Case Report: Scalp pityriasis versicolor may be a neglected problem.

Pityriasis versicolor, a common skin fungal infection, is typically observed on trunk and limb skin. Here, we highlight an unusual presentation: scalp involvement, often overlooked due to its asymptomatic, mildly scaly patches. We report four pediatric cases, emphasizing the potential underestimation of this scalp variant. This case series underscores the importance of considering this diagnosis in patients with unexplained scalp hypopigmentation, especially in males with short hair who may readily notice these subtle changes. The report contributes to the understanding of this variant's clinical presentation and emphasizes the need for awareness among clinicians to ensure accurate diagnosis and appropriate management.

Systematic Review and Meta-analysis on Synthetic Antifungal versus Keratolytic Agents for Topical Treatment of Pityriasis Versicolor.

Background: Pityriasis versicolor is a common fungal infection of the superficial skin layer caused by Malassezia furfur, a normal commensal in the skin. Keratolytic agents are popular, cheap, and readily available over-the-counter treatments for pityriasis versicolor. Conventional antifungal agents are more expensive, requiring prescription, and may induce resistant strains. However, evidence of their comparative safety and efficacy is still lacking. Objectives: To assess the efficacy and safety of synthetic antifungals compared to keratolytic agents in the topical treatment of pityriasis versicolor through a systematic review. Methods: We searched the following databases: MEDLINE (from 1966) through PubMed, CENTRAL (Issue 9 of 12, September 2021), EMBASE (from 1974), LILACS (from 1987); Herdin (from 1970), www.clinicaltrials.gov, www.isrctn.com, www.trialregister.nl. We contacted researchers in the field, hand searched relevant conference abstracts, and the Journal of the Philippine Dermatological Society 1992-2019. We included all randomized controlled trials involving patients with diagnosed active pityriasis versicolor where topical antifungal was compared with a topical keratolytic for treatment. Two review authors independently applied eligibility criteria, assessed risk of bias using the Cochrane collaboration tool, and extracted data from included studies. We used RevMan 5.3 to pool dichotomous outcomes using risk ratios (RR) and continuous outcomes using the mean difference (MD), using random-effects meta-analysis. We tested for statistical heterogeneity using both the Chi² test and the I² test. We presented results using forest plots with 95% confidence intervals. We planned to create a funnel plot to determine publication bias but were unable to due to few studies. A Summary of Findings table was created using GRADE profile software for the primary outcomes. Results: We included 8 RCTs with a total of 617 participants that compared azole preparations (ketoconazole, bifonazole and econazole) versus keratolytic agents (selenium sulfide, adapalene, salicylic-benzoic acid). Pooled data showed that azoles did not significantly differ from keratolytic agents for clinical cure (RR 0.99, 0.88, 1.12; 4 RCTs, N=274, I2=55%; very low-quality evidence), and adverse events (0.59 [0.17, 2.06]; very low-quality evidence) based on 6 RCTs (N=536). There were two patients given a keratolytic agent (selenium sulfide shampoo) who had acute dermatitis and discontinued treatment. Conclusion: It is uncertain whether topical azoles are as effective as keratolytic agents in clinical clearance and occurrence of adverse events in patients with pityriasis versicolor. A wider search of grey literature and local studies are warranted. Larger RCTs with low risk of bias are recommended.

Exploring the antibiofilm efficacy of cinnamaldehyde against Malassezia globosa associated pityriasis versicolor.

