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Malassezia furfur is a lipophilic, yeast-like fungus that forms part of the normal human skin microflora and is associated with a wide range of infections, such as pityriasis versicolor, folliculitis, and systemic infections in immunocompromised patients. Although matrix-assisted laser desorption/ionization time-of-flight mass spectrometry has enabled rapid identification of Malassezia species, it is still a challenge to diagnose systemic infections because Malassezia fungemia can often be missed by automated blood culture systems. We report a case in which M. furfur in blood was detected by the presence of yeast-like fungi in blood smears. Yeast-like organisms were observed in the blood smears of a 3-year-old boy, taken over 2 weeks without any symptoms. He had undergone several courses of chemotherapy for neuroblastoma via an indwelling central venous catheter (CVC) that was placed in his right anterior chest for 11 months. Although the blood cultures obtained from an automated blood culture system were negative, M. furfur growth was detected in the subcultured blood taken from the CVC. The CVC was removed, and the scheduled chemotherapy was postponed. No systemic M. furfur bloodstream infection occurred; the infection resolved spontaneously without any specific treatment; only prophylactic fluconazole was administered. M. furfur fungemia may not be diagnosable by an automated blood culture system. Further, M. furfur may not cause infections in humans even when administered intravenously. This report may lead to the discovery of factors related to human infectivity of this disease in the future.

Allergists/immunologists see a variety of skin disorders, some of which have a known immunologic basis whereas others do not. We review the prevalence, etiology, clinical presentation, and effective and low-cost care of common dermatologic conditions seen in outpatient practices. Conditions discussed include pityriasis alba, seborrheic dermatitis, rosacea, acne, tinea infections, intertrigo, lichen planus, tinea versicolor, lichen simplex chronicus, scabies, pityriasis rosea, keratosis pilaris, and seborrheic keratosis. An understanding of frequently encountered cutaneous diseases and their therapies will help provide immediate access to treatment and improve the experience for both the affected patient and the clinician.

The genus Malassezia represents the dominant eukaryotic component of the skin microbial flora. There are complex interactions between this commensal and the skin, leading to various Malassezia-caused or Malassezia exacerbated skin conditions.To identify Malassezia species in lesions of patients with pityriasis versicolor (PV), atopic dermatitis (AD), and seborrheic dermatitis (SD), as well as corresponding sites in healthy subjects according to the culture methods used for Malassezia species isolation.Scrapings were collected from 80 patients (40 PV, 20 AD, and 20 SD) and 30 healthy subjects. For 10-14 days, specimens were cultured on Dixon's medium and Malt extract agar. Direct microscopic examination with Gram's stain, subculture on Hi chrome agar, Dixon's medium at various temperatures, Tweens assimilation, and hydrolysis of tryptophan were used for the identification of yeast isolates.The isolation frequency of Malassezia species in healthy subjects was 13.3% for M. furfur, 10.0% for M. globosa, and 3.3% for M.sympodialis. In patients with SD, M. furfur was isolated more frequently from scalp lesions (25.0%) and then M. sympodialis (15%) and M. globosa (10%). Malassezia sympodialis was the most prevalent isolated species in AD lesions (20%), followed by M. furfur (10%). Malassezia species isolation was found to be most prevalent in PV lesions, with M. furfur being the most prevalent identified species (52.5 %), followed by unidentified species (20%).Malassezia species composition was similar in PV, SD, and healthy subjects, with M. furfur being the commonest isolate, while Malassezia sympodialis was the prevalent species isolated in AD lesions. Chrome agar media can be promising for the identification of Malassezia species phenotypically. However, species differentiation has to be complemented by molecular methods.

Gradations in skin color are a consequence of differing amounts of melanin and their varying distribution. Although many darkly pigmented skin lesions are melanocytic and can be attributed to melanin content, the color of a black lesion can also be due to blood, necrotic tissue, or exogenous pigment. The source, pattern, and distribution of the color in black lesions usually offer important insight into its etiology. This contribution reviews conditions that can take on a black color, discussing the cause of the hue and any additional impact sun exposure may have.

Malassezia (M.) genus includes commensal yeasts of increasing medical importance, as they result in many diseases, ranging from pityriasis versicolor (PV) to systemic infections. Previous studies reported geographical variations in distribution of Malassezia species in PV lesions. The aims of the current study were to define the clinico-demographic features of PV in Tunisia, to characterize Malassezia isolates using phenotypic and molecular techniques and to find out any association between species and clinico-demographic parameters. In total, 120 PV patients were enrolled in this study. Skin scrapings were collected and inoculated on Sabouraud agar and modified Dixon medium. Malassezia species were identified using conventional phenotypic methods and 26 s rDNA PCR-RFLP. The highest prevalence of PV was observed among young adults' group. The most affected body areas were the back and neck. In overall, 50.8% and 35% of PV cases had pruritus and history of recurrence respectively. The overall concordance between phenotypic and molecular methods was high (80.95%). The discordant results are rather due to the presence of multiple species in a single culture than true misidentification. Using PCR-RFLP, M. furfur was the most isolated species (38.7%) followed by M. globosa (37.7%), M. restricta and M. sympodialis. No statistically significant association was noted between Malassezia spp. and clinico-demographic characteristics. Unlike many reports from temperate climate countries, M. furfur and M. globosa along together were the most frequently isolated species in Tunisian PV patients. Although phenotypic methods remain simple and cost-effective, molecular techniques are considered as fast and accurate methods for diagnosis purposes.

