Medical Care
Both topical and oral antifungals are effective agents in the treatment of Pityrosporum folliculitis (PF). Oral antifungals have the advantage of dramatic, immediate clearing of the lesions and are the most effective treatment. [33]
Patients have been successfully treated with oral pulse itraconazole and weekly fluconazole. M sympodialis is highly sensitive to terbinafine, while other species are more resistant to treatment with this medication. [34]
Many patients improve with topical azole medications, but some cases require oral therapy. A course of oral ketoconazole was previously the treatment of choice, but given the potential for severe adverse events with this medication, it is no longer recommended. [18] Oral medication should be discontinued when the lesions resolve. Because relapse almost always occurs when treatment is withdrawn, topical ketoconazole is indefinitely continued after successful initial treatment with oral medication.
Other topicals that are used to treat Pityrosporum folliculitis are ciclopirox olamine cream, econazole cream, alcohol and salicylic acid solution (with or without benzoic acid 5%), propylene glycol 50% in water, and selenium sulfide shampoo. [35] Other topical treatments with some reported success include tea tree oil, honey, tacrolimus, and cinnamic acid. [36]
In cases associated with antibiotic use, discontinuing the antibiotic may be helpful.
Retinoids, which are used for comedones in acne, have no effect because no comedones are present in Pityrosporum folliculitis. [37, 38]
Tetracycline does not help in Pityrosporum folliculitis, and it may exacerbate the condition by further destroying the normal bacterial skin flora and allowing further spread of Malassezia yeasts.
Other studies suggest topical photodynamic therapy with methyl aminolevulinate may be a potential therapy for recalcitrant Malassezia folliculitis. [39]
Consultations
No consultations are necessary in Pityrosporum folliculitis.
Prevention
Advise patients with Pityrosporum folliculitis to avoid predisposing factors such as emollients, occlusive topicals, occlusive nylon clothing, immunosuppressants, steroids, and antibiotics.
Long-Term Monitoring
Regular clinical follow-up may be necessary in Pityrosporum folliculitis (PF) to monitor the patient's condition and refill prescriptions.
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This photo is high-power hematoxylin and eosin staining of a biopsy confirming Pityrosporum folliculitis. There is a hair shaft within a hair follicle with scattered amphophilic staining circular Pityrosporum yeast. Courtesy of Ronald Rapini, MD.
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Left: A 25-year-old man with complaints of slightly pruritic, monomorphic follicular papules, pustules, and secondary keloid on the upper trunk and neck. Right: Scanning electron microscopy of the hair follicle from the upper trunk. This demonstrated a large number of globular or orbicular-ovate yeasts of budding daughter cell, with collar structure around the budding. Courtesy of Wikimedia Commons by Ran Yuping et al (https://commons.wikimedia.org/wiki/File:Pityrosporum_folliculitis_2.jpg).