BACKGROUND: Malassezia globosa is a commensal basidiomycetous yeast occurring on the skin that causes pityriasis versicolor (PV) and seborrheic dermatitis, but that has also been implicated in other dermatoses. Cinnamaldehyde (CM) has antibacterial, antioxidant, and anti-inflammatory activities, but the effect of CM on M. globosa-infected PV has not been clarified. PURPOSE: The study aimed to investigate the possible antifungal and antibiofilm activities of CM against M. globosa-infected PV in vivo and in vitro. METHODS: The broth microdilution method was used to determine the minimum inhibitory concentration (MIC) of CM against M. globosa. The crystal violet staining assay and XTT assay were used to investigate the inhibition of CM on biofilm formation and the eradication of mature biofilms. The visualizations of the biofilm and cell distribution in the biofilm matrix were performed with a scanning electron microscope and confocal laser scanning microscope. The kits of antioxidant kinase were used to determine the activities of oxidative stress markers in M. globosa-stimulated HaCaT cells. Western blot assays were used to evaluate the role of TLR2/NF-κB in vitro. Furthermore, the protective effect of CM was assessed in M. globosa-associated PV mice. The expressions of inflammatory cytokines and apoptosis were screened using ELISA assays. The expressions of interleukin-6 and tumor necrosis factor-α were measured by an immunohistochemistry method in vivo. RESULTS: Our results showed that the MIC of CM against planktonic cells of M. globosa was 4 µg/ml and treatment with 20 × MIC CM eradicated mature biofilms of M. globosa. In vitro, after CM treatment the levels of oxidative stress indicators (i.e., superoxide dismutase, catalase, glutathione) significantly increased, while the levels of malondialdehyde decreased. In addition, the expression of TLR2/NF-κB in HaCaT cells was significantly reduced after CM treatment. On the other hand, an in vivo therapeutic effect of CM was assessed against M. globosa-infected mice. The fungal load on the skin decreased after treatment with CM compared to the M. globosa-infected group. In addition, the uninfected animals showed a normal skin structure, whereas, the M. globosa-infected mice showed extensive infiltration of neutrophils in skin tissues that improved after treatment with CM. Meanwhile, the levels of inflammatory and apoptotic factors improved after CM treatment. CONCLUSION: Our results showed that CM inhibits the biofilm formation of M. globosa and eradicates mature biofilms of M. globosa. Treatment with CM significantly decreased oxidative stress, apoptosis, and inflammatory markers in the skin tissue and HaCaT cells. Hence, this study suggests that CM is a good candidate therapeutic agent against M. globosa-induced PV infections because of its antifungal, antibiofilm, and anti-inflammatory properties.

Malassezia-associated skin diseases in the pediatric population.

Malassezia are yeast species that commonly colonize healthy skin. However, they have been associated with or implicated in the pathogenesis of numerous skin disorders, particularly in the setting of pediatric populations. In this review, we will focus on several Malassezia-associated skin conditions manifesting in infants, children, and adolescents: pityriasis versicolor, Malassezia folliculitis, infantile and adolescent seborrheic dermatitis, head and neck dermatitis, and neonatal cephalic pustulosis. We examine the literature and provide an overview of these conditions, including clinical presentation in diverse skin colors, diagnosis, risk factors, and treatment and management. Additionally, we summarize and highlight some of the proposed theories on the role of Malassezia spp. in the pathogenesis of these skin conditions.

Hypopigmented Atrophic Pityriasis Versicolor: A Case of Diagnostic Dilemma.

Pityriasis versicolor (PV) also referred to as Peter Elam's disease or tinea versicolor is caused by the Malassezia species which is a chronic-relapsing widespread mycosis. The most common sites involved are the shoulders, upper arms, back, upper trunk, and chest. Atrophying PV is a very rare variant that has rarely been reported in the Indian literature. Hence, in this case report, a 29-year-old male presented with chief complaints of multiple asymptomatic, light-colored lesions over his chest, shoulder, and arms for three months. On examination, multiple well-defined hypopigmented macules of varying sizes with fine scales were observed on the patient's chest, shoulders, and arms. Dermoscopic examination revealed nonuniform perifollicular hypopigmentation with clearly demarcated borders, patchy scaling, and inconspicuous ridges and furrows. Moreover, a histopathological examination was performed that reported flattening of rete ridges along with fungal hyphae and spores which consequently confirmed the diagnosis. The medical intervention with antifungal agents was prescribed by the dermatologist, after which the lesion was completely resolved and the follow-up period reported no recurrence of the lesions demonstrating positive outcomes. In conclusion, diagnosing atrophic PV which is a rare variant of PV can be challenging. Hence, accurate diagnosis along with appropriate and adequate intervention can lead to the resolution of the condition and can prevent its recurrence.

Follicular Psoriasis: A Case Report and Review of Literature.