Pityriasis versicolor (PV) is a superficial mycosis caused by yeast of the genus Malassezia. The most common isolated Malassezia species in PV lesions differ among M. furfur, M. globosa and M. sympodialis. We purpose to determine the distribution of Malassezia species in PV patients at the seafarers’ medical service in Dakar, Senegal and to examine whether any association between identified Malassezia species and patients’ profile. From May 2017 to August 2017, first a questionnaire was filled to get informative data before collection of skin scrapings taken from most scaly site using sterile scalpel blade and application of scotch® for direct examination (DE). At the laboratory, DE, culture and identification by MALDI-TOF MS were done. One hundred patients with PV – all men – were included with a mean age of 34 years. Among seafarers, 81% were sailors. Clinical prevalence of PV was highest in aged adults patients with ages of 31 to 60 years (56%). Seafarers with high level of education were less representative with only 2%. The mean duration of the PV was 26.83 months. 20% of subjects suffered lesions in more than one location. The chest was the most affected anatomical site. Furthermore, possible predisposing factors associated with PV were also detected. DE was positive in 95% but culture growth only in 46%. MALDI-TOF MS analysis of the positive cultures could be performed in 84.8% (39/46). Only M. furfur was identified in 100% (39/39). In definitive, M. furfur is the only causative agent of PV in Dakar.

Background Malassezia furfur is lipodependent yeast like fungus that causes superficial mycoses such as pityriasis versicolor and dandruff. Nevertheless, there are no standard reference methods to perform susceptibility test of Malassezia species yet. Aims Therefore, in this study, we evaluated the optimized culture medium for growth of this lipophilic yeast using modified leeming-Notman agar and colorimetric resazurin microtiter assay to assess antimycotic activity of fluconazole against M. furfur. Results The result showed that these assays were more adjustable for M. furfur with reliable and reproducible MIC end-point, by confirming antimycotic activity of fluconazole with MIC of 2 μg/ml. Conclusion We conclude that this method is considered as the rapid and effective susceptibility testing of M. furfur with fluconazole antifungal activity.

International audience; BACKGROUND: Malassezia species, usually part of normal human skin microbiota, may also cause cutaneous infections, mainly pityriasis versicolor (PV) which may rapidly spread in crowded communities, particularly in students' dormitories and sport leisure centers.OBJECTIVE: Few studies have been conducted on PV in students in the Middle East. The present study was designed to determine prevalence of Malassezia species and related diseases in students from city of Sabzevar, Northeast Iran.METHODS: Specimens were collected from 189students and analyzed by direct microscopy and cultures. Following PCR amplification of the large subunit of ribosomal DNA, species were identified by restriction fragment length polymorphism analysis (RFL-PCR).RESULTS: PV was suspected for 28students which was confirmed by direct examination and cultures. Cultures also revealed positive for 13students with healthy skin. Four Malassezia species were identified, with M.restricta as the most prevalent. A higher rate of PV was observed compared to other regions in Iran. However, despite the lipophilic feature of Malassezia species, no significant association was observed between PV or Malassezia species and fatty skin or gender.CONCLUSION: This study determined the frequencies of Malassezia species in part of Northeast Iran, but further studies are needed to identify risk factors for PV.

Pityriasis versicolor is a superficial fungal infection caused by Malassezia spp. The aim of this study is to propose the definition of a new clinical entity: the recurrent and disseminated pityriasis versicolor (RDPV). All patients with RDPV were enrolled over an eight-month period. Clinical and epidemiological data were obtained, Malassezia ( M.) species were isolated in cultures and identified by phenotypic and molecular characterization, skin biopsies were taken from active lesions, serum levels of immunoglobulin E were obtained and therapeutic schemes were evaluated. A total of 16 patients were included (11 male, 5 female). The most frequently isolated species were M. japonica (n = 3) and M. furfur (n = 3). This is the first study that isolates M. japonica in patients with pityriasis versicolor; interestingly, those were recalcitrant patients. Seven patients (43.8%) had no cure with any of the proposed treatments; among those, 5 (71.4%) had increased serum IgE levels. The most effective treatment was itraconazole 200 mg daily for 28 days. The RDPV has very different features from the classic form, including a poor response to treatment, and the isolation of different Malassezia species; therefore, we propose a hypothesis for the definition of a new clinical condition (RDPV), which could be a result of the interaction Malassezia -host.

Vitiligo has a variety of presentations, including focal, acrofacial, segmental, and generalized forms. Thorough knowledge of these presentations is important to make the correct diagnosis. Signs of activity are important to recognize so that treatment is optimized. Clinical findings of confettilike depigmentation, trichrome and inflammatory vitiligo, and the Koebner phenomenon should alert the clinician that a patient's disease is likely to worsen. These patients may require systemic treatment to stabilize their disease. Many other skin disorders present with hypopigmentation or depigmentation and must be distinguished to determine the right diagnosis, advise the patient on prognosis, and prescribe the correct treatment.

