Zits of Another Kind
A teen boy has tried everything for his "zits" without improvement. Take a close look at the eruption. Acne? Or, something else? Another Case Study from the Clinic.
A 15-year-old boy has tried over the past 3-4 months various topical acne medications for his "zits" with no meaningful response.
The mother presents all medications given to her son for this condition.
Medications taken for acne: Retin-A, benzoyl peroxide, tetracycline, dicloxacillin
He has had mild facial acne over the past 2-3 years; now breakouts occur on trunk and arms and are extremely pruritic. No family history of acne or skin disorders.
History: denies steroids, other drugs/medications; no swimming/hot tub exposure; no animal exposure.
Physical examination: Small dome-shaped papules in follicular locations mixed with inflammatory pustules noted on chest, back, arms.
Scattered papules and pustules on trunk and upper arms.
Papules and pustules on upper left arm/chest.
Affected area on right upper arm.
Close-up of affected area on right upper arm.
Acne is ruled out based on the following: occurs in areas where there are sebaceous glands (ie, face), not on arms, abdomen, trunk; acne is not prurutic; lesions have not responded to acne medicines.
What's the diagnosis? Acne vulgaris, cutaneous candidiasis, cutaneous sporotrichosis, eosinophilic pustular folliculitis, steroid acne, pseudomonas folliculitis, pityrosporum folliculitis, fire ant bites, lichen spinulosis.
Answer: Pityrosporum folliculitis (PF): benign acneiform eruption often misdiagnosed as acne vulgaris. Caused by overgrowth of Malassezia yeast found in normal cutaneous flora.
Acne vulgaris and PF coexist in ~12% to 27% of cases.
Oral antifungal treatment is first line and results are rapid; confirms diagnosis. FDA 5/2016 warning states ketoconazole should not be used. Itraconazole is recommended.
Summary: Avoid pityrosporum recurrence -- continue oral treatment 5-7 days after visual clearance; recommend weekly use of antifungal shampoo.
Other topical treatment for pityrosporum: Selenium sulfide as a lotion, shampoo, body soap; alcohol and salicylic acid solution (w or w/o benzoic acid 5%); propylene glycol 50% in water.
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Additional reading
- FDA Drug Safety Communication: FDA warns that prescribing of Nizoral (ketoconazole) oral tablets for unapproved uses including skin and nail infections continues; linked to patient death. May 19, 2016.
- Gaitanis G, Velegrakis A, Mauser P, Bass Lukas ID. Skin diseases associated with Malassezia yeasts: facts and controversies. Clin Dermatol. 2013;31:455-63.
- Pedrosa AF, Lisboa C, Gonçalves Rodrigues A. Malassezia infections: a medical conundrum. J Am Acad Dermatol. 2014;71:170-6.
- Rubenstein RM, Malerich SA. Malassezia (pityrosporum) folliculitis. J Clin Aesthet Dermatol. 2014;7:37-41.
- Viana de Andrade AC, Pithon MM, Oiticica OM. Pityrosporum folliculitis in an immunocompetent patient: clinical case description.Dermatol Online J. 2013;19:19273.
To a 15-year-old boy the only kind of zits other than the ones on his adolescent face are zits that go away--and those aren't the type that are frustrating the teen in this case.Dr Jonathan Schneider and his virtual resident puzzle over lesions that have been present for several months and resemble acne but present a number of signs and symptoms not at all characterisitic of that condition.In the slides below, Dr Schneider presents history, physical exam results, and images that should help you ID this other kind of zit.Back to Basics with a Classic Case Study from the Clinic
