ARTICLE
Pityriasis versicolor (PV) is a chronic, benign and asymptomatic skin
disease, which affects predominantly young adults of both sexes. It is
composed of two color types, one of which is brown (pigmented), the other
white (achromatic) [1]. Recently, a red colored type, PV rubra, has been
reported by Horiuchi [2], Ohtani et al. [3] and Katoh et al.
[4]. However, there was no identification of species of Malassezia.
In this study, we report six similar cases of PV rubra, and identify the
species M. sympodialis isolated from the scales of two different
lesions at a 6 week-interval in the same person by the method of Makimura
et al. [5]. Capillaroscopically, there was telangiectasis in the
erythematous lesion, but neither in brown nor in white lesions. Therefore,
we report the cases with discussion about the mechanism causing telangiectasis
in the dermis.
Case reports
Case 1
A 46 year-old male with SLE, who has been treated by oral administration
of corticosteroid (predonisolone; PSL15 mg/day) for four years and is
well controlled, noticed erythema on the chest and trunk for one month
in Oct, 1995. He noted neither fever nor general fatigue. Physical examination
disclosed many soybean-sized or thumb-sized erythema (Fig.
1a), some of them with pigmentation. Differential diagnosis was seborrheic
dermatitis, patch granuloma annulare [6] and annular erythema, etc, but
neither induration nor pruritus was noticed. The scales on the erythema
were clearly taken with Scotch-tape (Fig.
1b) and many sausage-like short segmented fungal elements were seen
with positive Giemsa stain (Fig.
1c), although no confirmation was done by wood light. The results
of laboratory investigations were within normal limits except for immunogloblin
A (675 mg/dl), anti-nuclear (x 320, homogeneous & speckled types),
anti-SS-A (x 59) and anti-SS-B (x 1.3) antibodies. Many small whitish
colonies were grown on Sabouraud's agar culture containing cycloheximide
(Mycosel) with olive oil. However, the strain was not identified. Capillaroscopically,
the reddished lesions were confirmed as blood vessel dilatation (Fig.
1d, e). The lesion improved two weeks after application of anti-fungal
ointment (isoconazole nitrate).
Case 2
A 57 year-old male with systemic scleroderma (SSc; diffuse type), who
had been treated by oral administration of corticosteroid (PSL10 mg/day)
and immuran (100 mg/day) for three years and was well controlled, noticed
erythema on the back since Dec. 8, 1995. He noted neither pruritus nor
pain. Physical examination disclosed several thumb-sized erythema. The
scales on the erythema were clearly taken with Scotch-tape and many sausage-like
short segmented fungal elements were seen with positive Giemsa stain,
although no confirmation was done by wood light. The results of laboratory
investigations were within normal limits except for immunogloblin A (148
mg/dl) and M (69 mg/dl), anti-nuclear (x 80, homogeneous and cytoplasmic
types), anti-SS-A (x 8.6) antibodies. Many small whitish colonies were
grown on Mycosel culture with olive oil. However, the strain was not identified.
Capillaroscopically, the reddished lesions were confirmed as blood vessel
dilatation. The lesion improved two weeks after application of anti-fungal
ointment (isoconazole nitrate) without any pigmentation.
Case 3
A 21 year-old female with SLE, who had been treated by oral administration
of corticosteroid (PSL15 mg/day) and mizoribin (150 mg/day) for eight
years and was well controlled, noticed erythema on the chest and neck
for one year in Nov., 1996. She applied anti-fungal ointment for the lesions,
and the lesions recurred several times. However, she noted neither pruritus
nor pain. Physical examination disclosed several soybean-sized or thumb-sized
erythema. The scales on the erythema were clearly taken with Scotch-tape
and many sausage-like short segmented fungal elements were seen with positive
Giemsa stain, although no confirmation was done by wood light. The results
of laboratory investigations were within normal limits except for anti-nuclear
(x 320, homogeneous & speckled types), anti-SS-A (x 31.2) and anti-RNP
(x 10.7) antibodies. Many small whitish colonies were grown on Mycosel
with olive oil. However, the strain was not identified. Capillaroscopically,
the reddished lesions were confirmed as blood vessel dilatation. The lesion
improved two weeks after application of anti-fungal ointment (isoconazole
nitrate).