Background/objective Pregnant women experience a myriad of physiological and metabolic changes that affect different organ systems in the body. Cutaneous and appendageal alterations that manifest during pregnancy are largely modulated by hormonal, immunologic, and metabolic factors. Detailed reports encompassing physiological changes and specific dermatoses of pregnancy and effects of various dermatoses on pregnant women are scanty in literature. This study was conducted to examine in detail both physiological changes and specific dermatoses. The cutaneous changes are divided into physiological changes, skin diseases aggravated by pregnancy, and specific dermatoses of pregnancy. The objectives were to study the various cutaneous changes of pregnancy and to know the proportion of these cutaneous manifestations in pregnant women. Methods This study included 600 pregnant women attending the Obstetrics and Gynecology Department of a tertiary teaching hospital in Northern Kerala, India. Detailed history elicitation and complete physical and dermatological examination were performed. Skin biopsy was performed in relevant cases. Results Cutaneous changes were seen in a majority of patients, of which physiological changes were the most common (99%). The most common cutaneous manifestation was hyperpigmentation (526; 87.6%), followed by striae gravidarum (72.8%). Other changes were vascular, including pedal edema (10%), pregnancy gingivitis (1.8%), and varicose veins (1%). Infections were the common dermatological problem in this study group. The most common infections were vulvovaginal candidiasis (21%), Tinea versicolor (6%), scabies (2.8%), dermatophytosis (1.5%), and sexually transmitted infection (0.5%). Specific dermatoses were seen in 12 cases (2%), with the most common being pruritic urticarial papules and plaques of pregnancy (1.3%). Conclusion Pregnant women are prone to suffer from a wide range of dermatological problems apart from specific dermatoses of pregnancy. The study emphasizes the need for a detailed and meticulous examination of these patients to detect these various disorders.

Ethnopharmacological relevance Skin diseases are common health problems which affecting to all ages. In Thailand, the number of patients diagnosed with skin diseases is increasing every year. Nowadays, The Ministry of Public Health is supporting and promoting herbs for treating various disorders, including disorders of the skin to reduce the problem of antibiotic resistance and adverse drug reactions. This study aimed to: (1) enumerate the herbal weeds for treating skin disorders; (2) study local knowledge of weed utilization for treating skin disorders according to the folk healers in Songkhla and Krabi province; and (3) study quantitative data by Informant consensus factor (ICF), Use value (UV) and Fidelity level (FL) value. Materials and methods Field surveys and Semi-structured interviews about the local names, parts of plants used, preparation and use method, as well as local properties were done. The data were further analyzed by descriptive statistics, interpretation and quantitative indexes (ICF, UV as well as FL). Results The results discovered 44 herbal species of weeds belonging to 41 genera in 25 families. The most used plant families were Amaranthaceae (6 species). Most plants were used to treat abscess (18 species; 40.91%). The highest UV was recorded for Commelina benghalensis (0.65). The highest ICF values were found in vitiligo, ringworm, tinea versicolor and burns (1.00 each). The highest FL values were recorded for Cleome gynandra, Cleome viscosa, Sphenoclea zeylanica, Acmella oleracea, Leersia hexandra, Cyperus involucratus, Phyllanthus urinaria and Iresine herbstii (100.00 each). A review of the literatures revealed that 34 plant species had already been tested for their pharmacological activities. The biological activities associated with treatment of skin diseases can be divided into four categories: antimicrobial, anti-inflammatory, wound healing and antioxidant activity. Conclusion The information indicates that herbal weedy utilization is still importance to the treatment of traditional healers through accumulated experience for a long time. Therefore, this study is a guide to the conservation of folk medicinal knowledge. It might be implied as the basis for drug development and application of herbal weeds to treat skin disorders along with promoting sustainable use of natural resource.

Superficial fungal infections grow in dark and moist areas and invade various parts of the body. These infections are easily treatable in immunocompetent individuals. In immunosuppressed individuals, the presentation can be quite severe, requiring use of more potent antifungal agents. The treatment for these conditions consists of topical antifungal agents, creams, and oral systemic medications. The use of prednisone can alter the appearance of superficial fungal infections, making them difficult to diagnose. It is important for primary care providers to become adept at understanding the epidemiology, transmission, clinical presentation, diagnosis techniques, and treatment options available.

Aim of the study This study aimed to determine the prevalence of Tinea capitis and Tinea versicolor , and evaluate the efficacy of bee products in management of skin disorders in Congolese school children. Methodology Medical screening and care for skin disorders were carried out in five Congolese schools from November 2010 to April 2011. Hematological and mycological analyses were performed. Of the 2728 children, there were 305 patients with either Tinea capitis or Tinea versicolor . Of them, 242 eligible patients were randomly allocated to one of the following topical treatment arms: 2% Miconazole ; 50 mg/ml Brazilian green propolis extracts (BPE); 100 mg/ml BPE; Acasia honey or Vaseline. Oneway ANOVA test was performed to assess the significance of the difference between treatment groups at baseline (day 1), adjusting for age, gender and the severity score of skin symptoms. Unpaired t -test was performed to assess the difference between treatments in terms of skin symptoms improvement, WBC count, leukocytes and erythrocytes sedimentation rate (ESR) on day 28 of treatment. Results This study showed that Miconazole ( p p Miconazole and Acasia honey ( p Conclusions Brazilian green propolis extracts improved skin lesions as efficiently as did Miconazole and may serve as an alternative treatment for Tinea mycosis .