Introduction: Psoriasis is an autoimmune papulosquamous disorder characterized by erythematous plaques. There are various subtypes, of which follicular psoriasis (FP) is an underreported entity, presenting as scaly follicular papules. Only a few cases have been reported, with limited dermoscopy findings having been described. This report aims to review the literature and emphasize the role of dermoscopy in the diagnosis of this rare variant. Case Report: A 31-year-old diabetic and obese male presented with symmetrical, itchy, scaly follicular lesions on his axillae, elbows, and knees for 6 months. Clinical differentials included follicular pityriasis rosea, pityriasis versicolor, or eczema. Dermoscopy revealed white scales and erythematous areas with multiple red dots present around hair follicles. Histopathology showed distended follicular infundibula with parakeratotic scales and psoriasiform changes, leading to a diagnosis of FP. Treatment with topical mometasone furoate and oral levocetirizine led to complete resolution within a month. Discussion: FP is a relatively uncommon subtype of psoriasis, manifesting differently in adults and juveniles. Although its exact cause remains unknown, hair follicle immune cells and/or keratin 17 (K17) may be involved. Dermoscopy can help distinguish it by revealing typical features including perifollicular white scales and vascular structures. Further epidemiological studies and long-term follow-up are needed for a comprehensive understanding of FP.

Dermoscopic Perspective of Pityriasis Versicolor in a Cross-Sectional Study.

Background: Pityriasis versicolor is a common superficial fungal infection which is usually easily diagnosed with Wood's lamp examination and 10% potassium hydroxide mount. However, these modalities have varying sensitivity and specificity. Aims and Objectives: This study aimed to ascertain the dermoscopic features of pityriasis versicolor lesionally as well as perilesionally using dermoscopy, a non-invasive diagnostic tool. Materials and Methods: In this cross-sectional study, consecutive patients with pityriasis versicolor underwent dermoscopic examination of lesions and 2 cm around lesions, noting lesional and perilesional features. Semi-objective grading of pigmentation, scaling, and vascularity was done. The association between parameters was determined using heat maps and violin plots with Kolmogorov-Smirnov test. Lesional analysis was performed since lesions at different sides showed disparate features. Results: A total of 353 lesions from 233 patients (males = 150/233; 64.38% and females = 84/234; 36.05%) were studied. On lesional dermoscopy, pigmentary and scaling abnormalities were universal. 258/353 (73.1%) of lesions showed vascular abnormalities. Perilesionally, scaling (223/353; 63.17%) followed by pigmentation (205/353; 58.07%) and vascular changes (111/353; 31.44%) constituted the most common dermoscopic abnormalities and were noted in 294/353 (83.29%) of lesions overall. Increased disease duration corresponded with increased intensity of perilesional pigmentation alterations, perifollicular (P = 0.04), and follicular scales (P = 0.02). Conclusion: Awareness of dermoscopic features could improve the diagnostic accuracy in doubtful cases of pityriasis versicolor. Vascular findings are common and may point to an underlying inflammatory pathogenesis. Perilesional findings constitute early dermoscopic features of pityriasis versicolor and hint at the need for treatment beyond the confines of lesions. Larger follow-up studies and research into immunopathogenesis may be of further benefit.

Fungal coexistence in the skin mycobiome: a study involving Malassezia, Candida, and Rhodotorula.

Evidence of fungal coexistence in humans points towards fungal adaptation to the host environment, like the skin. The human commensal Malassezia has evolved, especially residing in sebum-rich areas of the mammalian body where it can get the necessary nutrition for its survival. This fungus is primarily responsible for skin diseases like Pityriasis versicolor (PV), characterized by hypo or hyperpigmented skin discoloration and erythematous macules. In this manuscript, we report a 19-year-old healthy female who presented with a one-year history of reddish, hypopigmented, asymptomatic lesions over the chest and a raised erythematous lesion over the face. Upon clinical observation, the patient displayed multiple erythematous macules and erythematous papules over the bilateral malar area of the face, along with multiple hypopigmented scaly macules present on the chest and back. Based on the above clinical findings, a diagnosis of PV and Acne vulgaris (AV) was made. Interestingly, the patient was immunocompetent and didn't have any comorbidities. Upon isolation of skin scrapings and post-culturing, we found the existence of three fungal genera in the same region of the patient's body. We further went on to confirm the identity of the particular species and found it to represent Malassezia, Rhodotorula, and Candida. We report how Malassezia, the predominant microbial resident skin fungus, coexists with other fungal members of the skin mycobiome. This study on an applied aspect of microbiology also shows how important it is to identify the fungal organism associated with skin infections so that appropriate therapeutics can be advised to avoid cases of relapse.

