Download Pityriasis Versicolor

Yeast infection of the Skin
Dr. Ahmed A. Kawen
Dermatology & Venereology
Pityriasis Versicolor
It is a common fungal skin infection. The old name,
tinea versicolor, should be dropped, as the disorder is
caused by commensal yeasts (Pityrosporum) and not
by dermatophyte.
Cause:

Pityriasis versicolor is caused by the dimorphic
organism (Malassezia), which is the pathogenic form of
the commensal yeasts (Pityrosporum). It is a lipophilic
organism (presents in highest number in areas with
increased sebaceous activity).
P. versicolor


Recent researches has shown that, the genus
Malassezia includes 12 species, all these
species are lipophilic except M. pachydermatis is
non lipophilic.
The majority of pityriasis versicolor is caused
by Malassezia globosa, while the classical old
species is Malassezia furfur.
Predisposing factors:
Cushing syndrome, pregnancy, OCP, malnutrition,
corticosteroid therapy, heat, and humidity; cause the
Pityrosporum to convert to its pathogenic form
(Malassezia).
Presentation and course:
 The disease mostly seen in adolescent and young
adult (age of high sebaceous activity) and rare in
children, and mostly occur in summer months. Typical
sites are the upper trunk; neck, chest, upper back, &
shoulders (areas with high sebaceous activity).

P. versicolor
●It presents as asymptomatic or slightly itchy, scaly,
hypopigmented (in dark skin) or hyperpigmented (in
white skin) macules (so termed versicolor). The scales
are accentuated by stretching.
●The infectivity of the disease is very low and can be
regarded as non-infectious.
●Mechanisms of pigmentary change are unclear;
darkening may result from hyperkeratosis, but
lightening result from direct inhibitory effect on
melanocytes by the carboxylic acids which is released
by the organisms
Tinea Versicolor
More
apparent
in the
summer.
Tinea
Vesicolor
Hyperpigmented
Variety
Looks Like: intertrigo,
erythrasma ….
Diagnosis:
•Scrape lightly – fine white scale
•KOH Positive for short hyphae and spores
(Spaghetti and meatballs)
•Woods Light – pale yellow white fluoresce.
•Culture rarely done.
Tinea Vesicolor – Woods Light
Yellow White
Tinea Versicolor Microscope
P. Versicolor - Differential
•Vitiligo
•Pityriasis Alba
•Pityriasis Rosea
Vitiligo
White
without
scale.
Pityriasis Alba
Frequently on face,
KOH neg. Few
lesions.
May have fine white
scale.
Pityriasis Rosea
•Papules or
plaques with
Collarette of
scale, KOH (-),
Woods light
neg.
Treatment:
Topical: it is indicated for limited disease, treatment
options include:
1- Imidazole (miconazole, clotrimazole, and
ketoconazole) cream, twice daily for 2–4 weeks.
Ketoconazole shampoo for 5-10 minutes daily for 3
days.
2- Selenium sulphide suspension or shampoo for 10
minutes daily for one week.
3-Terbinafine spray.
4- Recently Iraqi researches proved that lactic acid
solution and diclofenac gel are effective alterative
therapies.
Systemic Treatment
Indicated for extensive or resistant infection
or frequent recurrences, include:
- Itraconazole (200 mg once daily for one week),
-fluconazole (400 mg single dose),
-or ketoconazole (400 mg single dose).
-
P. Versicolor-Treatment
Notes : - Hypopigmentation resolves slowly
-No scale when scraped indicates cure.
-Sunlight helps restore pigment
•Prevention:
recurrence is common after any treatment, so it may be
prevented by: once weekly application of ketoconazole
shampoo or Selenium shampoo’s prophylaxis before summer
in some patients or once monthly oral itraconazole,
fluconazole, or ketoconazole for 6 months.
Introduction
Pityrosporum folliculitis :
Is a common inflammatory skin disorder that is seen
mainly in young adult person. Its an infection of the hair
follicle that is thought to be caused by the common
cutaneous lipophilic yeast like fungus, Malassezia furfur .
The disease is often misdiagnosed as truncal acne so
that traditional acne therapies, especially antibiotics,
worsen PF.
Diagnosis of pityrosporum folliculitis(PF):Depends on the following criteria :-
1-characteristic morphological picture:
The rash of pityrosporum folliculitis is dimorphic, with pruritic
erythematous follicular papules and pustules. affecting mainly the
upper back and some time adjacent areas are involved.
2- Positive Wood’s light examination.
3- Positive Direct microscopical examination.
4-Skin biopsy stained with PAS stain positive for pityrosporum.
5-prompt response to the antifungal drugs.
Differential diagnosis of pityrosporum folliculitis:
-
Truncal acne:-differentiated from PF by the following :
-Lesions
of acne are polymorphic with presence of
comedones, cysts or scars.
-The distribution of truncal acne on the back (affect
mostly the periphery).
-Presence of other acne lesion elsewhere (e.g. face) .
- Absence of itching.
-Failure of response to the antifungal treatments.
-Bacterial folliculitis.
-Steroid –induced folliculitis .
-Pustular drug eruption .
patient with Pityrosporum folliculitis: Before treatment with antifungal.
patient with truncal acne: After treatment with antifungal..
Candidiasis(Candidosis or Moniliasis)