Case 4
A 30 year-old female with SLE, who was treated by oral administration
of corticosteroid (PSL15 mg/day) for two years and was well controlled,
noticed several erythemous lesions on the right axillae for 1-2 years,
and visited the Department of Dermatology of Prefectural Gifu Hospital
on May 7, 1998. The results of laboratory investigations were within normal
limits except for immunogloblin G (1,888 mg/dl) and complement (C4;
15 mg/dl), anti-nuclear antibodies (x 160, homogeneous & speckled
types). The scales on the erythema were clearly taken with Scotch-tape
and many sausage-like short segmented fungal elements were seen with positive
Giemsa stain, although no confirmation was done by wood light. The lesion
improved two weeks after application of anti-fungal ointment (isoconazole
nitrate) without any pigmentation.
Case 5
A 43 year-old female with Sjögren's syndrome who had been followed
up in a clinic for five years and was well controlled, noticed erythema
on the neck and the dorsum of the trunk every summer season for several
years. She applied anti-fungal ointment on the lesions, but the lesions
soon recurred. She noted slight surface hypersensitivity, but neither
pruritus nor pain. Physical examination disclosed several soybean-sized
or thumb-sized erythema on the neck and the dorsum of the trunk. The scales
on the erythema were clearly taken with Scotch-tape and many sausage-like
short segmented fungal elements were seen with positive Giemsa stain.
The results of laboratory investigations were within normal limits except
for anti-nuclear (x 320, homogeneous & speckled types), anti-SS-A
(x 500) and anti-SS-B (x 110) antibodies. Many small whitish colonies
were grown on Mycosel culture with olive oil. However, the strain was
not identified. The lesion improved two weeks after application of anti-fungal
ointment (isoconazole nitrate). Histopathological features of the lesion
on the dorsum of the trunk showed no epidermal hyperplasia without elongation
of rete ridges and no inflammatory cell infiltration in the dermis, which
revealed neither seborrheic dermatitis nor patch granuloma annular as
reported by Mutasim and Bridges [6], however, there was only dilatation
of small blood vessels in the dermis. In the horny layers, many yeastlike
or fine filamentous structures with PAS and Grocott stains were seen (not
shown).
Case 6
A 31 year-old male noticed erythema on the dorsum of the trunk and the
chest for 1 month, and visited the Department of Dermatology of Prefectural
Gifu Hospital on June 3, 1999. He was in good general health. Physical
examination disclosed many thumb-sized erythema on the dorsum of the trunk
(Fig. 2a) and soybean-sized
erythema on the chest (Fig.
2b). The scales on the erythema were clearly taken with Scotch-tape
and many sausage-like short segmented fungal elements were seen with positive
Giemsa stain (Fig. 2c)
as well as previous cases. The results of routine laboratory investigations
were within normal limits. Several whitish colonies were grown on Mycosel
culture with olive oil from both lesions of the chest and the dorsum of
the trunk.
Histopathological features of the lesion on the dorsum of the trunk
showed no epidermal hyperplasia without elongation of rete ridges and
only dilatation of small blood vessels without any inflammatory cell infiltration
in the dermis (Fig. 2d).
Telangiectasis was reconfirmed capillaroscopically as well as in Case
1. In the horny layers, many yeastlike or fine filamentous structures
with PAS and Grocott stains were seen (Fig.
2e). Both clinical and histopathological features led to speculation
of PV infection. M. sympodialis was identified from the lesion
of the chest, and again from the lesion of the dorsum of the trunk. The
patient was treated with antifungal ointment (bifonazole), and the lesions
on the chest diminished within two weeks.
All above cases were found from May, 1995 through June, 1999, however,
no reccurrence has been seen in these years.
