Azad Kassim MD, Hasa, Saudi Arabia on November
Presence of lesions for long time (5 years),with no response
to anti-acne measures, absence of comedones and lack of scars
are all make the diagnosis of pityrosporum folliculitis most
likely. In such cases simple side lab. KOH test can confirm
the diagnosis and further confirmation may be done by PAS stain.
I totally agree that an initial oral antifungal therapy with
cyclic course of itraconazole 200 mg qd for 1-2 weeks per month
(1-2 cycles) or a weekly dose of 150 mg fluconazole for 4-6
weeks is a good idea. Further relapses can be prevented by maintaining
patients on either ketoconanazole 2% shampoo or selenium sulfide
2.5% shampoo twice per week for 6-8 weeks then once per week
for subsequent uses.
Walter G Larsen MD, Portland, OR, USA on November
This disease is now called Malassezia folliculitis.
In addition to the treatment prescribed I add ZNP soap since
it has a tendency to recur.
Amanda Oakley FRACP, Hamilton, New Zealand on
November 29, 2005
I have found a short course of isotretinoin effective for malassezia
Janet Hickman MD, Lynchburg, VA, USA on November
I agree that it is difficult to identify Pityrosporum on KOH.
They are more easily visualized by staining the smear with Wright
Giemsa stain as you would a Tzanck smear. Nile Blue stain is
even more useful, though not as apt to be available in the office.
Stephen Glinick MD, Providence, RI, USA on
November 29, 2005
I believe that I have seen predominantly two presentations
for this entity. First are the milder forms that look like forehead
comedones but don"t respond to topical retinoids. I usually
treat these patients with a two week course of Ketoconazole
200mg bid. In most cases they will have cleared and I then move
them to Nizoral shampoo several times per week and topical Ketoconazole
cream daily, both used chronically. Occasionally the patient
will need a second course of oral Ketoconazole some months down
the line if the topicals don't hold things in check. I feel
that oral Ketoconazole is so reliably diagnostic that I have
abandoned biopsying for confirmation. In fact, unless immunocompromised,
if the patient doesn't clear with oral ketoconazole then they
didn't have Pitorosporon Folliculitis to begin with. I have
never found KOH to be elucidating since yeast forms can be seen
even if the folliculitis component is absent. (By the way I
think the term "folliculitis" is a bit misleading
here because most lesions are barely inflammatory in this subset).
The second presentation is much less common and looks like
bad nodulocystic acne. I have discovered these only by biopsying
nodules that completely resisted conventional oral acne regimens.
Usually treatment resistant acne that goes on to Isotretinoin
gets at least partial control with oral antibiotics. When that
has not been the case I have considered nodular pityrosporon
folliculitis before embarking on Isotretinoin. I have occasionally
wondered if I have actually treated some patients who really
had nodular pityrosporum folliculitis with Isotretinoin thinking
they had nodulocystic acne and gotten them better by default
via shutting down the sebaceous glands.
Khaled El-hoshy M.D., Troy, Michigan, USA on
November 30, 2005
Topical ketoconazole shampoo for 10 min qod , 2-4 weeks is
usually v helpful
Omid Zargari MD, Consultant Dermatologist,
Booali Medical Group, Rasht, Iran on Nov 30,
Pityrisporal folliculitis (PF) vs. Acne vulgaris; in my estimation,
there are some clues which help a dermatologist to differentiate
these two diseases. 1) Pityrisporal folliculitis is pruritic,
especially after sweating. 2) Trunk involvement and sparing
of the face are among the other features of PF. 3) Furthermore,
antibiotics have no role in treating PF, Indeed they make PF
Concerning therapy, I believe that a combination of systemic
and topical azoles would be effective therapy for PF. Another
point; regarding that Malassezia are common residents of skin
and have some roles in the pathogenesis of acne, sometimes I
use topical antifungals in combination with routine anti-acne
agents in treating acne.
Laxmisha Chandrashekar MD, India on December
Although a well known entity it is often overlooked. Apart
from oral antifungals, I also prefer addition of topical tretinoin
to the treatment regimen as the folliculitis tends to be very
resistant to therapy