Superficial mycoses are fungal infections limited to the stratum corneum and its adnexal structures. The most frequent types are dermatophytoses or tineas. Tinea versicolor involves the skin in the form of hypochromic or hyperchromic plaques, and tinea nigra affects the skin of the palms with dark plaques. White piedra and black piedra are parasitic infections of scalp hairs in the form of concretions caused by fungal growth. Diagnosis of these mycoses is made from mycologic studies, direct examination, stains, and isolation, and identification of the fungi. Treatment includes systemic antifungals, topical antifungals, and keratolytics.

Dermatophytoses are infections caused by keratinophilic fungi known as dermatophytes. Several steps are required for infection to take place: contact, adherence, and invasion of keratin layers. The severity of the infection depends on the type of agent, environmental factors, and the host immunologic status. Tinea versicolor is caused by the Malassezia spp yeasts, which are microorganisms that belong to normal biota in seborrheic areas, but some contributing factors, such as the application of oily preparations, creams, an increase in ambient humidity, corticosteroid abuse, or genetic predisposition can induce its overgrowth in both filamentous and yeast structures. Exposure to sunlight stimulates the production of azelaic acid, which causes the appearance of hypopigmented spots. Currently, there is no scientific explanation for hyperpigmented lesions.

Pramiconazole is a broad-spectrum triazole antifungal with potential for oral treatment of pityriasis versicolor.We sought to assess the efficacy and tolerability of 5 doses of pramiconazole relative to placebo.This was a randomized, multicenter, double-blind, placebo-controlled, 28-day, dose-finding study. A total of 147 patients were randomized to treatment with placebo or one of 5 doses of pramiconazole; treatment lasted for 3 consecutive days. Efficacy was based on mycological response, severity of clinical signs and symptoms, and the Investigator Global Assessment of lesion clearance.A statistically significant (P.001) dose-dependent effect was observed. When compared with placebo, a significant response (P.05) was obtained for all but the lowest single dose of pramiconazole. There were no serious, treatment-related adverse events or other safety concerns.The follow-up period was limited to 1 month after treatment onset.Pramiconazole is a well-tolerated and effective treatment for pityriasis versicolor and the most effective treatment regimen in this study included 200 or 400 mg taken once, and 200 mg taken once daily for 2 or 3 days.

La pitiriasis versicolor es una infeccion fungica superficial de la piel producida por hongos lipofilicos dimorficos pertenecientes al genero Malassezia spp., que forman parte de la flora normal de la piel. De las especies descritas, las responsables mas frecuentes de la clinica son M. globosa, M. sympodialis y M. furfur . En Espana, el agente patogeno mas frecuente es M. globosa . Se presenta en forma de maculas redondas u ovales de pequeno a mediano tamano y coloracion, eritematosas, hiperpigmentadas o hipopigmentadas. Su superficie suele estar cubierta por una fina descamacion. Son mas frecuentes en las areas de distribucion de las glandulas sebaceas, sobre todo en el tercio superior del tronco, de forma especial en la espalda, la raiz de los miembros superiores, el cuello y con menor frecuencia en la cara. En su tratamiento se han utilizado diferentes agentes terapeuticos topicos (ciclopiroxolamina, azoles, griseofulvina, terbinafina, succinato de litio) o sistemicos (ketoconazol, itraconazol, fluconazol).

Background Renal transplant recipients are predisposed to superficial fungal infections caused by graft-preserving immunosuppressive therapy. Reports have documented a wide range of prevalence rates for superficial fungal infections in this patient group. Objective The aim of this study was to determine the prevalence and clinical and mycological features of superficial fungal infections in renal transplant recipients at our center. Methods One hundred two consecutively registered renal transplant recipients (34 women, 68 men) and 88 healthy age- and sex-matched persons acting as controls (30 women, 58 men) underwent screening for the presence of superficial fungal infection. Skin scrapings and swabs were obtained from the dorsum of the tongue, upper part of the back, toe webs, and any suspicious lesions. Nail clippings were also collected. All samples were examined by direct microscopy and were stained with calcofluor white. The samples were cultured in Sabouraud dextrose agar, mycobiotic agar, and dermatophyte test medium. Candida species were identified on the basis of germ-tube production, spore formation in cornmeal agar, and results of biochemical testing. Dermatophytes were identified on the basis of colonial and microscopic morphologic features in conjunction with results of physiologic evaluation (in vitro hair perforation test, urease activity, temperature tolerance test, and nutritional test). Results Sixty-five (63.7%) of the 102 renal transplant recipients had cutaneous-oral candidiasis, dermatophytosis, or pityriasis versicolor, whereas only 27 (30.7%) of controls had fungal infection. Pityriasis versicolor was the most common fungal infection in the patient group (36.3%), followed by cutaneous-oral candidiasis (25.5%), onychomycosis (12.7%), and fungal toe-web infection (11.8%). Pityriasis versicolor and oral candidiasis were significantly more common among the renal transplant recipients, whereas the frequency of dermatophytosis in patients and controls was similar. Candida albicans was the main agent responsible for oral candidiasis, and Trichophyton rubrum was the most common dermatophyte isolated. Analysis showed that age, sex, and duration of immunosuppression did not significantly affect the prevalence of superficial fungal infection. Cyclosporine treatment and azathioprine therapy were identified as independent risk factors for superficial fungal disease. Conclusions The prevalence of opportunistic infections with Pityrosporum ovale and C albicans is increased among renal transplant recipients, probably owing to the immunosuppressed state of this patient population. However, renal transplant recipients are not at increased risk of dermatophytosis.

