Malassezia (Pityrosporum) Folliculitis

Abstract
Malassezia (Pityrosporum) folliculitis is a fungal acneiform condition commonly
misdiagnosed as acne vulgaris. Although often associated with common acne, this
condition may persist for years without complete resolution with typical acne medications.
Malassezia folliculitis results from overgrowth of yeast present in the normal cutaneous
flora. Eruptions may be associated with conditions altering this flora, such as
immunosuppression and antibiotic use. The most common presentation is monomorphic
papules and pustules, often on the chest, back, posterior arms, and face specifically on the
forehead and along the jaw. Oral antifungals are found to be effective treatment and result
in rapid improvement. This article reviews and updates readers on this not uncommon,
but easily missed, condition.

What is Pityrosporum Folliculitis?

Pityrosporum folliculitis is an inflammatory skin disorder thats triggered by any of several types of
yeast known as Malassezia, which occur naturally on skin. For most of us, Malassezia coexists peacefully
on our skins surface and within the pores (also known as follicles). But for others, especially people
with oily skin between the ages of 1345 and lowered immunity, these yeasts can cause persistent
inflammation deep inside the pore lining (hence the name folliculitis, which translates to inflamed
follicles).

Malassezia folliculitis presents itself in the form of oily, monomorphic follicular papules and pustules
on the forehead, cheeks, jawline, chest, and back. They are usually accompanied by skin irritation,
burning sensation and extreme itching.

Besides causing folliculitis, Malassezia is also notorious for causing several other skin problems like
Seborrheic Dermatitis, Blepharitis, Onychomycosis, etc. It should be noted that Malassezia on its own
is completely harmless and it exists as the cutaneous micro-flora in most of our bodies. So why does a
naturally existing micro-flora turn into our foe?
What is Malassezia?
Malassezia yeast is found in the Stratum Corneum and Pilar Folliculi where it uses its own lipases and
phospholipases to hydrolyze triglycerides from sebum into free fatty acids for their own nutritive lipid
source, thus leading to proliferation. It is an opportunistic organism, which changes from the
saprophytic phase to the pathogenic mycelian phase under certain conditions, such as increased
temperature, greasy skin, sweating and immunosuppression and lowered sex hormones. The relation
between sex hormones and immunity is found to be direct and hence, its no surprise that
immunosuppressed patients have lower sex hormones i.e. testosterone in males and estrogen in
females.

Extensive research shows that patients with compromised immunity and lowered sex hormones are at
the highest risk of being affected by any of the diseases caused by this yeast. The evidence of this includes
patients diagnosed with HIV and other immuno-suppression disorders. It is worth noting that people
not suffering through serious immuno-suppression disorders may be suffering with chronically lowered
immunity which could be caused by micro-nutrient deficiency primarily vitamin D and endocrine
disruption both affecting immunity and hormonal functioning of the body.

Treatments for Malassezia Folliculitis

It fairly common for this skin condition to be misdiagnosed as acne vulgaris, bacterial folliculitis or any
other type of acne. Unlike acne which is caused by bacterial infection, Malassezia folliculitis is merely
an inflammation of the affected follicles and its lining. Malassezia folliculitis can be differentiated from
the other two skin conditions by the lack of response to oral and topical antibiotics, absence of
comedones and the often pruritic nature of the lesions.

The easiest way to distinguish folliculitis from acne is closely observing the symptoms. If the skin
condition does not spread from the affected area to other parts of the body then it is not acne but
folliculitis. Also, unlike acne folliculitis has specific triggers varying from person to person. These may
include humidity, elevated temperatures during summer, excessive sweating, use of balms, lotions,
creams and sunscreens, occlusive clothing, etc.

As pointed out earlier the primary cause of the yeast Malassezia to play havoc on the skin is lowered
immunity along with adverse skin conditions. Treating these should be part of a regime that also
includes the use of oral antifungals as primary weapon of attack. Building up the immunity and
correcting hormonal functioning of the body is equally important in building up the defenses against
the recurring skin condition. Effective prescription includes oral fluconazole 100mg daily, topical
clotrimazole cream applied twice daily, and tretinoin 0.0375% cream. Drastic improvements have
been noted within 24 hours. After use for two to three months, oral antifungal may be tapered to every
other day and so on.

The most effective treatment is oral antifungal medication, particularly in the beginning as the yeast is
located deep within the hair follicle. Topical antifungals are useful as adjunctive therapy as well as
maintenance and prophylactic therapy, especially as recurrence is common. One study, by Levy et al,
studied three different treatment regimens among patients. The first group received topical
ketoconazole alone, the second received oral ketoconazole, and the third group received both oral
ketoconazole with topical ketoconazole. They report that these treatments promoted cure in 12, 75, and
75 percent of 26 patients, respectively, indicating the increased efficacy of oral antifungals.
Furthermore, this indicates that the addition of topical antifungal while on an oral medication may not
have any increased efficacy, although further studies are required to determine recurrence rates in each
group. Antifungal medications are also useful for their anti-inflammatory mechanisms.

Conclusion
Malassezia folliculitis may persist for many years if it is misdiagnosed as acne vulgaris. For this reason,
it is important to consider this diagnosis in patients failing to respond to typical acne medications, in
particular those with pruritic, 1 to 2mm monomorphic papules and pustules. The diagnosis of
Malassezia (Pityrosporum) folliculitis can be identified via the usual clinical presentation, direct
microscopy and culture, histopathological examination, and rapid efficacy of oral antifungal treatments.
This disease occurs more commonly in hot, humid environments, especially in individuals with
excessive sweating or occlusions of the skin.

When deciding treatment regimens, it is important to observe what triggers flares. Treatments may be
required during summer months as the weather is more hot and humid or during periods of increased
sweating, such as intense exercise or outdoor work. Occlusive clothing and topical products, such as
make-up, lotion, or sunscreens may also promote flares. As acne vulgaris and MF coexist in 12.2 to 27
percent of cases, it may be necessary to combine antifungal treatments along with typical acne
medications. Use of antibiotics; however, may alter normal flora and lead to the yeasts overgrowth. For
this reason, other anti-acne medications are preferred over antibiotics, as antibiotics are
counterproductive.