Malassezia Folliculitis - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

Malassezia is a common occupant of the human skin surface and causes disease only under certain conditions. M.globosa, M.sympodialis, and M.restricta are involved in the occurrence of Malassezia folliculitis. When Malassezia proliferates in excess and gains entry into the hair follicles, it can result in the occurrence of Malassezia or (Pityrosporum) folliculitis. These acne appear as clusters of small, itchy, red papules or bumps on the skin. Sometimes, these bumps can become big, form whiteheads, and contain white or yellow pus.

How Does Malassezia Folliculitis (Fungal Acne) Differ From Regular Acne?

Both these conditions can be confused with each other since both cause pimples. Regular acne occurs due to the blockage of hair follicles with oil, bacteria, and dead skin. Malassezia folliculitis is caused by a fungus that infects the hair follicles.

The primary difference between fungal acne and regular acne is that fungal acne (Malassezia folliculitis) can cause itchiness, while regular acne (acne vulgaris) does not. Also, Malassezia folliculitis lacks the basic features of acne, like the presence of whiteheads or blackheads (comedones). These two types of acne can occur together, but the treatment modalities are different. Hence, it is important to differentiate between these two conditions.

Who Is More Prone to Develop Malassezia Folliculitis?

The following are more susceptible to developing Malassezia folliculitis:

• Those living in hot and humid regions.

• Production of excess sebum (oily substance manufactured in the sebaceous glands).

• Excessive sweating (hyperhidrosis).

• Use of antibiotics.

• Immunosuppressed individuals like those living with HIV (human immunodeficiency virus) and also with the use of topical and oral steroids.

• Blockage from the use of sunscreens and moisturizers.

• Presence of other fungal infections like seborrheic dermatitis (a skin condition that results in the formation of scaly patches and red skin, especially on the scalp) and tinea versicolor (a fungal infection that causes small, discolored patches of skin).

What Parts of the Body Are Affected by Malassezia Folliculitis?

Malassezia folliculitis is a common skin condition and affects the following body parts:

• Face, particularly the forehead.

• Shoulders.

• Scalp (usually near the hairline).

• Arms.

• Chest.

• Back.

What Are the Causes of Malassezia Folliculitis?

Malassezia yeast is naturally present in the skin of almost every individual. The yeast can, however, trigger a problem when there is an obstruction or damage in the hair follicles that paves the way for the entry of the yeast. The hair follicle can also get damaged due to the following reasons:

• Excessive rubbing of skin against skin.

• Shaving, waxing, or plucking hair.

• Wearing tight-fitting clothes.

• Presence of damp and hot skin.

• Rubbing or touching the skin frequently.

• Using a hot tub.

• Antibiotic medications can cause or aggravate Malassezia folliculitis. This is because antibiotics can lower the levels of good bacteria on the skin and enhance the proliferation of yeast that results in fungal acne.

Malassezia folliculitis neither spreads from one person to another nor does it indicate poor personal hygiene.

What Are the Signs and Symptoms of Malassezia Folliculitis?

Malassezia folliculitis occurs in areas that are oily. The signs and symptoms are as follows:

• The sudden outbreak of pimples that resembles a rash.

• Formation of clusters of bumps that resemble each other in size and appearance and are uniform and symmetrical.

• The acne in acute cases may occur as 1 mm (millimeter)-wide pustules, vesicles, or papulopustules. The outer layer of the skin thickens in chronic cases.

• Each pimple may be lined by a red border or ring.

• The skin can be painful, itchy, and a burning sensation may be experienced.

• The major sites of occurrence of these bumps are the chin, forehead, chest, neck, shoulders, upper arms, and upper back.

How Can Malassezia Folliculitis Be Diagnosed?

Malassezia (pityrosporum) folliculitis is not a serious medical issue; one must not panic. However, it can be easily misdiagnosed as it mimics acne vulgaris. The symptoms can cause discomfort, and if the symptoms are persistent and difficult to treat, specific diagnostic tests may be required. One can consult a dermatologist (skin specialist) who will diagnose the condition in the following ways:

• Examination of the skin and inquiry about the history and nature of the symptoms.

• Obtaining a sample of the skin to be examined under the microscope.

• Wood’s lamp, which uses a small black light, may be used to look for areas of skin that appear fluorescent yellow or green.

• Potassium hydroxide preparation of skin scrapings can show the presence of budding yeasts but hyphae are less common.

• The culture of Malassezia species is not done regularly since it requires special media for the growth of these species.

• Yeasts can be observed within the hair follicles and sometimes around the dermis on histopathological examination.

Other methods include tape stripping, swabs, contact plates, direct microscopy, and dermoscopy.

How Can Malassezia Folliculitis Be Treated?

The treatment methods include:

• Since antifungals work well against fungal infections, the dermatologist may prescribe an oral antifungal like Itraconazole or Fluconazole. These are prescribed as off-label treatments since they are not approved by the U.S. (United States) Food and Drug Administration (FDA) for treating this specific condition.

• Topical antifungal medication in the form of antifungal shampoo can be prescribed to those who cannot take oral antifungal medications.

• A selenium sulfide shampoo that is easily available can be used and applied on the neck and scalp. Also, it can be allowed to drip onto the chest, shoulders, and back.

• Studies are in progress to test whether photodynamic therapy can be employed in the treatment of Malassezia folliculitis if the condition does not respond well to other treatment methods. Photodynamic therapy uses both light and a drug (photosensitizer) to damage unhealthy cells.

• If the folliculitis is due to immunosuppression, the treatment must aim at resolving the immunosuppression.

• Home remedies like tea tree oil can also be effective against Malassezia folliculitis, but such remedies have to be discussed with one’s dermatologist.

Are There Any Side Effects With the Use of Oral Antifungal Medications?

Common side effects include:

• Nausea and vomiting.

• Abdominal pain.

• Diarrhea.

What Are the Ways to Prevent Malassezia Folliculitis?

Malassezia folliculitis can be prevented in the following ways:

• One must be careful while shaving, waxing, or plucking.

• Clean and well-maintained hot tubs must be used.

• Bathing suits must be washed and dried before every use.

• One must wear loose clothes while exercising and during hot and humid climates.

• One must shower and change into new clothes immediately after exercising or working out.

• Any irritant or product that resulted in the condition must be stopped for about a month.

• Warm compresses can be given to the area a few times a day.

• Oil-containing skin products and or sunscreens should be avoided.

Conclusion:

Malassezia or Pityrosporum folliculitis is a fungal infection caused by the Malassezia species, which is a common resident of the skin. Damage or obstruction of the hair follicles can cause these fungi to gain entry and infect the hair follicles. One need not be worried about this condition as it is treatable. The symptoms can resolve within a few weeks following the treatment. It can sometimes persist for years and relapse with the cessation of the treatment. Long-term treatment may be necessary in cases of multiple recurrences or in those who are at high-risk. By following good skin care hygiene and application of topical antifungal shampoo, recurrence can be prevented.