Cutaneous fungal infections cause significant morbidity for healthy and ill patients. The incidence of some dermatomycoses is increasing, despite availability of newer and better topical and systemic treatments. Fungal remnants last months to years under the ideal conditions, allowing continued spread of infection. Mycoses treated in one area may recur because of organism travel from concomitant areas of infection. Failure of patients and physicians to recognize a fungal etiology early may lead to more extensive, severe, or difficult-to-treat infections. Finally, a patient's concurrent illnesses may play a part in susceptibility and ability to manage fungal infections. For these reasons, scientists have studied and developed newer antifungal agents with better efficacy and greater convenience in dosing. These drugs, however, still have side effects and medication interactions that may limit their use in some patients. Better efforts to educate patients and physicians alike may aid in faster recognition and treatment of dermatophytoses. More research is needed to continue to develop drugs suitable for use in a broader range of patients and diagnostic tests that may be quicker or more specific than conventional ones.

Anti-fungal resistant hypopigmented macules in an adolescent Abstract Progressive macular hypomelanosis of the trunk is a disease of unknown origin that often goes unrecognized in the clinical setting. We present an adolescent with this condition initially diagnosed as tinea versicolor. She was asymptomatic, with hypopigmented macules located on the trunk and with no previous history of inflammation, infection or injury. Pro- gressive macular hypomelanosis is a common disorder that has frequently been misdiagnosed, probably because it is often considered a post-inflammatory hypopigmentation or pityriasis versicolor.

OBJECTIVE: This study was aimed at the development of a DNA-based procedure directly applicable to pathological skin scales and at the assessment of its value in rapid laboratory confirmation and identification of each of the seven Malassezia species. These lipophilic basidiomycetous yeasts in predisposed individuals are involved in pityriasis versicolor, seborrheic dermatitis, blepharitis, folliculitis, atopic dermatitis and fungemia. Standard identification procedures to species level are available, but so far no system for direct detection and characterization of Malassezia species in clinical specimens is available. METHODS: Malassezia DNA was extracted from pathological skin scales by a modified hexadecyltrimethylammonium bromide (CTAB) method and amplified by single and nested polymerase chain reaction (PCR), assays using the general fungal ITS 1/4 and 3/4 primers for amplification of sequences from the Malassezia major ribosomal DNA complex. Restriction fragment length polymorphism (RFLP) analysis of PCR products was used in subsequent species identification. DNA extracted from culture-positive skin scales was also tested by PCR and the RFLP patterns obtained were analyzed. RESULTS: A total of 36 isolates were tested. Distinct pure culture and skin-scale ITS 3/4 HinfI and AluI restriction patterns differentially identified M. furfur, M. globosa, M. restricta, M. sympodialis, M. pachydermatis, M. obtusa and M. slooffiae. Malassezia DNA was extracted from pathological skin scales and RFLP identified solitary and multiple Malassezia species in the same specimen. Molecular identification was confirmed by cultures and biochemical tests. Concurrent detection and identification of Candida and Yarrowia species was also feasible from skin scales. CONCLUSION: The proposed method, described for the first time, could provide a sensitive and rapid detection and identification system for Malassezia species, which may be applied to epidemiological surveys and routine practice. Clin Microbiol Infect

Epidural analgesia is usually contraindicated in case of infection at the site of needle insertion. Tinea versicolor is a benign superficial cutaneous fungal infection caused by the proliferation of a skin commensal yeast of low pathogenicity. We report the case of a pregnant woman with a tinea versicolor in the lumbar region, who benefited from a labor epidural analgesia, realised with reinforced antiseptic measures. No neurological or infectious complication occurred.

