanying the pityrosporum folliculitis. This is not surprising because increased skin oil also encourages acne but in this case there is an overgrowth of the normal skin bacteria rather than yeast.

Treatment must deal with both the yeast overgrowth and any predisposing factors, otherwise the condition will recur. Unfortunately we often either do not know, or cannot correct, all the factors that make one susceptible so the condition has a tendency to return once the antiyeast treatment is stopped. Topical therapy is not always effective, and may be worth a try. These include Nizoral or Selsun shampoos, applied for about 10 minutes and washed off in the shower. This is repeated once a week. Other topical treatments include 50% propylene glycol in water applied twice daily with a gauze pad for 3 weeks, then twice a week or Lamisil solution, sprayed on the skin surface, for 14 days then weekly or for just a few spots apply Loprox or Nizoral cream twice a day. Oral treatments are the most effective. The two used are Nizoral and Sporonox. One will need to wait a week or two for clearing, and recurrences are to be expected. A last resort is Accutane pills. These are general guidelines and a dermatologist can help decide the best treatment.

http://www.americanchronicle.com/articles/16713 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 middleaged adults. Weary et al first described Pityrosporum folliculitis in 1969, and, later in 1973, Potter et al[1] identified Pityrosporum folliculitis as a separate clinical and histologic diagnosis. Yeasts, specifically Malassezia furfur, are the pathogenic agents in Pityrosporum folliculitis. M furfur has been linked to several skin diseases, including seborrheic dermatitis, folliculitis, pityriasis versicolor, and atopic dermatitis.[2] 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. Pityrosporum folliculitis is caused by Malassezia species that are part of the cutaneous microflora and not by exogenous species.[3] However, the focus of this article is M furfur, which is considered the pathologic agent of Pityrosporum folliculitis. 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 Pityrosporum folliculitis 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 Pityrosporum 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 Pityrosporum folliculitis, 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.

Epidemiology
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 Pityrosporum folliculitis. People living in warm and humid climates have a higher incidence of Pityrosporum folliculitis. One clinic in the Philippines documented that 16% of all patient visits were a result of Pityrosporum

folliculitis.[4] A 2008 report from China cites that 1.5% off all dermatology patients were diagnosed with Pityrosporum folliculitis, most of them healthy, middle-aged males.[5]
Mortality/Morbidity

Pityrosporum folliculitis may be a bothersome condition (ie, severe pruritus), but the lesions are benign. Some underlying conditions that predispose the patient to Pityrosporum folliculitis include diabetes mellitus, immunodeficiency, and systemic candidiasis[6] ; these conditions may cause morbidity. Consider the presence of predisposing conditions when Pityrosporum folliculitis is diagnosed.
Race

No known racial differences in the frequency of Pityrosporum folliculitis exist.

Sex

Reports of Pityrosporum folliculitis 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-tomale ratio is 1.5:1.
Age

Pityrosporum folliculitis is recognized as one that affects youths and young and middle-aged adults[7] ; Pityrosporum folliculitis is most common in those aged 13-45 years. However, 3 cases of Pityrosporum folliculitis 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 highdose antibiotics.[8]

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.[9]

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.[9]

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,[10] 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.[11] Many patients have coexisting seborrheic dermatitis.[6]

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: o Diabetes mellitus o Cushing disease [12] o Hodgkin disease o 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[13] o HIV infection o Corticosteroids and/or immunosuppressant therapy following organ transplantation[14, 15, 16] o Crohn disease treated with infliximab a monoclonal antibody against tumor necrosis factor alpha.[17] An increase in sebum production, such as that in pregnancy,[18, 19] 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[20] are other conditions that are associated with Pityrosporum folliculitis. Other related and coexisting conditions may include the following: o Seborrheic dermatitis o Confluent and reticulated papillomatosis [21] o Systemic candidiasis

Some individuals seem to have an innate propensity for Pityrosporum folliculitis. o 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. o In the same experiment, Pityrosporum folliculitis did not develop in patients with no prior diagnosis of the condition.

Differentials

Acne Vulgaris Bedbug Bites Candidiasis, Cutaneous Contact Dermatitis, Allergic Drug Eruptions Eosinophilic Pustular Folliculitis Fire Ant Bites Folliculitis Insect Bites Lichen Spinulosus Lymphomatoid Papulosis Milia Miliaria Papulopruritic eruption of HIV Pseudomonas Folliculitis Sporotrichosis Urticaria, Cholinergic