C. albicans is a common inhabitant of the
gastrointestinal and genitourinary tracts, and skin

C. albicans is an opportunistic organism. Under the
right conditions e.g. decreased immunity, moisture
and decreased competing flora, It can cause lesions
of the skin, nails, and mucous membranes
Predisposing factors:
1- Mechanical factors: local occlusion, moisture and/or
maceration, dentures, occlusive dressings, and obesity.
2- Nutritional factors: iron deficiency, and malnutrition.
3- Physiologic alterations: extremes of age, and
pregnancy.
4- Systemic illnesses: endocrine disease (diabetes
mellitus, cushing disease), malignancy, and
immunodeficiency.
5- Iatrogenic: catheters and medications (steroid, broad
spectrum AB, and OCP).
Presentation of Candidiasis
primary lesion is a red pustule.
Most Common: pustules dissect horizontally
through the stratum corneum leaving a red,
glistening denuded surface with long continuous
border with satellite lesions.
Clinical pictures;
1.
2.
Oral candidiasis; thrush & perleche.
Cutaneous candidiasis;
–
–
–
3.
4.
Intertrigo.
Erosio-interdigitalis blastomycetica.
Paronychia.
Genital candidiasis;
Systemic candidiasis;
Oral Candidasis
Oral candidiasis (Thrush)

The mucous membrane of the mouth may
be involved in healthy infant

In the newborn the infection may be
acquired from contact with the vaginal tract
of the mother
Types of thrush



(1)Pseudomembranous Candidiasis (Thrush):
White-to-creamy plaques on any mucosal surface.
Removal with a dry gauze pad leaves an erythematous mucosal surface. Can involve dorsum
of tongue, buccal mucosa, hard/soft palate,
pharynx, esophagus.
(2)
Erythematous
(Atrophic)
Candidiasis:
Smooth, red, atrophic patches(atrophic papillae)

(3) Hyperplastic candidiasis: white plaques
that cannot be wiped off.

It is often the first manifestation of AIDS.
Thrush
Oral candidasis
Angular Cheilitis(Perleche)

White plaques with slight erythema of the
mucous membrane at the angles of mouth.
Maceration and fissures may be present

Is commonly related to C.albicans, but may
be caused by coagulasepositive S. aureus
and
Gramnegative
bacteria.
Similar
changes may caused by nutritional
deficiency e.g. riboflavin and iron.
Angular cheilitis
Genital candidiasis:






A- Vulvovaginitis:
white curdy plaques adherent to the inflamed mucous membranes,
and a whitish discharge. The eruption may extend to the groin folds.
Overgrowth of candida can cause the labia to be erythematous,
moist.
There might be e pruritus, burning and curd-like discharge
Pregnancy, high-dose estrogen and longterm tamoxifen treatment
are a predisposing factors
About 20% of asymptomatic women are vaginal carriers. During
pregnancy, this rises to 40%
Candidiasis can be sexually transmitted and this is probably most
important in recurrent infections
B-Balanitis and Balanoposthitis



in males similar changes occur under the
foreskin, and on the glance.
Balanitis is more common in the
uncircumcised man
The skin is erythematous and glazed with
pustules and erosions
Candidal intertrigo Flexural candidiasis:



Can involve groins or armpits; intergluteal
cleft; under large breasts; under
overhanging abdominal folds; or in the
umbilicus.
Red moist patches surrounded by a fringe
of macerated epidermis (“collarette” scale).
Tiny pustules and papules are observed
closely adjacent to the patches, termed
“satellite or daughter” lesions


A moist glazed area of erythema and maceration
appears in a body fold; the edge shows soggy
scaling, with outlying satellite papulopustules. These
changes are most common in the groin, axillae, or
under the breasts.
Napkin candidiasis: it is a type of flexural candidiasis,
occurs usually due to occlusion by wet diapers, and
misuse of steroid combination compounds (as
nystacort, which contain potent steroid and weak
antifungal agents).
Intertrigo
Intertrigo
ddx

Differentiated from contact dermatitis by:




(1) Involvement of the folds
(2) Occurrence of many small erythematous “satellite”
or “daughter” lesions scattered along the edges of the
larger patch(es)
Rx: Topical anticandidal agents are effective. Recurrent
cases may be associated with gut colonization and
need Rx with oral nystatin
Perianal candidiasis

May present as a pruritus ani

Pruritus and burning can be very severe

Characterized by erythema, maceration and less
commonly fissure

Rx: topical anticandidal agents are effective. Oral
antifungals are alternative
Paronychia:




Candida albicans may be the sole pathogen in chronic
paronychia, or be found with other micoorganisms as
Proteus or Pseudomonas. The proximal and sometimes
the lateral nail folds of one or more fingers become
bolstered and red and the cuticles are lost. Mostly seen
in house wife (water and detergent exposure).
Acute paronychia is usually bacterial (staph. aureus).
Candidal nail infection: generally results from
candidal paronychia and starts near the nail fold. The
nail plate becomes ridged and yellow.

Usually the fingernails are affected more
than toenails

Patients commonly have an atopic
background

Frequently seen in diabetics and those with
heavy hand work
Erosio interdigitalis blastomycetica
Oval shaped macerated white area on the finger webs,
mostly the third web between the middle and ring
finger. Mostly seen in diabetic patients, or in persons
with frequent water exposure of their hands.
On the feet it is the fourth web space that is most
often involved
Clinically, this may be indistinguishable from tinea
pedis
Erosio-interdigitalis blastomycetica
- Chronic mucocutaneous candidiasis:


It is a chronic, treatment-resistant, candidal infections
of the skin, nails, and mucous membranes. There are
specific inherited abnormalities in cell-mediated
immunity,several different forms have been described
including those with autosomal recessive and
dominant inheritance patterns.
Chronic mucocutaneous candidiasis:
Systemic candidiasis:

This is seen against a background of severe
illness, leucopenia or immunosuppression.
The skin lesions are begin as erythymatous
macules that may become papular, nodular,
pustular, or ulcerative.
Investigations:




1- KOH examination: candida appears as oval cells
(yeast),
and
sometimes
as
elongated
cells
(pseudohyphae).
2- Culture: Sabouraud's Dextrose Agar.
3- Investigations for the suspected predisposing factors.
●Wood's light is not useful in all types of candidal skin
infection.
Treatment:





General measures:
Predisposing factors should be sought and
eliminated.
Topical:
Imidazole group (miconazole, clotrimazole, and
ketoconazole), amphotericin, nystatin, and gention
violet, all are effective topically.
Systemic








Oral itraconazole (twice daily) or fluconazole (once
weekly) can be used,
they are indicated for:
1- Recurrent candidiasis in immunocompromised.
2- Sever or recurrent genital infection.
3- Candidal paronychia and nail infections.
4- Chronic mucocutaneous candidiasis.
5- Systemic candidiasis.
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