Onychomycosis refers to a fungal infection of the nail bed and secondarily the nail plate. This could be caused by dermatophytes, Candida species, and nondermatophyte molds. Tinea unguium is infection of the nail bed/plate by dermatophytes. The modified classification of onychomycosis is distal and lateral subungual onychomycosis, proximal subungual onychomycosis, superficial onychomycosis, endonyx onychomycosis, and total dystrophic onychomycosis. In general, only about 50% of all abnormal-appearing toenails can be attributed to mycologically proven onychomycosis. The other causes for abnormally-appearing nails include psoriasis, trauma, and lichen planus. The newer oral antifungal agents itraconazole, terbinafine, and fluconazole have become primary treatments of onychomycosis and other superficial fungal infections; however, griseofulvin, is widely used to treat tinea capitis and ketoconazole, is preferred by some for the treatment of tinea versicolor. Each of the new oral agents has been shown to be effective and safe in dermatomycoses. Diabetic patients are more prone to development of onychomycosis compared with normal individuals. Because of the potential for morbidity, the feet in diabetic patients need to be examined carefully, with appropriate treatment of any fungal or bacterial infection. The management strategies with onychomycosis include no therapy, use of effective topical therapies if available, mechanical or chemical debridement, or oral antifungal therapy. In some instances the most appropriate approach is a combination of two of the above-mentioned therapy modes, for example, oral therapy and mechanical debridement. The preferred dosage regimens are itraconazole (pulse), terbinafine (continuous), and fluconazole (once-weekly). Once a cure has been achieved, management includes education and counseling of the patient to reduce the chances of recurrence of disease. There is a growing body of experience in which the new oral antifungal agents have been used to treat tinea capitis and other superficial infections in children. The data suggest that itraconazole, terbinafine, and fluconazole are effective and safe in children. (Curr Probl Dermatol 2001;13:213-48)

Tinea versicolor is a common superficial fungal infection caused by a lipophilic yeast. This chronically recurring opportunistic infection is especially prevalent in tropical and semitropical regions. The topical short-term application of ketoconazole 2% shampoo may provide effective and safe therapy for tinea versicolor.The purpose of this study was to evaluate the efficacy and safety of a single application (1 day) versus three daily applications (3 days) of ketoconazole 2% shampoo versus placebo shampoo in the treatment of mycologically confirmed tinea versicolor.Three hundred twelve patients were included in the primary analyses for this 31-day study. Global evaluation scores were measured on days 10 and 31 with a 5-point scale (1 = healed to 5 = worsening), and a cellophane tape test was done at baseline and days 3, 10, and 31. Efficacy was assessed by clinical response, defined as both a global evaluation score of 1 (healed) and a negative cellophane tape test on day 31. Signs and symptoms of tinea versicolor (scaling, itching, erythema, hypopigmentation, hyperpigmentation) also were evaluated at baseline, day 10, and day 31 with a 4-point scale (0 = absent to 3 = severe).Both regimens of ketoconazole shampoo were significantly (P.001) more effective than placebo for rate of clinical response, global evaluation scores, and mycologic outcomes (cellophane tape test). The clinical response rates at day 31 were 73%, 69%, and 5% for the 3-day ketoconazole, 1-day ketoconazole, and placebo groups, respectively. The difference in the efficacy of the two ketoconazole treatment regimens was not statistically significant. There were no significant differences between any of the treatment groups in the number of patients who experienced adverse events. No serious adverse events occurred and no patient withdrew from the trial prematurely because of an adverse event.Ketoconazole 2% shampoo, used as a single application or daily for 3 days, is safe and highly effective in the treatment of tinea versicolor.

Pityriasis versicolor is a superficial recurring mycotic infection frequently encountered in tropical countries. The challenge for clinicians is selecting an antifungal therapy that produces long-lasting cure, good patient compliance, and a low incidence of adverse effects. Three open-label, randomized, comparative multicenter studies were conducted in South America to assess the efficacy and safety of fluconazole (two 300-mg doses given 1 week apart, and, if necessary, a third dose given 1 week later) with those of ketoconazole (200 mg daily for 10 or 14 days), itraconazole (200 mg daily for 7 days), or clotrimazole 1% cream (two applications daily for 21 days) in the treatment of patients with mycologically proven pityriasis versicolor. Clinical signs and symptoms of skin infection and microscopic examination and cultures of lesion scrapings were assessed at baseline and on days 14, 30 (or 37 for patients who received the third fluconazole dose), and 60. Safety was assessed on days 7, 14, 30 (or 37 for patients who received the third fluconazole dose), and 60. A total of 388 patients received study drug: 194 in the three fluconazole groups and 194 in the ketoconazole, itraconazole, and clotrimazole comparator groups. The combined clinical response rate (cure plus improvement) at early follow-up (day 14) in the fluconazole treatment groups was 91.2%, a response that was maintained at the day 60 evaluation. Similar clinical response rates were found among patients treated with the comparator drugs. Although the eradication rate at day 14 was significantly lower in the fluconazole group (39.1%) than in the itraconazole group (56.5%), no significant differences in eradication rate between fluconazole and each of the comparator drugs were found at later follow-up assessments (days 30 and 60). The highest rate of reinfection (15.3%) was found in itraconazole-treated patients at day 60. The incidence of adverse events was low in all treatment groups, and no clinically significant laboratory abnormalities were reported. The results of these studies indicate that fluconazole administered as two or three weekly 300-mg doses to patients with pityriasis versicolor was well tolerated and at least as effective as accepted regimens employing ketoconazole, itraconazole, and topical clotrimazole. This fluconazole regimen represents an attractive alternative to prolonged daily oral or topical therapy.