Part 1: Understanding the role of Malassezia spp. in skin disorders: Malassezia yeasts as commensal or pathogenic organisms of human and animal skin.

INTRODUCTION: Malassezia spp. are a group of lipid-dependent basidiomycetes yeasts acting as commensal organisms of the human and animal skin. However, under some not well-defined circumstances, these yeasts may switch to opportunistic pathogens triggering a number of skin disorders with different clinical presentations. The genus comprises of 18 lipid-dependent species with a variable distribution in the hosts and pathologies thus suggesting a host- and microbe-specific interactions. AREA COVERED: This review highlighted and discussed the most recent literature regarding the genus Malassezia as a commensal or pathogenic organisms highlighting Malassezia-associated skin disorders in humans and animals and their antifungal susceptibility profile. A literature search of Malassezia associated skin disorders was performed via PubMed and Google scholar (up to May 2023), using the different keywords mainly associated with Malassezia skin disorders and Malassezia antifungal resistance. EXPERT OPINION: Malassezia yeasts are part of the skin mycobiota and their life cycle is strictly associated with the environment in which they live. The biochemical, physiological, or immunological condition of the host skin selects Malassezia spp. or genotypes able to survive in a specific environment by changing their metabolisms, thus producing virulence factors or metabolites which can cause skin disorders with different clinical presentations.

Confluent and Reticulated Papillomatosis Resembling Pityriasis Versicolor and Acanthosis Nigricans: Case Report.

Confluent and reticulated papillomatosis (CARP) is a rare disorder mostly seen in young adults. It is characterized by persistent dull-brown, centrally confluent, peripherally reticulate macules and papules, which coalesce to form patches and plaques on the upper trunk and neck. It is commonly confused with pityriasis versicolor and acanthosis nigricans (AN). We report the case of a 15-year-old male with multiple pigmented confluent and reticulated patches and plaques on the neck, trunk, and chin for 3 years, which was successfully treated with oral minocycline, resulting in complete resolution of lesions within 2 weeks. The morphology of CARP resembles that of various other dermatological conditions such as AN and pityriasis versicolor, and, as a result, it is frequently misdiagnosed and mistreated, leading to social embarrassment for the patient. Therefore, it is prudent for dermatologists to carry out comprehensive clinical and histopathological assessments to facilitate prompt diagnosis and management of this condition.

Tinea Versicolor in a Three-Month Infant: A Case Report and Literature Review.

Tinea versicolor (TV) is a superficial fungal disease caused by Malassezia furfur, most commonly affecting adolescents and adults. TV is uncommon among newborns, particularly those aged under one year. Poor hygiene and perspiration, immunosuppression, the use of oils and greasy lotions, hyperhidrosis, and corticosteroids may all contribute to the appearance of the condition. It is clinically distinguished by hypopigmentation or hyperpigmentation. Most often, it occurs over the trunk. Treatment for TV usually begins with the use of a topical antifungal. This case report presents a rare TV in a three-month-old boy who exhibited multiple hypopigmented macules on his trunk without pruritus. Examination of the wood lamp showed bright yellow fluorescent lesions. The potassium hydroxide (KOH) preparation revealed yeast and short mycelial forms, confirming the diagnosis of TV. The baby was given a clotrimazole solution for topical use twice a day. KOH preparation was negative, and the lesions had improved at the time of the two-month follow-up. This case highlights the importance of considering TV as a potential diagnosis in infants with atypical skin manifestations, although it is more commonly seen in older individuals.

Post-Inflammatory Hypopigmentation: Review of the Etiology, Clinical Manifestations, and Treatment Options.