Patch test using the strains of PV rubra and
nigra
In two healthy controls (a 51 year-old male and a 25 year-old female),
patch tests using cultured Malassezia strain obtained from the
erythematous and pigmentous lesion in a case of a 33 year-old male with
PV rubra (left side of neck) and nigra (right axillae) were carried out
for 48 hours. As a result, there were slightly capillaroscopical telangiectatic
changes in the patch test lesion using the strain obtained from the erythematous
lesion of PV rubra, but no change in the brown lesion of PV nigra in the
male (not shown), although there was a negative reaction in both patch
tests in both healthy controls.
Discussion
Malassezia yeasts isolated from human skin were classified in
two morphological and clinical entitiles, Pityrosporum ovale associated
with pityriasis capitis and seborrheic dermatitis and Pityrosporum
orbiculare with PV and other human cutaneous diseases [7]. As a result
of taxonomic analysis of the genus Malassezia by using morphology
and molecular biology such as DNA/DNA complementary and LSU rRNA sequence
similarity [8], the genus has been enlarged to include seven species [9];
one lipid-independent species, M. pachydermatis and six lipid-dependent
species, M. furfur, M. sympodialis, M. globosa, M. obtusa, M. restricta
and M. slooffiae.
In this study, we have neither experienced the transformation of PV
rubra to nigra nor alba as indicated by Horiuchi [2]. He reported four
cases of PV rubra; two of them transformed PV rubra into nigra (25 and
39 year-old males) and one into alba (36 year-old male) three days after
the application of anti-fungal ointment (isoconazole). He reported no
background of systemic autoimmune diseases such as SLE, SSc and Sjögren's
syndrome. Although the combination of both PV rubra and nigra was seen
in our three cases (No. 1, 2 and 3 in Table
I), these clinical data may reveal that PV rubra has no relation to
PV nigra. Subsequently, it is possible that PV rubra is independent from
PV nigra, but it is not sure. Systemic autoimmune diseases such as SLE,
SSc and Sjögren's syndrome were present in five of our cases, but
some immunological disorder may not be closely related to the occurrence
of PV rubra as well as PV nigra and alba. Although Ohtani et al.
[3] reported three middle aged males (45, 46 and 53 year-old) with PV
rubra without any description of their clinical course and background
in a meeting (only abstract is available), Katoh et al. [4] found
that an erythematous lesion in a 46 year-old male with PV rubra cured
with pigmentation two weeks after the application of anti-fungal ointment
(ranoconazole). A review of the literature showed only 8 cases including
Ohtani et al. [3] and Katoh et al. [4], however, the causative
fungus in all cases was not detected.
This article reports an interesting case caused by M. sympodialis,
which was reconfirmed twice, because Makimura et al. [5] reported
that 7 strains were isolated from PV, 3 from seborrhoeic dermatitis, 1
from atopic dermatitis and 11 from healthy controls; in all 22 strains
of M. sympodialis. M. sympodialis is the predominant species in
the healthy trunk, because Erchiga et al. [1] reported that M.
sympodialis was also found in 16 of 43 healthy skin samples from PV.
Additionally, M. sympodialis is also isolated from dogs [10] and
cats [11, 12] as well as human normal skin [13, 14]. However, M. sympodialis
triggers the severe form of common cephalic pustulosis (neonatal acne)
in infants with this benign disorder [15] and malignant otitis externa
[16], which is a very rare systemic infection.
It is still unclear whether this strain is closely associated to the
pathogenesis for occurrence of PV rubra or not. However, the strain may
stimulate blood vessel dilatation in the dermis, because patch test using
cultured strain from the lesions of PV rubra and nigra in one of two healthy
controls revealed telangiectasis capillaroscopically in the former patch
tested lesion. Therefore, the strain from PV rubra may be related to the
function of blood vessel dilatation in the dermis. Further detailed investigation
of the functional cause of telangiectasis, including several cytokines,
will be needed in the future.
Article accepted on 1/10/01
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