The opportunistic yeast Malassezia pachydermatis is commonly recovered from both normal and diseased skin of warm-blooded animals. The diversity of M pachydermatis isolates obtained from a wide range of hosts was investigated by the partial sequencing of the large subunit (LSU) ribosomal RNA. Among 100 isolates examined, seven types (Ia-Ig) were discriminated on the basis of nucleotide sequence diversity. The seven types differed by one to five mutations, all of them corresponding to transitions. The predominant sequence, type Ia, appeared to be ubiquitous since it was observed in isolates recovered from domestic and wild carnivora, from a monkey and from man. In contrast the sequence types Ic, Id and Ig seemed to be more host-specific; they included isolates recovered exclusively from rhinoceros, dogs and ferrets, respectively. None of the seven sequence types correlated with isolation from healthy skin or a particular lesion (otitis externa or other dermatitis). The study indicated that the skin of an animal may be colonised by more than one type of M pachydermatis.

The therapeutic efficacy of Cassia alata leaf extract against Pityriasis versicolor has been reported for the first time involving humans. For the collection of clinically effective antifungal compounds from the leaves of Cassia alata, a simple procedure has been devised. A 10-year human study indicates that the leaf extract can be reliably used as a herbal medicine to treat Pityriasis versicolor. The leaf extract has no side-effects.

The most common disorders of hypopigmentation in children are pityriasis alba, vitiligo, nevus depigmentosus, and tinea versicolor. Pityriasis alba usually presents as ill defined, scaly patches of hypomelanosis on the cheeks of children with an atopic diathesis. The face is also a favored site for vitiligo, but the distribution is periorificial, and the pigment loss is complete because of a destruction of melanocytes. Vitiligo is an acquired, progressive disorder in contrast to nevus depigmentosus, which is a stable, congenital leukoderma. The localized form of nevus depigmentosus must be distinguished from an ash leaf spot, the earliest cutaneous manifestation of tuberous sclerosis, whereas the systematized form may be confused with hypomelanosis of Ito, another neurocutaneous disorder. The lesions of tinea versicolor favor the upper trunk of adolescents, and potassium hydroxide examination of the associated scale reveals hyphal and yeast forms of P. orbiculare. Any inflammatory process in the skin such as dermatitis or psoriasis can resolve with areas of hypopigmentation.

Age of the patient, climate, season, and local environmental factors influence the onset and course of tinea versicolor (pityriasis versicolor). A number of effective topical therapies are available. In addition, a single dose of 400 mg of oral ketoconazole eliminates the disease and can be used prophylactically in some cases to prevent recurrence.

The use of short-term oral azoles is an alternative to topical therapy in patients with tinea versicolor.We compared the efficacy and safety of oral itraconazole with that of placebo in 36 patients with mycologically proven tinea versicolor.Patients were randomly assigned to 7 days of treatment with either itraconazole, 200 mg once daily, or placebo. A potassium hydroxide examination and assessment of scaling, erythema, pruritus, and global condition were performed at baseline and at 4 weeks after treatment.The itraconazole-treated group demonstrated significant improvement over both baseline (p0.01) and placebo (p0.02) in scaling, erythema, and pruritus. Sixty-seven percent of itraconazole-treated patients were free of symptoms at week 5, as compared with 12% of placebo-treated patients. Ninety-four percent of itraconazole-treated patients were considered to be healed or markedly improved at the study's end point compared with 6% of placebo-treated patients (p0.01). A total of 89% in the itraconazole-treated group had a negative potassium hydroxide examination at the follow-up visit compared with 6% in the placebo-treated group (p0.01). There was a single report of a possibly treatment-related adverse event in each treatment group.Short-term treatment with itraconazole is effective and well tolerated in the management of tinea versicolor.

Pityrosporum ovale is a lipophilic yeast that is part of the normal human adult cutaneous flora. It is both a saprophyte and an opportunistic pathogen associated with pityriasis versicolor, Pityrosporum folliculitis, seborrheic dermatitis, and some forms of atopic dermatitis. Systemic infections have also been described. In this article the diagnosis and management of pityriasis versicolor, Pityrosporum folliculitis, seborrheic dermatitis, and atopic dermatitis will be discussed.