Post-inflammatory hypopigmentation is a common acquired pigmentary disorder that is more prominent in skin of color, leading to great cosmetic and psychosocial implications. Often, a diagnosis with a pigmentary disorder can negatively impact an individual's health-related quality of life and may result in stigma. Although most cases of post-inflammatory hypopigmentation resolve spontaneously over time, a systematic diagnostic approach can help with identifying the underlying etiology and informing treatment strategies. It can be due to cutaneous inflammation, sequelae of inflammatory or infectious dermatoses, or dermatologic procedures. Therefore, a thorough understanding of the epidemiology, patient history, physical exam findings, and clinical features of post-inflammatory hypopigmentation phenomenon can explain the primary cause to providers and allow for patient education. It is also important to understand the various therapeutic approaches available and the efficacy of these options, which will inform providers to choose the appropriate therapy for patients. Although algorithms exist for classifying acquired disorders of hypopigmentation, there are no established algorithms for the diagnosis and treatment of post-inflammatory hypopigmentation, which warrants further exploration and discourse.

Tinea versicolor in a premature infant.

Tinea versicolor (TV) is a fungal skin infection that classically affects adolescents and young adults. Occasionally, it may be seen on the face of infants. We report an unusual case of widespread cutaneous TV in a premature infant.

Detection of IL-17A and IL-17F gene polymorphism in recurrent and disseminated pityriasis versicolor: a case-control study.

Recurrent and disseminated pityriasis versicolor (RDPV) is a common clinical entity, characterized by its recurrent and disfiguring nature. Studies demonstrated host genetic variations in the immune response, especially the role of IL-17 in antifungal immunity. This study aimed to detect whether IL-17A and F gene polymorphisms are found in cases of RDPV. It included 100 cases of RDPV and 100 age and sex matched controls, from which EDTA blood samples were taken for single-nucleotide polymorphism analysis. IL-17A (rs2275913) and F (rs763780) were associated with a significantly increased incidence of developing RDPV. IL-17A and F gene polymorphism could be implicated as a risk factor for the development of RDPV.

Human leukocyte antigen system associations in Malassezia-related skin diseases.

BACKGROUND: The human leukocyte antigen system (HLA) is divided into two classes involved in antigen presentation: class I presenting intracellular antigens and class II presenting extracellular antigens. While susceptibility to infections is correlated with the HLA system, data on associations between HLA genotypes and Malassezia-related skin diseases (MRSD) are lacking. Thus, the objective of this study was to investigate associations between HLA alleles and MRSD. MATERIALS AND METHODS: Participants in The Danish Blood Donor Study (2010-2018) provided questionnaire data on life style, anthropometric measures, and registry data on filled prescriptions. Genotyping was done using Illumina Infinium Global Screening Array, and HLA alleles were imputed using the HIBAG algorithm. Cases and controls were defined using filled prescriptions on topical ketoconazole 2% as a proxy of MRSD. Logistic regressions assessed associations between HLA alleles and MRSD adjusted for confounders and Bonferroni corrected for multiple tests. RESULTS: A total of 9455 participants were considered MRSD cases and 24,144 participants as controls. We identified four risk alleles B*57:01, OR 1.19 (95% CI: 1.09-1.31), C*01:02, OR 1.19 (95% CI: 1.08-1.32), C*06:02, OR 1.14 (95% CI: 1.08-1.22), and DRB1*01:01, OR 1.10 (95% CI: 1.04-1.17), and two protective alleles, DQB1*02:01, OR 0.89 (95% CI: 0.85-0.94), and DRB1*03:01, OR 0.89 (95% CI: 0.85-0.94). CONCLUSION: Five novel associations between HLA alleles and MRSD were identified in our cohort, and one previous association was confirmed. Future studies should assess the correlation between Malassezia antigens and antigen-binding properties of the associated HLA alleles.

Tinea versicolor: an updated review.

