Atypical folliculitis caused by Malassezia spp. in immunosuppressed patients

Abstract

Background: Folliculitis due to Malassezia spp. (MF), caused mainly by Malassezia furfur, is clinically characterized by an acneiform eruption expressing follicular papules and pustules, predominantly on the trunk. Diagnosis of MF requires confirmation of the presence of yeasts in the hair follicle. The treatment of choice is topical or oral with azoles. We report two cases of folliculitis due to Malassezia spp. of atypical distribution in immunosuppressed patients. Case reports: Case 1. We describe a 14-year-old male patient diagnosed with chondroid osteosarcoma who required surgical treatment and chemotherapy. He was hospitalized for fever and neutropenia, presenting a rash of papulopustular lesions on the upper and lower extremities and neck. Direct examination and biopsy were performed to conclude the diagnosis of disseminated atypical Malassezia spp. folliculitis. Case 2. We describe a 16-year-old male patient diagnosed with synovial sarcoma, treated with surgical resection and chemotherapy. During hospitalization due to fever and neutropenia, he presented with disseminated dermatosis of the head, trunk, and upper extremities, showing multiple follicular papules and pustules with erythematous base; on the trunk, there were few lesions. In the supraciliary region, he showed erythema and furfuraceous desquamation. Direct examination of a follicle showed thick-walled round yeasts compatible with MF. Conclusions: MF is a frequent entity but of low diagnostic suspicion. Immunosuppressed patients may manifest atypical clinical characteristics in non-seborrheic areas, implying diagnostic difficulty. Biopsy and direct examination are essential to corroborate the etiology in patients with immunosuppression or with a non-classical presentation.

Keywords

• Folliculitis. Malassezia. Atypical. Immunosuppression.