Acanthosis nigricans is a marker for disorders of insulin action, endocrine abnormalities, and cancer of internal organs. To evaluate the clinical significance of this marker the systemic alterations and clinical features of 26 patients with acanthosis nigricans seen at two institutions were reviewed. Most subjects affected by acanthosis nigricans were female (20 patients), Caucasian (22 patients), in the third decade of life (13 patients), and overweight (24 patients greater than 120 percent ideal body weight). Gonadal disease, present in 17 patients, was expressed as polycystic ovary syndrome (11 cases), disorders of prolactin secretion (two cases, one with polycystic ovary syndrome), streak gonads (one case), and hypogonadism of the male (four cases). Thyroid disease and tinea versicolor were present in four patients each. Three patients were receiving insulin therapy for diabetes mellitus, and in two additional patients diabetes mellitus was detected during the diagnostic workup. All patients had elevated fasting insulin levels; most of them also had an exaggerated insulin response to a glucose load. Two of 18 patients tested had antibodies against the insulin receptor in the circulation. Skin biopsy of acanthosis nigricans lesions from all 26 patients showed a typical pattern of hyperkeratosis, acanthosis, and epidermal papillomatosis. Colloidal iron staining showed glycosaminoglycan infiltration of the papillary dermis (21 of 21 cases), consisting mainly of hyaluronic acid. It is concluded that: (1) hyperinsulinenemia and local dermal glycosaminoglycan deposition are regular features in acanthosis nigricans and (2) patients with acanthosis nigricans should be screened for diabetes mellitus, gonadal disease, and hypothyroidism.

The effect of cholesterol and cholesterol esters on Pityrosporum cultures has been studied. A mixture from 0.25% to 2.0% of cholesterol:cholesteryl stearate:glyceryl mono-stearate (2.0:1.5:2.0) added to Bacto Yeast Morphology Agar plus oleic acid was able to induce hyphae in cultures of both Pityrosporum orbiculare and P. ovale . This result is discussed with respect to the cholesterol effect on cell membranes and to the occurrence of cholesterol and cholesterol esters in the scaling patches of Pityriasis versicolor .

The yeast, Pityrosporum orbiculare, isolated from lesions from lesions of tinea versicolor, grows in vitro only if fatty acids from the C12 to C24 series are added to the culture medium. Except for elaidinic and nervonic acids, all saturated and unsaturated fatty acids tested support growth. P. orbiculare can synthesize various lipid fractions containing both saturated and unsaturated fatty acids from a single fatty acid. Glucose and asparagine stimulate growth but exogenous vitamins do not.

The purpose of this investigation was to produce experimental tinea versicolor in rabbits and humans with Pityrosporum orbiculare . Inoculation with P. orbiculare under plastic occlusion on the glabrous follicle-rich inside of the rabbit ear resulted in a tinea versicolor-like lesion after 1 week in 3 of 4 animals. One week after inoculation with P. orbiculare under plastic occlusion, experimental infections similar to those found clinically in tinea versicolor were seen in 10 of 12 patients with a history of tinea versicolor and in 3 of 6 normal volunteers. It was not possible to produce experimental infections without occlusion. Spontaneous healing usually occurred.

A number of effective antifungal agents are now available for topical use. Although topical medications are not effective in hair and nail infections, most patients with dermatophytosis, candidiasis, and tinea versicolor can be treated topically with success. The newer agents such as haloprogen and the imidazoles have a broad spectrum of activity and can be used in any of these three conditions. Several new antifungals have recently been released, and other new agents as well as antifungal-corticosteroid combinations will soon be available.

The effect of various heteroaroyl groups in the 17-position of topical corticosteroids has been studied. The corticosteroids esterified at C17 were of 9 alpha,11 beta-dichloro, 9 alpha-chloro 11 beta-hydroxy and 9 alpha-fluoro 11 beta-hydroxy series. Among the 17-acyl groups 2'-furoates were most extensively investigated, although 2'-thenoates, 3'-thenoates and 3'-furoates were also examined. Many of these esters exhibited enhanced topical anti-inflammatory potencies. The most potent compounds investigated were the 21-chloro 17(2'-furoates) either in the 9 alpha,11 beta-dichloro, or in the 9 alpha-chloro 11 beta-hydroxy series. These compounds were at least 6 times as potent as betamethasone 17-valerate. Among 16-substituents studied 16 alpha-methyl compounds had the highest potency. Topical anti-inflammatory potencies were determined by using a 5-day modification of the croton oil ear assay in mice. The more potent compounds were also evaluated in the P. ovale induced chronic psoriaform lesion in the guinea-pig.

Using the indirect immunofluorescence technique no differences were observed in intensity of staining when antisera against Pityrosporum orbiculare and P. ovale or IgG fractions of these were incubated with P. orbiculare and P. ovale cells. However, a weaker reaction was observed with these antisera and P. pachydermatis cells. With IgG fractions the nonspecific fluorescence was minimized. Fungal cells in biopsies from tinea versicolor lesions showed a brilliant staining with the IgG fractions of antisera against P. orbiculare . This investigation indicates a close antigenic relationship between all of the 3 Pityrosporum species. A common antigenicity was found between P. orbiculare and P. ovale cells as well as between P. orbiculare cells from culture and the fungal cells in biopsies from tinea versicolor lesions. This strongly suggests that these 2 species are identical with each other and with the organism found in tissue.

The safety of topical selenium sulfide lotion in man has been demonstrated previously. Twenty male patients with a diagnosis of tinea versicolor were randomly assigned to two parallel groups who applied selenium sulfide lotion or the vehicle to the entire skin surface, excluding mucous membranes, for 10 minutes once daily for 7 consecutive days. Blood and urine selenium levels were determined before and after treatment and showed no significant differences between the active drug and vehicle groups on any study day. It would appear that no significant absorption of selenium took place as a result of this treatment regimen.