Background: Tinea versicolor is a common superficial fungal infection of the skin with various clinical manifestations. This review aims to familiarize physicians with the clinical features, diagnosis and management of tinea versicolor. Methods: A search was conducted in July 2022 in PubMed Clinical Queries using the key terms "tinea versicolor" OR "pityriasis versicolor". The search strategy included all clinical trials, observational studies and reviews published within the past 10 years. Results: Tinea versicolor is caused by Malassezia species, notably M. globosa, M. furfur and M. sympodialis. The condition is characterized by scaly hypopigmented or hyperpigmented macules/patches, primarily located on the upper trunk, neck and upper arms. The diagnosis is usually based on characteristic clinical features. If necessary, a potassium hydroxide preparation test can be performed to reveal numerous short, stubby hyphae intermixed with clusters of spores. Most patients with tinea versicolor respond to topical antifungal therapy, which has a better safety profile (fewer adverse events, fewer drug interactions) and lower cost compared to systemic treatment and is therefore the treatment of choice. Oral antifungal therapy is typically reserved for patients with extensive disease, frequent recurrences or disease that is refractory to topical therapy. Advantages of oral antifungal therapy include increased patient compliance, shorter duration of treatment, increased convenience, less time involved with therapy and reduced recurrence rates. On the other hand, oral antifungal therapy is associated with higher cost, greater adverse events and potential drug-drug interactions and is therefore not the first-line treatment for tinea versicolor. Long-term intermittent prophylactic therapy should be considered for patients with frequent recurrence of the disease. Conclusion: Selection of antifungal agents depends on several factors, including efficacy, safety, local availability, ease of administration, likelihood of compliance and potential drug interactions of the antifungal agent.

Epidemiological, clinical and mycological characteristics of pityriasis versicolor: Results of a study from a teaching hospital in rural part of Northern India.

Background and Objectives: Pityriasis versicolor is a common fungal infection of the skin which leads to the formation of scaly and discoloured small lesions on skin. The main objective of this study is to describe clinical and mycological characteristics and the predisposing factors in patients with pityriasis versicolor. Material and Methods: In this prospective, observational, hospital-based cross-sectional study, patients of all ages with clinically suspected lesions of pityriasis versicolor were included. After detailed history and thorough clinical examination, skin scrapings were examined with 10% potassium hydroxide (KOH) under light microscope. The scrapings were also subjected to culture examination. Results: A total of 113 patients [78 (69.0%) male; 35 (31%) female] were included in the study. A total of 87 (76.9%) patients were from rural area. Outdoor occupation and positive family history of pityriasis versicolor was present in 65 (57.5%) and 38 (33.6%) patients, respectively. Recurrent episodes were reported by 66 (60%) patients. Excessive sweating and oily skin were seen in 36 (31.8%) and 24 (21.1%) patients, respectively. History of occlusive clothing was present in 22 (19.4%) patients. Chest, back, and shoulders were affected in 36 (31.8%), 22 (19.4%), and 08 (07.0%) patients, respectively. Hypopigmented lesions were seen in 97 (85.8%) patients. Patches and macules were observed in 60 (53.1%) and 53 (46.9%) patients, respectively. A total of 27 (23.8%) patients reported mild prutitus. A total of 79 (69.9%) patients were KOH positive and culture negative, whereas 26 (23.0%) patients were KOH as well as culture positive. Eight (7.0%) patients were both KOH and culture negative. Conclusion: Pytiriasis versicolor is more common in young adults and males with the most common presentation of hypopigmentation lesions. In our study population, presentation with large patches was more common than macular lesions. Pruritus was more in patients with large patches than those with macules.

In Vitro Assessment of Azole and Amphotericin B Susceptibilities of Malassezia spp. Isolated from Healthy and Lesioned Skin.

Malassezia yeasts have recently gained medical importance as emerging pathogens associated with a wide range of dermatological and systemic infections. Since standardized methods for in vitro antifungal susceptibility testing have not yet been established for Malassezia spp., related diseases are always treated empirically. As a result, a high rate of recurrence and decreased antifungal susceptibility have appeared. Thus, the aims of the study were to assess and analyze the in vitro susceptibility of Malassezia isolated from pityriasis versicolor (PV) lesions and healthy controls. A total of 58 Malassezia strains isolated from PV patients and healthy controls were tested. In vitro antifungal susceptibility testing was conducted using the CLSI broth microdilution with some modifications. Candida spp. criteria established in accordance with CLSI guidelines were used for data interpretation. Ketoconazole and posaconazole seemed to be the most effective molecules against Malassezia species. However, considerable percentages of itraconazole, fluconazole, and amphotericin B ''resistant'' strains (27.6%, 29.3%, and 43.1%, respectively) were revealed in this study. Malassezia furfur, M. sympodialis, and M. globosa showed different susceptibility profiles to the drugs tested. These results emphasize the importance of accurately identifying and evaluating the antifungal susceptibility of Malassezia species in order to guide a specific and effective treatment regimen.